Objective: To investigate the effect of a restricted intravenous fluid regimen versus a standard regimen on complications after colorectal resection. Summary Background Data: Current fluid administration in major surgery causes a weight increase of 3‐ 6 kg. Complications after colorectal surgery are reported in up to 68% of patients. Associations between postoperative weight gain and poor survival as well as fluid overload and complications have been shown. Methods: We did a randomized observer-blinded multicenter trial. After informed consent was obtained, 172 patients were allocated to either a restricted or a standard intraoperative and postoperative intravenous fluid regimen. The restricted regimen aimed at maintaining preoperative body weight; the standard regimen resembled everyday practice. The primary outcome measures were complications; the secondary measures were death and adverse effects. Results: The restricted intravenous fluid regimen significantly reduced postoperative complications both by intention-to-treat (33% versus 51%, P 0.013) and per-protocol (30% versus 56%, P 0.003) analyses. The numbers of both cardiopulmonary (7% versus 24%, P 0.007) and tissue-healing complications (16% versus 31%, P 0.04) were significantly reduced. No patients died in the restricted group compared with 4 deaths in the standard group (0% versus 4.7%, P 0.12). No harmful adverse effects were observed. Conclusion: The restricted perioperative intravenous fluid regimen aiming at unchanged body weight reduces complications after elective colorectal resection.

Effects of intravenous fluid restriction on postoperative complications: comparison of two perioperative fluid regimens: a randomized assessor-blinded multicenter trial.

Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer.

Background
Anastomotic leak (AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1–19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs.

Methods
A systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment.

Results
Of 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3–5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented.

Conclusion
Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making.

Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks.

Objective. Surgical technique and peri-operative management of rectal carcinoma have developed substantially in the last decades. Despite this, morbidity and mortality after anterior resection of the rectum are still important problems. The aim of this study was to identify risk factors for anastomotic leakage in anterior resection and to assess the role of a temporary stoma and the need for urgent re-operations in relation to anastomotic leakage.Patients and methods. In a nine-year period, from 1987 to 1995, a total of 6833 patients underwent elective anterior resection of the rectum in Sweden. A random sample of 432 of these patients was analysed (sample size 6.3%). The associations between death and 10 patient-and surgery-related variables were studied by univariate and multivariate analysis. Data were obtained by review of the hospital files from all patients.Results. The incidence of symptomatic clinically evident anastomotic leakage was 12% (53/432). The 30-day mortality was 2.1% (140/6833). The rate of mortality associated with leakage was 7.5%. A temporary stoma was initially fashioned in 17% (72/432) of the patients, and 15% (11/72) with a temporary stoma had a clinical leakage, compared with 12% (42/360) without a temporary stoma, not significant. Multivariate analysis showed that low anastomosis (≤ 6 cm), pre-operative radiation, presence of intra-opcrative adverse events and male gender were independent risk factors for leakage. The risk for permanent stoma after leakage was 25%. Females with stoma leaked in 3% compared to men with stoma who leaked in 29%. The median hospital stay for patients Arithout leakage was 10 days (range 5-61 days) and for patients with leakage 22 days (3-110 days).Conclusion. In this population based study, 12% of the patients had symptomatic anastomotic leakage after anterior resection of the rectum. Postoperative 30-day mortality was 2.1%. Low anastomosis, pre-operative radiation, presence of intra-operative adverse events and male gender were independent risk factors for symptomatic anastomotic leakage in the multivariate analysis. There was no difference in the use of temporary stoma in patients with or without anastomotic leakage.

Risk factors for anastomotic leakage after anterior resection of the rectum

Anastomotic disruption is perhaps the most dreaded complication after intestinal surgery. Some leaks presents in a dramatic fashion early in the postoperative period, leaving little doubt about the diagnosis. However, many others present in a far more subtle fashion, often relatively late in the postoperative period, and can be difficult to distinguish from other postoperative infectious complications.

It is this latter scenario where definitions are critical and retrospective analyses become rather suspect. In this light, it is not surprising that the reported incidence of anastomotic leakage varies so dramatically in the literature.1–7 The aim of this study was to use a rigorous, prospectively maintained complication database to more accurately define the incidence and presentation of anastomotic leakage after intestinal anastomosis.

Anastomotic Leaks After Intestinal Anastomosis: It's Later Than You Think

Background: Despite improvement in surgical techniques and stapling devices during the last 10 years, colorectal anastomoses are still prone to leakage. The purpose of this study was to assess the performance and safety of stapled anastomoses in rectal surgery and to identify factors that influence the occurrence of anastomotic leaks. Study Design: A review was undertaken of 1,014 patients who underwent stapled anastomoses tohttps://kc-rich-web1.cadmus.com/cgi-bin/cottage.pl the rectum or anal canal for colorectal cancer or benign disease between 1989 and 1995 in a tertiary care institution. Indications for operations, comorbidities at admission, preoperative bowel preparation, stapler size, intraoperative events, associated surgical procedures, and clinical outcomes were tested for any association with anastomotic leak. Results: A double stapled technique was used in 154 patients and a conventional single stapler technique was used in 860. Postoperative mortality was 1.6%, and the overall morbidity was 18.4%. Clinically apparent anastomotic leak developed in 29 patients (2.9%). Anastomotic dehiscence occurred in 22 of 284 patients (7.7%) after low stapling (within 7 cm from the anal verge) and in 7 of 730 patients (1%) after high stapling (p Conclusion: Low anastomoses were associated with a leak rate greater than with high colorectal anastomoses. We conclude that anastomoses to the rectum using the circular stapler can be done with low mortality and morbidity.

Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients

PURPOSE: After curative surgery for rectal cancer, patients with pelvic recurrence may undergo curative surgical resection. We determined whether salvage surgery in appropriately selected patients could significantly lengthen disease-free survival time and if so what factors predicted this outcome. METHOD: We reviewed the records of all patients treated for rectal cancer at our institution between 1980 and 1993. Of 937 patients who underwent surgery with curative intent after proctectomy or transanal local excision, 81 (8.6 percent) experienced local recurrence. During the same period 36 patients with locally recurrent rectal cancer were referred from other institutions. Logistic regression analysis was used to identify predictors of salvage surgery. The Kaplan-Meier method was used to estimate cancer-specific and disease-free survival times in 43 patients who underwent salvage surgery. The Cox proportional hazard model was used to identify factors associated with these outcomes. RESULTS: Of 117 patients with locally recurrent rectal cancer, 43 (36.7 percent) underwent salvage surgery. Factors associated with higher chance of receiving salvage surgery were female gender, the first operation performed at outside institutions, and transanal local excision as the initial operation. For 43 patients who underwent salvage surgery, five-year cancer-specific and disease-free survival rates were 49.7 and 32.2 percent, respectively. No factors were significantly associated with death caused by cancer. However, a trend for poor prognosis was observed in patients with recurrence diameter >3 cm and tumor fixation Degree 2. CONCLUSION: Salvage surgery for properly selected patients with locally recurrent rectal cancer allows long-term palliation and significantly lengthens disease-free survival.

Locally recurrent rectal cancer: predictors and success of salvage surgery.

The use of laparoscopy to evaluate the peritoneal cavity by direct vision was first described in 1902 by Kelling [1]. After development of the video endoscope in the 1980s, the success of laparoscopic cholecystectomy procedures stimulated surgical oncologists to consider applying minimally invasive surgical (MIS) techniques broadly to cancer patients.

Andrea Vignali

Papers

Factors associated with the occurrence of leaks in stapled rectal anastomoses: a review of 1,014 patients

Locally recurrent rectal cancer: predictors and success of salvage surgery.

Minimally invasive surgery in surgical oncology