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BackgroundAnastomotic leakage (AL), a severe complication following colorectal surgery, arises from defects at the anastomosis site. This study evaluates the feasibility of predicting AL using machine learning (ML) algorithms based on preoperative data.MethodsWe retrospectively analyzed data including 21 predictors from patients undergoing colorectal surgery with bowel anastomosis at four Swiss hospitals. Several ML algorithms were applied for binary classification into AL or non-AL groups, utilizing a five-fold cross-validation strategy with a 90% training and 10% validation split. Additionally, a holdout test set from an external hospital was employed to assess the models' robustness in external validation.ResultsAmong 1244 patients, 112 (9.0%) suffered from AL. The Random Forest model showed an AUC-ROC of 0.78 (SD: ± 0.01) on the internal test set, which significantly decreased to 0.60 (SD: ± 0.05) on the external holdout test set comprising 198 patients, including 7 (3.5%) with AL. Conversely, the Logistic Regression model demonstrated more consistent AUC-ROC values of 0.69 (SD: ± 0.01) on the internal set and 0.61 (SD: ± 0.05) on the external set. Accuracy measures for Random Forest were 0.82 (SD: ± 0.04) internally and 0.87 (SD: ± 0.08) externally, while Logistic Regression achieved accuracies of 0.81 (SD: ± 0.10) and 0.88 (SD: ± 0.15). F1 Scores for Random Forest moved from 0.58 (SD: ± 0.03) internally to 0.51 (SD: ± 0.03) externally, with Logistic Regression maintaining more stable scores of 0.53 (SD: ± 0.04) and 0.51 (SD: ± 0.02).ConclusionIn this pilot study, we evaluated ML-based prediction models for AL post-colorectal surgery and identified ten patient-related risk factors associated with AL. Highlighting the need for multicenter data, external validation, and larger sample sizes, our findings emphasize the potential of ML in enhancing surgical outcomes and inform future development of a web-based application for broader clinical use.

Background Transanal tubes (TTs) have been used to prevent and reduce anastomotic leakage after rectal cancer surgery. The aim of this review was to investigate the efficacy and safety of the TT. Methods A systematic literature search was performed to identify randomized controlled trials and controlled clinical trials assessing the clinical efficacy and safety of TTs in rectal cancer surgery. Results Seven trials with 1609 participants were included. The TT group had a lower anastomotic leakage rate than the non-transanal tube group [RR 0.38; 95 % confidence interval (CI) 0.25–0.58; P  < 0.0001], as well as a lower reoperation rate (RR 0.31; 95 % CI 0.19–0.53; P  < 0.0001) and a shorter hospital stay (mean = −2.59 days; 95 % CI −3.69 to −1.49; P  < 0.0001). There were no significant differences in mortality between the two groups. Conclusion TT use in rectal cancer surgery is likely to be an effective and safe method of preventing and reducing anastomotic leakage and is associated with a decreased risk of reoperation and faster recovery.

Forty-three rats were randomly assigned to the following four groups: non-ischemic group (Control Group), 1 cm-long ischemic group (Group 1), 2 cm-long ischemic group (Group 2), and 3 cm-long ischemic group (Group 3). The rates of AL were 0% (0/10) in the Control Group, 22.2% (2/9) in Group 1, 25% (2/8) in Group 2, and 50% (4/8) in Group 3. The bursting pressure of the Control Group was significantly higher than that of the other groups (p < 0.01). Regarding the pathological findings, the granulation thickness and the number of blood vessels at the anastomosed site were significantly higher in the Control Group than in Group 3 (p < 0.05). Receiver operating characteristics analysis revealed that Slope was the most significant predictor of AL, with an area under the curve of 0.861. When the cutoff value of Slope was 0.4, the sensitivity and specificity for the prediction of AL were 75% and 81.4%, respectively. Quantitative analysis of ICG fluorescence angiography could predict AL in a rat model.

In order to prevent anastomotic leakage (AL) following rectal surgery, various solutions—such as intraoperative indocyanine green (ICG) angiography and transanal drainage tubes (TDT)—have been proposed. This study investigated the relationship between intestinal perfusion and fecal volume through TDT in laparoscopic low anterior resection (LAR). A total of 59 rectal cancer patients who underwent laparoscopic LAR with both intraoperative ICG angiography and postoperative TDT placement were retrospectively analyzed. The relationship between intestinal perfusion and fecal volume through TDT was examined. Based on the ICG fluorescence, the transection site was shifted more proximally in 20 cases (33.9%). Symptomatic AL occurred in seven patients (11.8%). The AL rate of the patients whose daily fecal volume exceeded 100 mL/day in 2 or more days was significantly higher than that of those whose daily fecal volume exceeded it in 0 or 1 day (44.4% vs. 6.0%; p < 0.01). Univariate and multivariate analyses showed that the need for a proximal shift of the transection site was significantly associated with a high fecal volume. The quantitative analysis of ICG fluorescence indicated that Fmax (the fluorescence difference between the baseline and maximum) was significantly associated with fecal volume through TDT.

Background Anastomotic leakage is still the major surgical complication following transthoracic esophagectomy with intrathoracic esophagogastrostomy (Ivor-Lewis procedure). Modifications of this standard procedure aim to reduce postoperative morbidity and mortality. Methods In this retrospective analysis of a 12-year period, 419 patients who had an Ivor-Lewis (IL) procedure for esophageal carcinoma were included. Due to modifications of the standard procedure, two different groups were compared with respect to their mortality and anastomotic leakage rate. In 181 patients (43.1%), esophagectomy and gastric reconstruction was performed as a one-stage procedure (classical IL group). Two hundred thirty-eight patients (56.9%) underwent a modified IL procedure that included minimally invasive gastric mobilization and a two-stage operation following ischemic conditioning of the gastric conduit. Results The hospital mortality rate was lower in the modified IL group without statistical significance (2.9 vs. 6.1%). Thirty-five anastomotic leaks were diagnosed postoperatively, 17 in the classical IL group (9.4%) and 18 in the modified IL group (7.6%). The rate of late leakages (after the 10th postoperative day) was higher in the modified IL group. Septic complications and mortality following anastomotic leakage were less frequent in the modified IL group. Leaks in the classical IL group predominantly required rethoracotomy, whereas leaks of the modified IL group were sufficiently treated with endoscopic stenting. Conclusions Surgical modifications of the classical IL procedure, including a minimally invasive approach and ischemic conditioning of the gastric conduit, seem to reduce postoperative morbidity and mortality. However, due to the retrospective design of this study, the impact of other factors influencing the outcome cannot be ruled out.

Background: Pelvic floor peritoneum reconstruction is a key step in various standard resections for open radical rectal cancer. However, during endoscopic surgery, most surgeons do not close the pelvic floor peritoneum. This study aims to evaluate the efficacy of pelvic peritonization during laparoscopic Dixon surgery using an observational study. Methods: A total of 189 patients, who underwent laparoscopic Dixon surgery at Tianjin Union Medical Center, China, were analyzed retrospectively. All of the cases were divided into two groups according to the differences of surgical procedure. The 92 patients in Group A (observation group) underwent pelvic peritonization and the 97 patients in Group B (control group) did not undergo this procedure. Postoperative complications were observed in the two groups, compared, and analyzed using the Chi-square or Fisher's exact test. Results: The incidence of anastomotic leakage was significantly lower in Group A than in Group B (P = 0.014). A significant difference was found in the postoperative short-term (P = 0.029) and long-term (P = 0.029) ileus rates between the two groups, with Group A exhibiting a lower rate than Group B. Patients in Group A had significantly lower rates of postoperative infections than those in Group B (χ2 = 7.606, P = 0.006; χ2 = 4.464, P = 0.035). Patients in Group A had significantly lower rates of deep venous thrombosis than those in Group B (χ2 = 8.531, P = 0.003). Conclusions: Pelvic peritonization effectively reduces postoperative complications, such as anastomotic leakage, which warrants its increased use in laparoscopic surgery.

Anastomotic leaks represent one of the most alarming complications following any gastrointestinal anastomosis due to the substantial effects on post-operative morbidity and mortality of the patient with long-lasting effects on the functional and oncologic outcomes. There is a lack of consensus related to the definition of an anastomotic leak, with a variety of options for prevention and management. A number of patient-related and technical risk factors have been found to be associated with the development of an anastomotic leak and have inspired the development of various preventative measures and technologies. The International Multispecialty Anastomotic Leak Global Improvement Exchange group was convened to establish a consensus on the definition of an anastomotic leak as well as to discuss the various diagnostic, preventative, and management measures currently available.

Purpose The aim of this study was to explore the choice of modality for diagnosis, treatments, and consequences of anastomotic leakage. Methods This is a retrospective study of consecutive patients who underwent surgery that included a colorectal anastomosis due to colorectal cancer, diverticulitis, inflammatory bowel disease (IBD), or benign polyps. Results A total of 600 patients were included during 2010–2012, and 60 (10%) had an anastomotic leakage. It took in mean 8.8 days (range 2–42) until the anastomotic leakage was diagnosed. A total of 44/60 of the patients with a leakage had a CT scan of the abdomen; 11 (25%) were initially negative for anastomotic leakage. Among all leakages, the anastomosis was taken down in 45 patients (76.3%). All patients with a grade B leakage ( n  = 6) were treated with antibiotics, and two also received transanal drainage. The overall complication rate was also significantly higher in those with leakage (93.3 vs. 28.5%, p  < 0.001), and it was more common with more than three complications (70 vs. 1.5%, p  < 0.001). There was a higher mortality in the leakage group. Conclusion This study demonstrated that one fourth of the CT scans that were executed were initially negative for leakage. Most patients with a grade C leakage will not have an intact anastomosis. An anastomotic leakage leads to significantly more severe postoperative complications, higher rate of reoperations, and higher mortality. An earlier relaparotomy instead of a CT scan and improved postoperative surveillance could possibly reduce the consequences of the anastomotic leakage.

Background The efficacy and safety outcomes of laparoscopy-assisted distal gastrectomy (LADG) with D2 lymph node dissection for locally advanced gastric cancer remain unclear. Therefore, we conducted a randomized, controlled phase II trial to confirm the feasibility of LADG in terms of technical safety, and short-term surgical outcomes were investigated. Methods Eligibility criteria included pre-operatively diagnosed advanced gastric cancer that could be treated by distal gastrectomy with D2 lymph node dissection; MP, SS, and SE without involvement of other organs; and N0–2 and M0. Patients aged 20–80 years were pre-operatively randomized. Results In total, 180 patients were registered and randomized to the open (89 patients) and laparoscopic arms (91 patients). Among 91 patients in the laparoscopic arm, 86 underwent laparoscopic gastrectomy according to the study protocol. Regarding the primary endpoint of the phase II trial, the proportion of patients with either anastomotic leakage or pancreatic fistula was 4.7 % (4/86). The grade 3 or higher morbidity rate, including systemic and local complications, was 5.8 %. Conversion to open surgery was required for 1 patient (1.2 %), without any intra-operative complication. The post-operative mortality rate was 0, and no patient required readmission for surgical complications within 6 months after initial discharge. Conclusions The technical safety of LADG with D2 lymph node dissection for locally advanced gastric cancer was demonstrated. A phase III trial to confirm the non-inferiority of this procedure to open gastrectomy in terms of long-term outcomes is ongoing. Registered Number: UMIN 000003420 ( www.umin.ac.jp/ctr/ ).

BackgroundAnastomosis-related complications such as bleeding, leakage, and strictures, continue to be serious complications of gastric cancer surgery. Presently, these complications have yet to be reliably prevented. Here we design a comprehensive leak testing procedure which combines gastroscopy, air, and methylene blue (GAM) leak testing. We aimed to evaluated the efficacy and safety of the GAM procedure in patients with gastric cancer.MethodsPatients aged 18–85 years without an unresectable factor as confirmed via CT were enrolled in a prospective randomized clinical trial at a tertiary referral teaching hospital and were randomly assigned to two groups: intraoperative leak testing group (IOLT) and no intraoperative leak testing group (NIOLT). The primary endpoint was the incidence of postoperative anastomosis-related complications in the two groups.Results148 patients were initially randomly assigned to the IOLT group (n = 74) and to the NIOLT group (n = 74) between September 2018 and September 2022. After exclusions, 70 remained in the IOLT group and 68 in the NIOLT group. In the IOLT group, 5 patients (7.1%) were found to have anastomotic defects intraoperatively, which included anastomotic discontinuity, bleeding, and strictures. The NIOLT group had a higher incidence of postoperative anastomotic leakage compared to the IOLT group: 4 patients (5.8%) vs 0 patients (0%), respectively. No GAM-related complications were observed.ConclusionThe GAM procedure is an intraoperative leak test that can be performed safely and efficiently after a laparoscopic total gastrectomy. GAM anastomotic leak testing may effectively prevent technical defect-related anastomotic complications in patients with gastric cancer who undergo a gastrectomy.Trial registration: Clinical Trials.gov Identifier: NCT04292496.