【Abstract】ObjectiveTo study the positive effect of recombinant human epidermal growth factor (rhEGF) on rabbit intestinal anastomotic wound healing after bowel resection. MethodsFortyeight white rabbits were randomly divided into study group in which rhEGF was injected and spinged in the submucosa and mucosa respectively during intestinal anastomosis after bowel resection, and control group in which only intestinal resection and anastomosis was performed. The leukocyte was counted. The incidence of anastomotic leakage and the synthesis of collagen fibrils and hydroxyproline were observed. ResultsThe leukocyte numbers in the anastomotic tissue in two groups rabbits increased slightly 3 d, 5 d and 7d after intestinal anastomosis, but the difference between study group and control group was insignificant (Pgt;0.05). The incidence of anastomotic leakage in the control group (16.7%) was higher than that of the study group (4.3%). The area of collagen fibrils 3 d, 5 d and 7d after intestinal anastomosis in the study group were significantly more than that in the control group (P＜0.05). Number of fibroblast was higher in the study group and the cells appeared bigger nucleus and dense colouration as well as enriched plasm. Angiogenesis in anastomosis tissue in the study group was significant and normal structure was present. Cell structure of anastomosis mucosa was damaged in the control group. Synthesis of hydroxyproline in anastomotic tissue 5 d and 7 d after anastomosis in the study group was more than that in the control group (P＜0.05).ConclusionInflammation was present in the whole process of wound healing, and local using of EGF had insignificant effect on system inflammation. EGF functions as chemoattractant and increases the recruitment of leukocytes, monocytes and fibroblasts into the wound area. EGF increases the production of collagen, angiogenesis and the synthesis of hydroxyproline. So EGF could promote wound healing and protect from anastomosis leakage in this study.
ObjectiveTo analyze the common reasons of anastomotic leakage following sphincter preservation for rectal cancer, and to explore the better prevention and treatment strategies.
MethodThe related literatures of the definition, common causes, and prevention and treatment status of anastomotic leakage were reviewed.
ResultsCurrently rectal cancer was one of common malignant tumors, including about 2/3 low rectal cancer.Recently, sphincter preserving surgery had become the preferred surgical procedure.However, the incidence of anastomotic leakage keeping in higher was still the most serious and common complications.Through improving the general condition of the patients, improving surgical techniques, and standardized treatment could effectively reduce the incidence of anastomotic leakage.
ConclusionReasonable preoperative assessment for the basic situation of patients with rectal cancer, standardized and individualized treatments, contribute to reduce incidence of anastomotic leakage and improve clinical outcomes in patients with low rectal cancer.
ObjectiveTo systematically review risk factors for esophagogastric anastomotic leakage (EGAL) after esophageal cancer surgery for adults to provide theoretical basis for clinical prevention and treatment.MethodsPubMed, Web of Science, The Cochrane Library, WanFang Data, VIP, CNKI and CBM were searched from inception to January 2020 to collect case control studies and cohort studies about risk factors for EGAL after esophageal cancer surgery. Two reviewers independently screened literature, extracted data and assessed risk of bias of included studies, and then, meta-analysis was performed by using RevMan 5.3 software.ResultsA total of 33 studies were included, including 19 case-control studies and 14 cohort studies, all of which had a Newcastle-Ottawa Scale (NOS)≥6. There were 26 636 patients, including 20 283 males and 6 353 females, and there were 9 587 patients in China and 17 049 patients abroad. The results of meta-analysis showed that the following factors could increase the risk for EGAL (P≤0.05), including patient factors (18): age, sex, body mass index (BMI), smoking history, smoking index (≥400), alcohol history, digestive tract ulcer, respiratory disease, lower ratio of forced expiratory volume in one second to forced vital capacity (FEV1/FVC), chronic obstructive pulmonary disease (COPD), coronary atherosclerosis, peripheral vascular disease, arrhythmia, diabetes, hypertension, cerebrovascular disease, celiac trunk calcification and descending aortic calcification; preoperative factors (6): abnormal liver function, renal insufficiency, American Society of Anesthesiologists (ASA) grading, neoadjuvant radiotherapy and preoperative albumin<35 g/L, preoperative lower albumin; intraoperative factors (7): retrosternal route, cervical anastomosis, thoracoscopic surgery, operation time≥4.5 h, tubular stomach, upper segment tumor, splenectomy; postoperative factors (5): respiratory failure, postoperative arrhythmia, use of fiberoptic bronchoscopy, pulmonary infection, deep venous thrombosis. Neoadjuvant chemotherapy could reduce the risk for postoperative EGAL (P<0.05). However, age≥60 years, upper gastrointestinal inflammation, diffusing capacity for carbon monoxide (DLCO%), thoracic surgery history, abdominal surgery history, glucocorticoid drugs history, neoadjuvant chemoradiotherapy, anastomotic embedding, end-to-end anastomosis, hand anastomosis, intraoperative blood loss and other factors were not significantly correlated with EGAL.ConclusionCurrent evidence suggests that the risk factors for postoperative EGAL include age, sex, BMI, smoking index, alcohol history, peptic ulcer, FEV1/FVC, COPD, diabetes, ASA grading, neoadjuvant radiotherapy, preoperative albumin<35 g/L, cervical anastomosis, thoracoscopic surgery, operation time≥4.5 h, tubular stomach, upper segment tumor, intraoperative splenectomy, postoperative respiratory failure, postoperative arrhythmia and other risk factors. Neoadjuvant chemotherapy may be the protection factor for EGAL. Due to limited study quality, more high quality studies are needed to verify the conclusion.
Objective To evaluate the role of curved-cutter-stapler in anus-preserving for low rectal cancer. Methods The clinical data of 32 patients with low rectal cancer from June 2007 to December 2008 who received low anterior resection and ultra low anterior resection by using curved-cutter-stapler were reviewed retrospectively. Results No operation death case, complete cutting and safe closure in all cases, one case was complicated with anastomotic leakage, and one case of rectovaginal fistula. Thirty patients were followed up 4 to 22 months after the operation, with an average time of 12.6 months, no hemorrhea of pelvic cavity and anastomotic stoma or anastomotic stenosis cases. Conclusion Curved-cutter-stapler has the advantages of complete cutting, safe closure and low complications, and easy being used in anus-preserving operation for low rectal cancer, which can increase the rate of anus-preserving.
The risk factors of esophagogastric anastomotic leak in the perioperative period include malnutrition, smoking, steroid use, bowel preparation, chemotherapy, duration of surgery, vasopressor drugs use, intravenous fluid administration, blood transfusion and surgical anastomotic technique, which can be reduced with the improvement of surgeons' ability to identify the high-risk patients. This article summarizes the specific measures for these risk factors: preoperative nutritional support for 5–7 d for malnourished patients, full intestinal preparation, perioperative smoking cessation, limitation of steroids and vasopressors drug applications, avoidance of early operations (<4 weeks) following chemotherapy, and the goal-directed fluid management.
Objective To assess the effectiveness and safety of hand-suture vs. stapling anastomosis in esophagogastrostomy. Methods The following databases such as CBM (1978 to February 2012), VIP (1989 to February 2012), CNKI (1994 to February 2012), WanFang Data (1980 to February 2012), The Cochrane Library, PubMed (1966 to February 2012), EMbase (1974 to February 2012), and relevant webs of clinical trials were searched to collect the randomized controlled trials (RCTs) and quasi-RCTs about hand-suture vs. stapling anastomosis in the incidence of anastomotic leakage following esophagogastrostomy. Moreover, relevant references and grey literature were retrieved on web engines including Google Scholar and Medical Martix, and the Chinese periodicals e.g. Chinese Journal of Oncology were also handsearched. According to the inclusion and exclusion criteria, the literature, was screened, the data were extracted, and the quality of the included studies was assessed. Then meta-analysis was conducted using RevMan 5.0 software. Results A total of 9 RCTs involving 2 202 patients were included. The result of meta-analysis was as follows: the incidence of anastomotic leakage in the stapling anastomosis group was lower than that in the hand-suture anastomosis group (OR=0.43, 95%CI 0.26 to 0.71, Plt;0.01). Conclusion Stapling anastomosis is superior to hand-suture anastomosis in reducing the incidence of anastomotic leakage following esophagogastrostomy. For the limited quality and quantity of the included studies, this conclusion has to be further proved by more high-quality studies.
Objective To evaluate preventive effectiveness of pocket esophagogastric anastomosis for postoperativeanastomotic leak，stricture and gastroesophageal reflux disease （GERD），and investigate clinical significance of Montreal definition and classification of GERD after esophageal reconstruction. Methods Clinical data of 1 078 patients whoreceived 2 different surgical procedures for resection of esophageal or cardiac carcinoma from June 2007 to June 2011 in our hospital were retrospectively analyzed. In the experimental group，there were 582 patients who received pocketesophagogastric anastomosis，including 403 male and 179 female patients with their age of 60.4±12.6 years. There were 399 patients with esophageal carcinoma and 183 patients with cardiac carcinoma，392 patients receiving esophagogastrostomyabove the aortic arch and 190 patients receiving esophagogastrostomy below the aortic arch respectively. In the control group，there were 496 patients who received conventional end-to-side esophagogastric anastomosis，including 343 male and 153 female patients with their age of 59.2±12.8 years. There were 322 patients with esophageal carcinoma and 174 patients with cardiac carcinoma，317 patients receiving esophagogastrostomy above the aortic arch and 179 patients receivingesophagogastrostomy below the aortic arch respectively. A survey questionnaire was made on the basis of relevant diagnosticstandards to investigate the incidence of postoperative anastomotic stricture and GERD of the 2 groups during follow-up.Results The incidence of postoperative anastomotic leak of the experimental group was significantly lower than that of the control group ［0% （0/582）versus 1.0% （5/496），χ2=5.835，P=0.016］. Patients in the experimental group had less severeGERD symptoms，and the percentage of patients who needed antacid therapy for extraesophageal symptoms of GERD ofthe experimental group was significantly lower than that of the control group ［1.6% （33/541） versus 12.6% （57/453），χ2=23.564，P=0.000］. The incidence of anastomotic stricture of the experimental group was significantly lower than that of thecontrol group ［0.9% （5/539） versus 7.3% （34/465），χ2=25.124，P=0.000］，and especially，the incidence of severe anastomoticstricture of the experimental group was significantly lower than that of the control group ［0% （0/539） versus 4.7% （22/465），χ2=24.883，P=0.000］. There was no statistical difference in five-year survival rate. Conclusion Pocket esophagogastric anastomosis is better than conventional end-to-side esophagogastric anastomosis for the prevention of postoperative anastomoticleak，stricture and GERD. Montreal definition and classification of GERD is suitable for the diagnosis of postoperativeGERD after esophageal reconstruction.
ObjectiveTo evaluate clinical value of colon leakage score (CLS), a preoperative predictive scoring system, for risk of anastomotic leakage after left-sided colorectal cancer surgery.
MethodsThe clinical data of 310 patients who underwent left-sided colorectal cancer surgery from January 2010 to December 2014 were studied retrospectively. Risk factors for postoperative anastomotic leakage were analyzed by univariate analysis. The sensitivity and specificity of CLS system were determined by receiver operating characteristic (ROC) curve analysis.
Resultsa total of 14 patients were diagnosed as anastomotic leakage. The point of CLS for the patients with anastomotic leakage was significantly higher than that for the patients without anastomotic leakage (14.21±5.76 versus 4.43±3.36, t=9.474, P=0.000). The results of ROC curve analysis showed that the sensitivity and specificity of the CLS system were 92.9% and 88.6%, respectively. The area under the curve was 0.957 (95% CI 0.924-0.991). The best cut off value of CLS was 10 (The Youden index was 0.867). The results of univariate analysis showed that the age, preoperative hemoglobin level, status of intestinal obstruction, and blood loss were associated with postoperative anastomotic leakage (P<0.05).
ConclusionThe preoperative predictive score system CLS could accurately predict occurrence of anastomotic leakage. While large, multicenter prospective randomized controlled trial is still needed to further confirm it.
Objective To explore an effective and minimal invasive drainage procedure for intrathoracic anastomotic leakage after esophagectomy.
Method A total of 14 patients (10 males and 4 females, aged 48 to 70 years) with encapsulated effusion due to thoracic anastomotic leakage after esophagectomy were performed accurate thoracic drainage which was guided by ultrasonography in Renji Hospital from January 2012 through December 2014. The J shape flexible catheter was placed into the effusion cavity near the leakage. Gasric drainage and enteral nutrition support were conducted as well.
Result All the patients with leakage healed smoothly. The hospital stay was 27 to 94 days. Time of drainage was 17 to 89 days. The drainage volume was 5-260 ml per day. No complication related to drainage occurred.
Conclusion Placing the J shape flexible catheter for plural drainage guided by ultrasonography or chest CT scan is a desirable and less injured therapy for intrathoracic leakage after esophagectomy.
Objective To analyse postoperative complications and cause of death for carcinoma of esophagus. Methods A retrospective study was undertaken for data of 2 085 patients with esophageal carcinoma from 1963 to 2003, the patients were divided into group A (332 cases,1963-1983), group B(727 cases,1984-1993) and group C (1 026 cases,1994-2003) by time. The postoperative complications and cause of death were analysed. Results Resectability rate, incidence rate of postoperative complications and hospital mortality were 90.84%(1 894/2 085), 11.61% (242/2 085) and 1.82% (38/2 085) respectively. Main complications were pulmonary complications (3.93%,82/2 085),anastomotic leak (3.12%,59/1 894), and cardiovascular disease (1.29%,27/2 085). Resectability rate of group B and group C were higher than that of group A, incidence rate of postoperative complications and hospital mortality of group B and group C were lower than that of group A. Resectability rate of group C were higher than that of group B, incidence rate of postoperative complications except pulmonary complications and hospital mortality of group C were lower than those of group B. Conclusions Pulmonary complications and anastomotic leak are main postoperative complications and cause of hospital death for carcinoma of esophagus, they are decreasing in recent years because of the progress of anesthetic,surgical technique and perioperative management.
