Risk factors of colorectal surgery: New multifaceted approaches

Pim Edomskis

Research output: Types of ThesisDoctoral ThesisInternal

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Abstract

In this thesis, the focus was on complications in gastrointestinal surgery, of which anastomotic leakage (AL), is the most important. In the world of gastrointestinal surgery, where precision and care are paramount, the quest to improve patient outcomes and reduce complications is an ongoing journey. The objective of this thesis is to better understand risk factors, to come across diagnostic challenges and multifaceted approaches to prevention and treatment

Part I: Risk factors and early detection of anastomotic leakage

In Chapter 2 a systematic review and meta-analysis was carried out to investigate whether arterial calcification is a risk factor for AL in esophageal surgery. Seven studies involving 1,860 patients were included in the analysis. The median anastomotic leakage rate was 17.2%. The meta-analysis found a statistically significant association between increased calcium score and anastomotic leakage for the thoracic aorta (OR 2.18), celiac axis (OR 1.62), and right post-celiac axis (OR 2.69). The study highlights the potential significance of arterial calcification as a risk factor for anastomotic leakage in esophageal surgery, with implications for patient risk assessment and possible preventive measures.
In Chapter 3 examined whether arterial calcification is a risk factor for developing AL in colorectal surgery. An individual patient data meta-analysis was performed for the most frequently used calcification scoring methods. Three other scoring methods were evaluated, and in four out of five studies, vascular calcification was associated with AL after colorectal surgery. However in this current study no significant association was found between AL and the amount of calcification in the aorta-iliac trajectory.

In Chapter 4 a case study that applied a user-centered design (UCD) approach in the early development of a medical device for detecting colorectal anastomotic leakage was presented. Over 12 months, collaboration between healthcare professionals and industrial partners resulted in well-defined functional specifications, ensuring a user-friendly, cost-effective design. The study provides valuable insights and best practices for future innovative medical device development.

Part II: Immunological markers for detection of colorectal anastomotic leakage

In Chapter 5 a systematic review that investigates the possible correlation between anastomotic leakage (AL) after colorectal surgery and the activity of matrix metalloproteinase-9 (MMP-9), an enzyme responsible for collagen and protein degradation in the extracellular matrix. Human studies showed mixed results, with five out of seven studies reporting elevated MMP-9 levels in patients with AL. Animal studies indicated that MMP-9 activity was highest near the anastomosis and decreased further away from it. While there is some evidence suggesting a connection between MMP-9 activity and colorectal AL, the findings are inconsistent.
In Chapter 6 a prospective study evaluated the role of different monocyte subsets, the association of patient and surgical characteristics with leukocyte responses. A total of 50 patients undergoing colorectal tumor resection with primary anastomosis was included. The study provides detailed insights into the immune response following colorectal cancer surgery. It highlights rapid changes in immune cell distribution and suggests a mixed profile of cellular activation and deactivation in monocytes as a response to surgery.
In Chapter 7 the same cohort was used and aimed to identify predictive parameters in monocytes associated with short-term complications following colorectal surgery, with a particular focus on anastomotic leakage (AL). Patients who developed AL had higher preoperative classical monocyte (CM) counts compared to those with uncomplicated surgeries. Patients who experienced prolonged hospital stays(LS) had higher preoperative HLA-DR expression on intermediate monocytes (IM). The expression of CD62L by classical monocytes (CM) continued to increase postoperatively until day 3 (POD3) in AL patients, while it declined in uncomplicated (UC) and LS patients. This study provides valuable insights into potential biomarkers for the early detection of complications after colorectal surgery, with a focus on anastomotic leakage.

Part III: Treatment of complicated diverticulitis

In Chapter 8 the results of a study comparing laparoscopic lavage and sigmoidectomy as treatments for perforated diverticulitis with purulent peritonitis over a 36-month follow-up period is presented. Patients with purulent peritonitis due to perforated diverticulitis were randomly assigned to either laparoscopic lavage or sigmoidectomy. Long-term follow-up data were available for 77 of the 88 originally included patients. After 36 months, there was no significant difference in cumulative morbidity or mortality between the two groups. However, the lavage group had significantly fewer reoperations than the sigmoidectomy group. The percentage of patients alive with a stoma was lower in the lavage group compared to the sigmoidectomy group.
In Chapter 9 a three-year follow-up of a randomised controlled trial comparing two surgical procedures for the treatment of perforated diverticulitis with peritonitis: Hartmann's Procedure (HP) and sigmoidectomy with primary anastomosis (PA) is outlined. A total of 119 patients (57 in the PA group and 62 in the HP group) completed the three-year follow-up. The 36-month stoma-free rate was significantly better for patients who underwent PA compared to HP (92% vs. 81%). Overall morbidity and mortality did not differ between the groups. However, more parastomal hernias occurred in the HP group, and the mean total in-hospital days after three years of follow-up was lower in the PA group.
In Chapter 10 a systematic review and meta-analysis of studies comparing the Hartmann’s procedure to sigmoidectomy with primary anastomosis for patients with purulent or fecal peritonitis was presented. A total of ten observational and four randomised studies were included. No difference in mortality and morbidity after the index procedure was found between both procedures. Secondly, PA patients were more likely to have their stoma reversed and to be stoma free during follow-up, as compared to HP patients. In addition, the occurrence of reversal-related morbidity was less likely in the PA group. This study concludes that there are several arguments supporting the preference for PA over HP in the treatment of perforated diverticulitis with purulent or fecal peritonitis, particularly in hemodynamically stable and immunocompetent patients.

Original languageEnglish
Awarding Institution
  • Erasmus University Rotterdam
Supervisors/Advisors
  • Lange, Johan, Supervisor
  • Kleinrensink, Gert-jan, Supervisor
  • Leenen, Pieter, Co-supervisor
Award date1 Oct 2024
Place of PublicationRotterdam
Print ISBNs978-94-93391-29-1
Publication statusPublished - 1 Oct 2024

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