acpgbi | advancing knowledge and treatment of bowel ......intraoperative intraoperative basic...
TRANSCRIPT
S Nachiappan, A Askari, A Currie, RH Kennedy, O Faiz30th June 2014
Tripartite Colorectal Meeting, Birmingham, UK
• ↑ local recurrence in rectal cancer• ↓ Long-term cancer specific
survival
• 16% died within 30 days• ↓ Long-term cancer specific
survival
• 4.5% of elective colorectal surgery underwent a reoperation within 28 days• Reoperation often for postop
bleeding & anastomotic leaks
To detect a possible anastomotic complication during the operation itself & allow remedial action
To prevent a postoperative leak or complication
To prevent a reoperation
To minimise patient morbidity and mortality
Anastomotic
Integrity
Ensure
Luminal
Patency
No Ischaemia
No Bleeding
No
Mechanical
Disruption
•Surgical anastomosis
•Colo-colonic
Anastomosis
•Colorectal
anastomosis
•Rectal anastomosis
•Ileorectal
anastomosis
•Intraoperative period
•Intraoperative care
•Peroperative
procedure
•Intraoperative
•Peroperative
•Anastomotic integrity
•Integrity
•Leak
•Dehiscence
•Perfusion
•Ischaemia
•Bleeding
*Latest search performed on 12th June 2013
Inclusion
• RCTs
• Non-randomised
comparative studies
• Case series
Exclusion
• Animal studies
• Case reports/technical tips
• Unclear postoperative
outcomes
Clinical
•Symptomatic
•May have had radiological
imaging subsequently
•Reoperation, Drainage or
conservative Mx
Radiological
•Asymptomatic
•Radiological imaging –
planned/routine
•eg. GG Enema at 8
weeks/prior to reversal
37 studies
Basic mechanical patency tests
(Air/fluid leak)
13
10
Case
series
1
Non-
randomised
study
2
RCT
Endoscopic visualisation
techniques
(intra-op colonoscopy +
leak test)
10
5
Case
series
5
Non-
randomised
studies
Microperfusion techniques
14
11
Case
series
2
Non-
randomised
studies
1
RCT
Postoperative
Intraoperative
Basic Mechanical
Patency TestsCase series
(10)
n = 816
Positive IOT*
90
13 POL
(7CL, 6RL)77 No POL
Negative IOT
726
47 POL
(26CL, 21RL)679 No POL
Positive IOT Negative IOT
13/90 47/726
14.4% 6.5%
7/90 26/726
7.7% 3.5%
IOT: Intraoperative testPOL: Postoperative leakCL: Clinical leakRL: Radiological leak
* With intraoperative rectifications• 61 sutured only• 20 sutured & defunctioned• 4 redone• 5 defunctioned only
Total Leak (CL+RL) rate▶▶▶
Clinical Leak rate▶▶▶
Postoperative
Intraoperative
Intraoperative
Basic Mechanical
Patency Tests
Non-
randomised
study (1)
n = 998
IOT
group
825
Positive IOT*
65
5 POL#
Negative IOT
760
29 POL
Control
group
173
14 POL
Tested Non-tested/Control
34/825 14/173
4.1% 8.1%
IOT: Intraoperative testPOL: Postoperative leak
* With intraoperative rectifications• 41 sutured• 10 sutured & defunctioned• 14 redone
Total (Clinical) Leak rate▶▶▶
# All sutured
Postoperative
Intraoperative
Intraoperative
Basic Mechanical
Patency Tests
RCTs (2)
n = 203
IOT
group
103
Positive IOT*
25
5 POL
(3CL, 2RL)
Negative IOT
78
9 POL
(3CL, 6RL)
Control
group
100
27 POL
(16CL, 11RL)
Tested Non-tested/Control
14/103 27/100
13.6% 27.0%
6/103 16/100
5.8% 16% IOT: Intraoperative testPOL: Postoperative leakCL: Clinical leakRL: Radiological leak
* With intraoperative rectifications• 25 sutured
Total Leak rate▶▶▶
Clinical Leak rate▶▶▶
37 studies
Basic mechanical patency tests
(Air/fluid leak)
13
10
Case
series
1
Non-
randomised
study
2
RCT
Endoscopic visualisation
techniques
(intra-op colonoscopy +
leak test)
10
5
Case
series
5
Non-
randomised
studies
Microperfusion techniques
14
11
Case
series
2
Non-
randomised
studies
1
RCT
Postoperative
Intraoperative
Endoscopic visualisation
(Intraoperative
colonoscopy)Case series
(5)
n = 713
Positive IOT*
57
12 POAC(6CL, 1staple line
bleed, 1 pelvic
collection, 4 ileus)
45 No POAC
Negative IOT
656
7 POAC
(7CL)649 No POAC
Positive IOT Negative IOT
12/57 7/656
21.1% 1.1%
6/57 7/656
10.5% 1.1%
IOT: Intraoperative testPOAC: Postoperative anast complicationCL: Clinical leakRL: Radiological leak
• With intraoperative rectifications• 10 suturing only• 14 haemostasis • 20 redone• 2 defunctioned only• 11 unknown
POAC rate▶▶▶
Clinical leak rate▶▶▶
Postoperative
Intraoperative
Endoscopic visualisation
(Intraoperative
colonoscopy)
Non-
randomised
studies (5)
n = 950
IOT
group
509
Positive IOT*
70
(56 air leaks, 14 staple
line bleeds
7 POAC
(7 CLs)
Negative IOT
439
32 POAC
(28 CL)
Control
group
441
26 POAC
(17 CL)
Tested Non-tested/Control
39/509 26/441
7.7% 5.9%
35/509 17/441
6.9% 3.9%
IOT: Intraoperative testPOAC Postoperative anast complication
• With intraoperative rectifications• 26 sutured• 8 haemostasis• 1 redone• 5 sutured/haemostasis &
defunctioned• 30 defunctioned
POAC rate▶▶▶
Clinical leak rate▶▶▶
37 studies
Basic mechanical patency tests
(Air/fluid leak)
13
10
Case
series
1
Non-
randomised
study
2
RCT
Endoscopic visualisation
techniques
(intra-op colonoscopy +
leak test)
10
5
Case
series
5
Non-
randomised
studies
Microperfusion techniques
14
11
Case
series
2
Non-
randomised
studies
1
RCT
First Author Year
Perfusion assessment technique Testing Access
(Operative access)
Study design N
Ambrosetti
1994 Doppler USS Open CS 194
Hallbook
1996
LDF Open CS 30
Vignali
2000 LDF Open CS 55
Seike
2007
LDF
Open CS
86
Boyle
2000 SLDF
Open CS
10
Sheridan 1987 Tissue Oxygen Tension
Open CS
50
Hall 1995 Tissue Oxygen Tension Open CS
62
Karliczek
2010 Visible Light O2 Spectroscopy
Open CS
77
Hirano
2006 Near Infrared O2 Spectroscopy
Open & lap CS
20
Parmeggiani 2012 IOC with Narrow Band Imaging
Transanal RCT
47 (27 vs 20)
Kudszus
2010 Laser Fluorescence ICG
Open & lap Case-Control 402 (201vs 201)
Jafari
2013 NIR ICG
Robotics Case-Control 38 (16 vs 22)
Sherwinter
2012 NIR ICG
Transanal CS
7
Sherwinter
2013 NIR ICG + ALT
Transanal CS
20
LDF = Laser Doppler FlowmetrySLDF = Scanning LDFNIR = Near InfraredICG = Indocyanine greenALT = Air leak test
First Author Year
Perfusion assessment technique Testing Access
(Operative access)
Study design N
Ambrosetti
1994 Doppler USS Open CS 194
Hallbook
1996
LDF Open CS 30
Vignali
2000 LDF Open CS 55
Seike
2007
LDF
Open CS
86
Boyle
2000 SLDF
Open CS
10
Sheridan 1987 Tissue Oxygen Tension
Open CS
50
Hall 1995 Tissue Oxygen Tension Open CS
62
Karliczek
2010 Visible Light O2 Spectroscopy
Open CS
77
Hirano
2006 Near Infrared O2 Spectroscopy
Open & lap CS
20
Parmeggiani 2012 IOC with Narrow Band Imaging
Transanal RCT
47 (27 vs 20)
Kudszus
2010 Laser Fluorescence ICG
Open & lap Case-Control 402 (201vs 201)
Jafari
2013 NIR ICG
Robotics Case-Control 38 (16 vs 22)
Sherwinter
2012 NIR ICG
Transanal CS
7
Sherwinter
2013 NIR ICG + ALT
Transanal CS
20
LDF = Laser Doppler FlowmetrySLDF = Scanning LDFNIR = Near InfraredICG = Indocyanine greenALT = Air leak test
First Author Year
Perfusion assessment technique Testing Access
(Operative access)
Study design N
Ambrosetti
1994 Doppler USS Open CS 194
Hallbook
1996
LDF Open CS 30
Vignali
2000 LDF Open CS 55
Seike
2007
LDF
Open CS
86
Boyle
2000 SLDF
Open CS
10
Sheridan 1987 Tissue Oxygen Tension
Open CS
50
Hall 1995 Tissue Oxygen Tension Open CS
62
Karliczek
2010 Visible Light O2 Spectroscopy
Open CS
77
Hirano
2006 Near Infrared O2 Spectroscopy
Open & lap CS
20
Parmeggiani 2012 IOC with Narrow Band Imaging
Transanal RCT
47 (27 vs 20)
Kudszus
2010 Laser Fluorescence ICG
Open & lap Case-Control 402 (201vs 201)
Jafari
2013 NIR ICG
Robotics Case-Control 38 (16 vs 22)
Sherwinter
2012 NIR ICG
Transanal CS
7
Sherwinter
2013 NIR ICG + ALT
Transanal CS
20
LDF = Laser Doppler FlowmetrySLDF = Scanning LDFNIR = Near InfraredICG = Indocyanine greenALT = Air leak test
First Author Year
Perfusion assessment technique Testing Access
(Operative access)
Study design N
Ambrosetti
1994 Doppler USS Open CS 194
Hallbook
1996
LDF Open CS 30
Vignali
2000 LDF Open CS 55
Seike
2007
LDF
Open CS
86
Boyle
2000 SLDF
Open CS
10
Sheridan 1987 Tissue Oxygen Tension
Open CS
50
Hall 1995 Tissue Oxygen Tension Open CS
62
Karliczek
2010 Visible Light O2 Spectroscopy
Open CS
77
Hirano
2006 Near Infrared O2 Spectroscopy
Open & lap CS
20
Parmeggiani 2012 IOC with Narrow Band Imaging
Transanal RCT
47 (27 vs 20)
Kudszus
2010 Laser Fluorescence ICG
Open & lap Case-Control 402 (201vs 201)
Jafari
2013 NIR ICG
Robotics Case-Control 38 (16 vs 22)
Sherwinter
2012 NIR ICG
Transanal CS
7
Sherwinter
2013 NIR ICG + ALT
Transanal CS
20
LDF = Laser Doppler FlowmetrySLDF = Scanning LDFNIR = Near InfraredICG = Indocyanine greenALT = Air leak test
First Author Year
Perfusion assessment technique Testing Access
(Operative access)
Study design N
Ambrosetti
1994 Doppler USS Open CS 194
Hallbook
1996
LDF Open CS 30
Vignali
2000 LDF Open CS 55
Seike
2007
LDF
Open CS
86
Boyle
2000 SLDF
Open CS
10
Sheridan 1987 Tissue Oxygen Tension
Open CS
50
Hall 1995 Tissue Oxygen Tension Open CS
62
Karliczek
2010 Visible Light O2 Spectroscopy
Open CS
77
Hirano
2006 Near Infrared O2 Spectroscopy
Open & lap CS
20
Parmeggiani 2012 IOC with Narrow Band Imaging
Transanal RCT
47 (27 vs 20)
Kudszus
2010 Laser Fluorescence ICG
Open & lap Case-Control 402 (201vs 201)
Jafari
2013 NIR ICG
Robotics Case-Control 38 (16 vs 22)
Sherwinter
2012 NIR ICG
Transanal CS
7
Sherwinter
2013 NIR ICG + ALT
Transanal CS
20
LDF = Laser Doppler FlowmetrySLDF = Scanning LDFNIR = Near InfraredICG = Indocyanine greenALT = Air leak test
Basic mechanical patency testing (leak testing) is beneficial & reduces postoperative anastomotic leak rates
A normal/negative intraoperative endoscopic visualisation test (intraoperative endoscopy) is associated with highly infrequent postoperative anastomotic complications
Greater use of intraoperative endoscopy to assess anastomosis, may prevent/reduce rates of anastomotic dehiscence.
Microperfusion assessment techniques are currently still experimental but hold potential for reducing anastomotic complications.
Academic Supervisors
◦ Mr Omar Faiz
◦ Professor Charles Vincent
Surgical Consultants and colleagues
S Nachiappan, A Askari, A Currie, RH Kennedy, O Faiz30th June 2014
Tripartite Colorectal Meeting, Birmingham, UK
The decision to divert is dependent on several factors
Patient age/ comorbidities/ ability to withstand the sequelae of a leak
Elective/emergency setting
Intraoperative parameters
Height of anastomosis
Possible adjuvant chemotherapy
In the review
◦ Basic:
CS = 5 out of 10 = 36 patients out of 150 patients
NRCT = 0 out of 1
RCT= 1 out of 2= 18 out of 143 patients
◦ IOC:
CS = Info not available in most
NRCT = Info not available in most
I was not able to ascertain total numbers of defunctioning ileostomies made prior to intraoperative test.
However what I noted was that patients who did have an ileostomy formed as a result of the◦ IOT/rectification,
Had no leak or
had a attenuated effect from any subsequent leaks.
The question I suppose would be whether we defunction anyone where we have concerns?
But there is the morbidity of an ileostomy we need to take note of as well.
So if we can target the specific patients who are at risk of a leak - and defunction them
And avoid defunctioning those at minimal risk, that would be ideal.
In this sense, intraoperative assessment of the anastomosis gives the surgeon◦ more information at that point itself
and ◦ allows an immediate rectification/action
to be taken at the same sitting/operation
The older studies routinely bowel prepped the patients, especially for the left sided resections
However, with the introduction of ERAS, this has reduced substantially.
For the purposes of this review. I did not look at bowel prep specifically
Of note studies: Cochrane review in 2011 noted no significant benefit of bowel prep.
Selective use in rectal surgery may be beneficial, but no significant effect was found.
KF Guenaga, D Matos
◦ Database Syst Rev, 2011
How was bleeding stopped?
◦ Endoluminally – APC
◦ Transabdominally with sutures
Li et al - Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc 2009
Routine IOE for patients undergoing elective laparoscopic colorectal surgerywith distal anastomosis can detect abnormalities at or around the anastomosis.
Although the RIOE group had fewer postoperative anastomotic complications, due to the small sample size, the 5.7-fold increase in anastomotic failure did not translate into significantly better postoperative outcomes than the SIOE group experienced.
A larger-scale single or multicenterprospective randomized study or a metaanalysis including similar studies is necessary for further investigation of this issue.
Important point
◦ Currently: it is mostly subjective and comparisons are made with a control eg the caecum
◦ The fluorescence for example can be measured and this is an area which has been exploited by laser fluouresence and ICG technology
◦ Some authors have suggested subjective scoring systems too