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Intraoperative adverse events and outcome after anterior resection of the rectum
Linköpings universitet, Institutionen för biomedicin och kirurgi, Kirurgi. Linköpings universitet, Hälsouniversitetet.
Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Avdelningen för kirurgi. Östergötlands Läns Landsting, Kirurgi- och onkologicentrum, Kirurgiska kliniken i Östergötland med verksamhet i Linköping, Norrköping och Motala.
University Hospital Örebro, Örebro, Sweden.
Linköpings universitet, Hälsouniversitetet. Linköpings universitet, Institutionen för biomedicin och kirurgi, Avdelningen för kirurgi. Östergötlands Läns Landsting, Kirurgi- och onkologicentrum, Kirurgiska kliniken i Östergötland med verksamhet i Linköping, Norrköping och Motala.
2004 (engelsk)Inngår i: British Journal of Surgery, ISSN 0007-1323, E-ISSN 1365-2168, Vol. 91, nr 12, s. 1608-1612Artikkel i tidsskrift (Fagfellevurdert) Published
Abstract [en]

Background: The aim of this population-based study was to analyse the relationship between intraoperative adverse events and outcome after anterior resection.

Methods: All 140 patients who underwent elective anterior resection in Sweden between 1987 and 1995, and who died within 30 days, were compared with a group of 423 randomly selected patients who underwent the same procedure during the same interval but survived the operation. Intraoperative adverse events and intraoperative measures taken were analysed in relation to outcome of surgery.

Results: Of those who died, 45.7 per cent had intraoperative adverse events compared with 30.3 per cent in the cohort group. Major bleeding, gross spillage of faeces, and two or more intraoperative adverse events were more common among those who died. When the anastomosis was considered unsatisfactory, it was more frequently reconstructed (restapled or completely resutured), with or without a temporary stoma, in those who survived. The use of a temporary stoma was comparable in the two groups when adverse events were present.

Conclusion: Intraoperative adverse events were important contributors to morbidity and mortality. Complete reconstruction of an unsatisfactory anastomosis, with or without addition of a temporary stoma, was more frequently performed in the survivors, and may have diminished the risk of postoperative death.

sted, utgiver, år, opplag, sider
2004. Vol. 91, nr 12, s. 1608-1612
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Identifikatorer
URN: urn:nbn:se:liu:diva-28272DOI: 10.1002/bjs.4530Lokal ID: 13379OAI: oai:DiVA.org:liu-28272DiVA, id: diva2:249076
Tilgjengelig fra: 2009-10-09 Laget: 2009-10-09 Sist oppdatert: 2017-12-13bibliografisk kontrollert
Inngår i avhandling
1. Rectal cancer surgery: Defunctioning stoma, anastomotic leakage and postoperative monitoring
Åpne denne publikasjonen i ny fane eller vindu >>Rectal cancer surgery: Defunctioning stoma, anastomotic leakage and postoperative monitoring
2006 (engelsk)Doktoravhandling, med artikler (Annet vitenskapelig)
Abstract [en]

The understanding of the mesorectal spread in rectal cancer has lead to wide acceptance of total mesorectal excision (TME) as the surgical technique of choice for carcinoma in the lower and mid rectum. While oncological results and survival have improved with TME-surgery, morbidity and mortality remain important issues. The most feared complication is symptomatic anastomotic leakage. The aim of this thesis was to focus on the role of the defunctioning stoma, risk factors, and postoperative monitoring in regard to anastomotic leakage in sphincter saving resection of the rectum.

Intraoperative adverse events were analysed in a retrospective population based case-control study in which all patients who underwent elective anterior resection in Sweden between 1987 and 1995, and who died within 30 days or during the initial hospital stay (n=140), were compared with patients chosen at random (n=423) who underwent the same operation during the same period, but survived the operation. Intraoperative adverse events were more frequent in those who died, and reconstruction of an anastomosis judged unsatisfactory by the surgeon improved the outcome.

In a population based retrospective case-control study, risk factors for symptomatic anastomotic leakage were investigated in randomly chosen sample of patients who underwent anterior resection in Sweden between 1987 and 1995 (n=432). Twelve per cent of the patients developed symptomatic leakage, and 25% of the patients with leakage ended up with a permanent stoma. In multivariate regression analysis, low anastomosis, preoperative radiotherapy, male gender and intraoperative adverse events were independent riskfactors for anastomotic leakage.

In a randomised multicentre trial patients operated with sphincter saving TME¨surgery for rectal cancer were randomised to a defunctioning stoma (n=116) or not (n=118). The overall rate symptomatic leakage was 19%. Patienst without a defunctioning stoma leaked in 28% and patients with a defunctioing stoma in 10%, a statistically significant difference (p<0.001) not previously demonstrated in any randomised trial of adequate size.

Postoperative monitoring with computed tomography scan (CT-scan) on postoperative day 2 and 7, and C-reactive protein (CRP) daily in 33 patients operated on with anterior resection of the rectum, demonstrated larger pelvic fluid collections in patients with leakage before the leakage was clinically diagnosed. CRP was increased from postoperative day 2 and onwards in patients in whom clinical leakage was diagnosed on median postoperative day 8.

In 23 patients who underwent anterior resection of the rectum, intraperitoneal metabolism was investigated using microdialysis technique measuring the carbohydrate metabolites lactate, pyruvate and glucose. Intraperitoneal cytokines IL-6, IL-10 and TNF-α were collected through a pelvic drain and analysed. In patients who developed leakage, the latate/pyruvate ratio was increased near the anastomosis on postoperative day 5 and 6, as well as IL-6 and IL-10 which were increased postoperatively day 1 and 2, while TNF-α was higher on day 1.

sted, utgiver, år, opplag, sider
Linköping: Linköping University Electronci Press, 2006. s. 72
Serie
Linköping University Medical Dissertations, ISSN 0345-0082 ; 940
Emneord
Anterior resection of the rectum, total mesorectal excision, TME, anastomotic leakage, defunctioning stoma, risk factors, intraoperative adverse events, population based study, postoperative monitoring, CT-scan microdialysis, cytokines
HSV kategori
Identifikatorer
urn:nbn:se:liu:diva-7695 (URN)91-85497-80-0 (ISBN)
Disputas
2006-04-20, Wilandersalen, Universitetssjukhuset i Örebro, Örebro, 09:15 (engelsk)
Opponent
Veileder
Tilgjengelig fra: 2006-11-06 Laget: 2006-11-06 Sist oppdatert: 2009-12-03bibliografisk kontrollert

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