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Surgeon specialty may increase the risk of anastomotic leak after right-sided colorectal resections

Thu, 06/21/2018 - 16:38
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Having the surgery performed by a general surgeon vs colorectal surgeon was associated with an increased risk of leak (12.1% versus 7.3%)

A new analysis of a large, international audit undertaken by the European Society of Coloproctology (ESCP) in 2015, which examined the role of technical factors on the healing of the join in the bowel following operations on the right side of the colon, found that neither the choice of type of stapler (cutting or non-cutting), nor over-sewing of the staple line affected the rate of leakage. However, having the surgery performed by a general surgeon vs colorectal surgeon was associated with an increased risk of leak (12.1% versus 7.3%).

“Colorectal resections carry a high burden of morbidity, with post-operative complications common,” said one of the authors of the paper, Dr Sanjay Chaudhri of the European Society of Coloproctology (ESCP) Cohort Studies Committee and from the University of Birmingham, Birmingham, UK. “One significant complication is a leak from the join in the bowel.  This impacts not only on short term survival, functional outcomes and quality of life, but in cancer patients also increases the risk of recurrence.”

The research featured in the paper, ‘The impact of stapling technique and surgeon specialism on anastomotic failure after right‐sided colorectal resection: An international multi‐centre, prospective audit’, published in Colorectal Disease and co-authored by the 2015 European Society of Coloproctology collaborating group, was undertaken to determine the relationship between stapling technique and anastomotic failure.

The researchers invited any unit performing gastrointestinal surgery to contribute data on consecutive adult patients undergoing right hemicolectomy or ileocolic resection to this prospective, observational, international, multicentre study. Patients undergoing stapled, side‐to‐side ileocolic anastomoses were identified and multilevel, multivariable logistic regression analyses were performed to explore factors associated with anastomotic leak.

In total, 1,347 patients were included from 200 centres in 32 countries and the overall anastomotic leak rate was 8.3%. Upon multivariate analysis, there was no difference in leak rate with use of a cutting stapler for apical closure compared to non‐cutting stapler (8.4% versus 8.0%, OR:0.91, 95% CI:0.54‐1.53, p=0.72). In addition, oversewing of the apical staple line, whether in the cutting group (7.9% versus 9.7%, OR:0.87, 95% CI:0.52‐1.46, p=0.60), or non‐cutting group (8.9% versus 5.7%, OR:1.40, 95% CI:0.46‐4.23, p=0.55) was also found to confer no benefit in terms of reducing leak rates. However, surgeons reporting to be general surgeons had a significantly higher leak rate than those reporting to be colorectal surgeons (12.1% versus 7.3%, OR:1.65, 95% CI:1.04‐2.64, p=0.04).

The authors note that it is possible that the difference in the leak rates between general and colorectal surgeons may be explained by factors other than their surgical ability. For example, general surgeons more frequently performed emergency procedures and operations out of hours. Although the study took these factors into account when comparing the groups of surgeons, it is possible there were other factors not accounted for in the analysis, which may have biased the findings.

“Surgical technique is an attractive target for reducing anastomotic leak rates, as it is operator-dependent, and is readily adaptable to new evidence. However, there is little high-quality evidence to support surgeons’ choices of technique including the type of stapler used for the join. This study provided real time data from a large, prospective, multicentre, international study,” explained Dr Chaudhri. “The study highlights that anastomotic leak is a complex and multifactorial problem and that there exist multiple acceptable technical variations for stapled anastomosis in modern practice. The association between operator specialism and anastomotic failure may highlight a training need. The ESCP are working with stapler manufacturers to help provide enhanced training in the use of gastrointestinal staplers for the benefit of our patients across Europe.”

“The ESCP is grateful to the ESCP collaborating group and the ESCP Cohort sub-committee for demonstrating the ability of international collaborative research to improve the evidence base for the treatment of patients,” said Chair of the ESCP Research Committee, Professor Dion Morton. “Given the findings, the ESCP plans to implement an international quality improvement programme in stapling with the aim of reducing anastomotic failure.”