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- Anastomotic Leak in Colorectal Cancer Surgery: From Diagnosis to Management or Failure - A Retrospective Cohort StudyPublication . Rama, Nuno; Parente, Diana; Silva, Cândida G.; Neves, Miguel; Figueiredo, Nuno; Alves, Paulo; Amado, Sandra; Lourenço, Óscar; Guarino, Maria Pedro; Rocha, Anabela; Castro-Poças, Fernando; Pimentel, JoãoAnastomotic leakage (AL) after colorectal resections is a common surgical experience and the most frequent major adverse outcome. Early recognition of AL is critical to reduce mortality. We aim to evaluate the incidence, diagnostic criteria, morbidity, and mortality related with AL.
- Intracorporeal versus extracorporeal anastomosis in laparoscopic right colectomy: short-term outcomesPublication . Gil, Inês Campos; Rama, Nuno; Parente, Diana; Sales, Inês; Alves, Paulo; Clara, Paulo; Amado, Sandra; Coelho, Miguel; Faria, VítorBackground: Recently, there has been a growing enthusiasm in developing new techniques of intracorporeal anastomosis following laparoscopic colectomy, which are more challenging than extracorporeal techniques. However, the evidence is still lacking regarding the outcomes’ comparison of both procedures. Methods: We designed a retrospective study comparing intracorporeal and extracorporeal anastomosis following laparoscopic right colectomy. A total of 115 consecutive patients operated for right colon disease were identified, from September 1st 2014 to May 31st 2017. Patient demographics included age, gender, ASA score, past abdominal surgery, anticoagulant and steroid therapy, Diabetes Mellitus and preoperative diagnosis. The analysed outcomes included length of stay, operative time, blood loss, extraction site, postoperative complications (ileus, anastomotic failure and surgical site infection), reoperation rate, readmission rate and 30-day mortality. Results: The extracorporeal group included 84 and the intracorporeal group 31 patients. The intracorporeal group had less surgical site infections (3,2% versus 27,4%, p<0,05). There were no statistically significant differences in operative time, blood loss, ileus, anastomotic failure or mortality. Conclusion: Our study reveals similar outcomes for both intra- and extracorporeal anastomosis following laparoscopic right colectomy. Therefore, intracorporeal anastomosis seems to be a feasible and safe technique in the hands of experienced laparoscopic colorectal surgeons.
- Usefulness of serum C-reactive protein and calprotectin for the early detection of colorectal anastomotic leakage: A prospective observational studyPublication . Rama, Nuno J G; Lages, Marlene C C; Guarino, Maria Pedro S; Lourenço, Óscar; Motta Lima, Patrícia C; Parente, Diana; Silva, Cândida S G; Castro, Ricardo; Bento, Ana; Rocha, Anabela; Castro-Pocas, Fernando; Pimentel, JoãoBACKGROUND: Colorectal anastomotic leakage (CAL) is one of the most dreaded complications after colorectal surgery, with an incidence that can be as high as 27%. This event is associated with increased morbidity and mortality; therefore, its early diagnosis is crucial to reduce clinical consequences and costs. Some biomarkers have been suggested as laboratory tools for the diagnosis of CAL. AIM: To assess the usefulness of plasma C-reactive protein (CRP) and calprotectin (CLP) as early predictors of CAL. METHODS: A prospective monocentric observational study was conducted including patients who underwent colorectal resection with anastomosis, from March 2017 to August 2019. Patients were divided into three groups: G1 – no complications; G2 – complications not related to CAL; and G3 – CAL. Five biomarkers were measured and analyzed in the first 5 postoperative days (PODs), namely white blood cell (WBC) count, eosinophil cell count (ECC), CRP, CLP, and procalcitonin (PCT). Clinical criteria, such as abdominal pain and clinical condition, were also assessed. The correlation between biomarkers and CAL was evaluated. Receiver operating characteristic (ROC) curve analysis was used to compare the accuracy of these biomarkers as predictors of CAL, and the area under the ROC curve (AUROC), specificity, sensitivity, positive predictive value, and negative predictive value (NPV) during this period were estimated. RESULTS: In total, 25 of 396 patients developed CAL (6.3%), and the mean time for this diagnosis was 9.0 ± 6.8 d. Some operative characteristics, such as surgical approach, blood loss, intraoperative complications, and duration of the procedure, were notably related to the development of CAL. The length of hospital stay was markedly higher in the group that developed CAL compared with the group with complications other than CAL and the group with no complications (median of 21 d vs 13 d and 7 d respectively; P < 0.001). For abdominal pain, the best predictive performance was on POD4 and POD5, with the largest AUROC of 0.84 on POD4. Worsening of the clinical condition was associated with the diagnosis of CAL, presenting a higher predictive effect on POD5, with an AUROC of 0.9. WBC and ECC showed better predictive effects on POD5 (AUROC = 0.62 and 0.7, respectively). Those markers also presented a high NPV (94%-98%). PCT had the best predictive effect on POD5 (AUROC = 0.61), although it presented low accuracy. However, this biomarker revealed a high NPV on POD3, POD4, and POD5 (96%, 95%, and 96%, respectively). The mean CRP value on POD5 was significantly higher in the group that developed CAL compared with the group without complications (195.5 ± 139.9 mg/L vs 59.5 ± 43.4 mg/L; P < 0.00001). On POD5, CRP had a NPV of 98%. The mean CLP value on POD3 was significantly higher in G3 compared with G1 (5.26 ± 3.58 μg/mL vs 11.52 ± 6.81 μg/mL; P < 0.00005). On POD3, the combination of CLP and CRP values showed a high diagnostic accuracy (AUROC = 0.82), providing a 5.2 d reduction in the time to CAL diagnosis. CONCLUSION: CRP and CLP are moderate predictors of CAL. However, the combination of these biomarkers presents an increased diagnostic accuracy, potentially decreasing the time to CAL diagnosis.
- The Usefulness of Inflammatory Biomarkers to Predict Anastomotic Leakage after Colorectal Surgery: Systematic Review and Meta-AnalysisPublication . Rama, Nuno; Lages, Marlene C. C.; G. Silva, Cândida; Motta Lima, Patrícia; Campos Gil, Inês; Guarino, Maria; Oliveira, P.; Dixe, Maria; A, Rocha; Castro-Poças, Fernando; Pimentel, JoãoAim: Anastomotic leakage (AL) is a severe postoperative complication in colorectal surgery, but its preclinical diagnosis may improve outcomes and increase anastomotic salvage. This study aimed to assess the added value of serum biomarkers for early detection of colorectal AL. Method: We performed a comprehensive literature review, and a qualitative and quantitative analysis of papers retrieved from MEDLINE, Embase, PubMed, Web of Science, Scopus and the Cochrane Library. We included all studies published before September 2021 assessing the serum biomarkers white blood cells (WBC), C-reactive protein (CRP), procalcitonin (PCT) and calprotectin (CLP) for the early diagnosis of AL. Results: Fifteen studies that evaluated three different systemic biomarkers in the context of AL were identified, including 5150 patients. Diagnostic test accuracy was estimated for CRP and PCT. On postoperative day (POD) 5, the highest AUC (87.1%) and specificity (80.2%) values were estimated for CRP. Random-effects meta-analysis and total effect sizes estimation for the biomarkers CRP, PCT and WBC were performed according to POD. The concentration of serum biomarkers is significantly higher in patients presenting AL. Regarding the qualitative analysis, there was significant heterogeneity in the inclusion of different subcategories of the consensus definition of colorectal AL in each paper’s definition. Conclusion: The serum biomarkers CRP and PCT are moderate predictors for AL, showing a high heterogeneity among the studies. Combinations of these biomarkers might improve predictive accuracy, but more studies will be necessary to conduct a quality metaregression.
- Pancreatic adenocarcinoma presenting as acute large bowel obstruction: case reportPublication . Gil, Inês Campos; Parente, Diana; Rama, Nuno; Lopes, Branco; Paulino, Virgínia; Amado, Cristina; Cunha, M. Fernanda; Sales, Inês; Faria, VítorIntroduction: Acute large bowel obstruction is a rare presentation of pancreatic cancer, with only six cases described in the revised literature. In all those cases, diagnosis was made either intraoperatively or post-mortem. Case presentation: A 63-year-old man presented in the emergency room with 4 days of bowel constipation associated with abominal pain and distention. Abdominal CT revealed a narrowing at the colonic splenic flexure and the colonoscopy revealed extrinsic compression at 40 cm from the anal verge. The patient was submitted to emergent exploratory laparotomy. We identified a mass involving the colonic splenic flexure, splenic hilum and the pancreatic tail. An en bloc subtotal colectomy, splenectomy and distal pancreatectomy was performed. Final pathology revealed a pancreatic ductal adenocarcinoma. The postoperative period was complicated with fecal peritonitis due to bowel perforation (day 3), hemoperitoneum secondary to pancreatic stump bleeding (day 10) and surgical site infection. The patient was discharged home on day 43. Conclusion: A high level of suspicion is necessary to take into account pancreatic carcinoma as a differential diagnosis of bowel acute obstruction.