S Nachiappan, A Askari, A Currie, RH Kennedy, O Faiz. 30 th June 2014 Tripartite Colorectal Meeting, Birmingham, UK

S Nachiappan, A Askari, A Currie, RH Kennedy, O Faiz 30 th June 2014 Tripartite Colorectal Meeting, Birmingham, UK

local recurrence in rectal cancer Long-term cancer specific survival 16% died within 30 days Long-term cancer specific survival 4.5% of elective colorectal surgery underwent a reoperation within 28 days Reoperation often for postop bleeding & anastomotic leaks

To detect a possible anastomotic complication during the operation itself & allow remedial action To prevent a postoperative leak or complication To prevent a reoperation To minimise patient morbidity and mortality

Ensure Luminal Patency No Mechanical Disruption Anastomotic Integrity No Ischaemia No Bleeding

Surgical anastomosis Intraoperative period Anastomotic integrity Colo-colonic Anastomosis Colorectal anastomosis Rectal anastomosis Ileorectal anastomosis Intraoperative care Peroperative procedure Intraoperative Peroperative Integrity Leak Dehiscence Perfusion Ischaemia Bleeding *Latest search performed on 12 th June 2013

Inclusion Exclusion RCTs Animal studies Non-randomised comparative studies Case series Case reports/technical tips Unclear postoperative outcomes

Clinical Radiological Symptomatic Asymptomatic May have had radiological imaging subsequently Reoperation, Drainage or conservative Mx Radiological imaging planned/routine eg. GG Enema at 8 weeks/prior to reversal

37 studies Basic mechanical patency tests (Air/fluid leak) 13 Endoscopic visualisation techniques (intra-op colonoscopy + leak test) 10 Microperfusion techniques 14 10 Case series 1 Nonrandomised study 2 RCT 5 Case series 5 Nonrandomised studies 11 Case series 2 Nonrandomised studies 1 RCT

Basic Mechanical Patency Tests Case series (10) Intraoperative * With intraoperative rectifications 61 sutured only 20 sutured & defunctioned 4 redone 5 defunctioned only Postoperative Positive IOT* 90 13 POL 77 No POL (7CL, 6RL) n = 816 Negative IOT 726 47 POL 679 No POL (26CL, 21RL) Total Leak (CL+RL) rate Clinical Leak rate Positive IOT Negative IOT 13/90 47/726 14.4% 6.5% 7/90 26/726 7.7% 3.5% IOT: Intraoperative test POL: Postoperative leak CL: Clinical leak RL: Radiological leak

Basic Mechanical Patency Tests Nonrandomised study (1) n = 998 Intraoperative IOT group 825 Control group 173 Intraoperative Positive IOT* 65 Negative IOT 760 * With intraoperative rectifications 41 sutured 10 sutured & defunctioned 14 redone Postoperative 5 POL # # All sutured 29 POL 14 POL Total (Clinical) Leak rate Tested Non-tested/Control 34/825 14/173 4.1% 8.1% IOT: Intraoperative test POL: Postoperative leak

Basic Mechanical Patency Tests RCTs (2) n = 203 Intraoperative IOT group 103 Control group 100 Intraoperative Positive IOT* 25 Negative IOT 78 * With intraoperative rectifications 25 sutured Postoperative 5 POL (3CL, 2RL) 9 POL (3CL, 6RL) 27 POL (16CL, 11RL) Total Leak rate Clinical Leak rate Tested Non-tested/Control 14/103 27/100 13.6% 27.0% 6/103 16/100 5.8% 16% IOT: Intraoperative test POL: Postoperative leak CL: Clinical leak RL: Radiological leak

Endoscopic visualisation (Intraoperative colonoscopy) Intraoperative Case series (5) n = 713 With intraoperative rectifications 10 suturing only 14 haemostasis 20 redone 2 defunctioned only 11 unknown Postoperative Positive IOT* 57 12 POAC (6CL, 1staple line bleed, 1 pelvic collection, 4 ileus) 45 No POAC Negative IOT 656 7 POAC 649 No POAC (7CL) Positive IOT Negative IOT POAC rate Clinical leak rate 12/57 7/656 21.1% 1.1% 6/57 7/656 10.5% 1.1% IOT: Intraoperative test POAC: Postoperative anast complication CL: Clinical leak RL: Radiological leak

Endoscopic visualisation (Intraoperative colonoscopy) Nonrandomised studies (5) n = 950 IOT group Control group Intraoperative 509 441 With intraoperative rectifications 26 sutured 8 haemostasis 1 redone 5 sutured/haemostasis & defunctioned 30 defunctioned Positive IOT* 70 (56 air leaks, 14 staple line bleeds Negative IOT 439 7 POAC 32 POAC 26 POAC Postoperative (7 CLs) (28 CL) (17 CL) Tested Non-tested/Control POAC rate Clinical leak rate 39/509 26/441 7.7% 5.9% 35/509 17/441 6.9% 3.9% IOT: Intraoperative test POAC Postoperative anast complication

First Author Year Perfusion assessment technique Testing Access Study design N (Operative access) Ambrosetti 1994 Doppler USS Open CS 194 Hallbook 1996 LDF Open CS 30 Vignali 2000 LDF Open CS 55 Seike 2007 LDF Open CS 86 Boyle 2000 SLDF Open CS 10 Sheridan 1987 Tissue Oxygen Tension Open CS 50 Hall 1995 Tissue Oxygen Tension Open CS 62 Karliczek 2010 Visible Light O2 Spectroscopy Open CS 77 Hirano 2006 Near Infrared O2 Spectroscopy Open & lap CS 20 Parmeggiani 2012 IOC with Narrow Band Imaging Transanal RCT 47 (27 vs 20) Kudszus 2010 Laser Fluorescence ICG Open & lap Case-Control 402 (201vs 201) Jafari 2013 NIR ICG Robotics Case-Control 38 (16 vs 22) Sherwinter 2012 NIR ICG Transanal CS 7 Sherwinter 2013 NIR ICG + ALT Transanal CS 20 LDF = Laser Doppler Flowmetry SLDF = Scanning LDF NIR = Near Infrared ICG = Indocyanine green ALT = Air leak test

Basic mechanical patency testing (leak testing) is beneficial & reduces postoperative anastomotic leak rates A normal/negative intraoperative endoscopic visualisation test (intraoperative endoscopy) is associated with highly infrequent postoperative anastomotic complications Greater use of intraoperative endoscopy to assess anastomosis, may prevent/reduce rates of anastomotic dehiscence. Microperfusion assessment techniques are currently still experimental but hold potential for reducing anastomotic complications.

Academic Supervisors Mr Omar Faiz Professor Charles Vincent Surgical Consultants and colleagues

S Nachiappan, A Askari, A Currie, RH Kennedy, O Faiz 30 th June 2014 Tripartite Colorectal Meeting, Birmingham, UK

The decision to divert is dependent on several factors In the review Basic: CS = 5 out of 10 = 36 patients out of 150 patients Patient age/ comorbidities/ ability to withstand the sequelae of a leak NRCT = 0 out of 1 Elective/emergency setting RCT= 1 out of 2= 18 out of 143 patients Intraoperative parameters IOC: Height of anastomosis Possible adjuvant chemotherapy CS = Info not available in most NRCT = Info not available in most

I was not able to ascertain total numbers of defunctioning ileostomies made prior to intraoperative test. However what I noted was that patients who did have an ileostomy formed as a result of the IOT/rectification, Had no leak or had a attenuated effect from any subsequent leaks. The question I suppose would be whether we defunction anyone where we have concerns? But there is the morbidity of an ileostomy we need to take note of as well. So if we can target the specific patients who are at risk of a leak - and defunction them And avoid defunctioning those at minimal risk, that would be ideal. In this sense, intraoperative assessment of the anastomosis gives the surgeon more information at that point itself and allows an immediate rectification/action to be taken at the same sitting/operation

The older studies routinely bowel prepped the patients, especially for the left sided resections However, with the introduction of ERAS, this has reduced substantially. Of note studies: Cochrane review in 2011 noted no significant benefit of bowel prep. Selective use in rectal surgery may be beneficial, but no significant effect was found. For the purposes of this review. I did not look at bowel prep specifically KF Guenaga, D Matos Database Syst Rev, 2011

How was bleeding stopped? Endoluminally APC Transabdominally with sutures Li et al - Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc 2009 Routine IOE for patients undergoing elective laparoscopic colorectal surgery with distal anastomosis can detect abnormalities at or around the anastomosis. Although the RIOE group had fewer postoperative anastomotic complications, due to the small sample size, the 5.7-fold increase in anastomotic failure did not translate into significantly better postoperative outcomes than the SIOE group experienced. A larger-scale single or multicenter prospective randomized study or a metaanalysis including similar studies is necessary for further investigation of this issue.

Important point Currently: it is mostly subjective and comparisons are made with a control eg the caecum The fluorescence for example can be measured and this is an area which has been exploited by laser fluouresence and ICG technology Some authors have suggested subjective scoring systems too