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1
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Ali D, Syed M, Gamboa AC, Hawkins AT, Regenbogen SE, Holder-Murray J, Silviera M, Ejaz A, Balch GC, Khan A. Association of omental pedicled flap with anastomotic leak following low anterior resection for rectal cancer. J Surg Oncol 2024; 129:930-938. [PMID: 38167808 DOI: 10.1002/jso.27572] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND AND OBJECTIVES Anastomotic leak following colorectal anastomosis adversely impacts short-term, oncologic, and quality-of-life outcomes. This study aimed to assess the impact of omental pedicled flap (OPF) on anastomotic leak among patients undergoing low anastomotic resection (LAR) for rectal cancer using a multi-institutional database. METHODS Adult rectal cancer patients in the US Rectal Cancer Consortium, who underwent a LAR for stage I-III rectal cancer with or without an OPF were included. Patients with missing data for surgery type and OPF use were excluded from the analysis. The primary outcome was the development of anastomotic leaks. Multivariable logistic regression was used to determine the association. RESULTS A total of 853 patients met the inclusion criteria and OPF was used in 106 (12.4%) patients. There was no difference in age, sex, or tumor stage of patients who underwent OPF versus those who did not. OPF use was not associated with an anastomotic leak (p = 0.82), or operative blood loss (p = 0.54) but was associated with an increase in the operative duration [β = 21.42 (95% confidence interval = 1.16, 41.67) p = 0.04]. CONCLUSIONS Among patients undergoing LAR for rectal cancer, OPF use was associated with an increase in operative duration without any impact on the rate of anastomotic leak.
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Affiliation(s)
- Danish Ali
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | - Maria Syed
- Department of Surgery, Aga Khan University Hospital, Karachi, Pakistan
| | | | - Alexander T Hawkins
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | | | - Jennifer Holder-Murray
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Matthew Silviera
- Department of Surgery, Washington University School of Medicine, St. Louis, Missouri, USA
| | - Aslam Ejaz
- Department of Surgery, The Ohio State University Wexner Medical Center and James Comprehensive Cancer Center, Columbus, Ohio, USA
| | - Glen C Balch
- Department of Surgery, Emory University, Atlanta, Georgia, USA
| | - Aimal Khan
- Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee, USA
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2
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Gené-Škrabec C, Cremades M, Fernández-Pujol A, Cortinovis S, Corral J, Julián JF, Parés D. Clinical results after external reinforcement of colorectal anastomosis: a systematic review. Int J Surg 2023; 109:4322-4332. [PMID: 37707516 PMCID: PMC10720808 DOI: 10.1097/js9.0000000000000747] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Accepted: 08/25/2023] [Indexed: 09/15/2023]
Abstract
OBJECTIVE The aim of this review is to describe and assess the existing methods to cover colorectal anastomoses with biomaterials and their clinical impact in reducing anastomotic leakage (AL). SUMMARY BACKGROUND DATA The most serious complication in colorectal surgery is AL. Despite improvements in its diagnosis and management, AL remains an unresolved issue. To prevent its appearance and clinical consequences, different external reinforcement techniques with synthetic or biomaterials have been described. METHODS A systematic review search of the available literature until June 2022 was performed, looking for all literature regarding external reinforcement of colonic or colorectal anastomoses. After the review process, a classification of materials was proposed into solid and liquid materials, and an assessment of their clinical impact was performed. The study protocol has been registered at PROSPERO and has been reported in the line with PRISMA and AMSTAR Guidelines 11,12 . RESULTS Ninety-seven articles that fulfilled inclusion criteria, were identified and revised. Overall, 18 of the selected articles focused on human clinical trials and 79 on animal models. Only fibrin sealants, collagen patches, and omentoplasty have shown positive results in humans. CONCLUSIONS Fibrin sealants, collagen patches, and omentoplasty are, so far, the most studied biomaterials. However, further studies are required to confirm these findings before definite recommendations can be made.
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Affiliation(s)
- Clara Gené-Škrabec
- Department of General Surgery, Hospital Universitari Germans Trias i Pujol, School of Medicine, Universitat Autònoma de Barcelona, Institut de Recerca Germans Trias i Pujol – IGTP, Barcelona, Spain
| | - Manel Cremades
- Department of General Surgery, Hospital Universitari Germans Trias i Pujol, School of Medicine, Universitat Autònoma de Barcelona, Institut de Recerca Germans Trias i Pujol – IGTP, Barcelona, Spain
| | | | - Sara Cortinovis
- Department of General Surgery, ASUGI Cattinara, Università degli studi di Trieste, Trieste, Italy
| | - Javier Corral
- Department of General Surgery, Hospital Universitari Germans Trias i Pujol, School of Medicine, Universitat Autònoma de Barcelona, Institut de Recerca Germans Trias i Pujol – IGTP, Barcelona, Spain
| | - Joan-F Julián
- Department of General Surgery, Hospital Universitari Germans Trias i Pujol, School of Medicine, Universitat Autònoma de Barcelona, Institut de Recerca Germans Trias i Pujol – IGTP, Barcelona, Spain
| | - David Parés
- Department of General Surgery, Hospital Universitari Germans Trias i Pujol, School of Medicine, Universitat Autònoma de Barcelona, Institut de Recerca Germans Trias i Pujol – IGTP, Barcelona, Spain
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3
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Sahebally SM, Chan E, Azmir A, Lu CT, Doudle M, Naik A, Nolan G, Von Papen M. Omentoplasty to reduce anastomotic leak in colorectal surgery: a meta-analysis. ANZ J Surg 2022; 92:1651-1657. [PMID: 35170188 DOI: 10.1111/ans.17553] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/01/2022] [Accepted: 02/06/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Anastomotic leaks (AL) remain a devastating complication following intestinal anastomoses resulting in increased morbidity and mortality. Wrapping the anastomosis with omentum may be protective although data are conflicting. We performed a meta-analysis to assess the effect of omentoplasty on colorectal anastomoses. METHODS PubMed, EMBASE and Cochrane databases were searched for relevant articles from inception until August 2021. All randomized controlled trials (RCT) that reported on the use of omentoplasty in colon and rectal surgery were included. The primary outcome was rate of overall AL while secondary outcomes included clinical and radiological AL, overall reoperation and mortality. Random effects models were used to calculate pooled effect size estimates. Sensitivity analyses were also performed. RESULTS Four RCTs were included capturing 1067 patients. The mean (SD) age of the cohort was 61.5 (±14.8) years. On random effects analysis, omentoplasty reduced rate of overall (OR 0.43, 95% CI = 0.21-0.87, p = 0.02) and clinical AL (OR = 0.35, 95% CI = 0.15-0.81, p = 0.01). However, there was no difference in radiological AL (OR = 0.77, 95% CI = 0.40-1.47, p = 0.42), overall reoperations (OR 0.48, 95% CI = 0.18-1.32, p = 0.16) or mortality (OR 0.52, 95% CI = 0.12 to-2.18, p = 0.37). On sensitivity analysis, assessing rectal anastomoses only, the results for overall AL remained similar (OR 0.28, 95% CI = 0.12-0.61, p = 0.002). CONCLUSION Although omentoplasty appears to reduce the rate of overall and clinical AL, the heterogeneity in the data prevents definitive recommendations from being made. Further well-designed trials are needed to investigate this technique.
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Affiliation(s)
| | - Erick Chan
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Alisha Azmir
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Cu Tai Lu
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Mark Doudle
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Arun Naik
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Gregory Nolan
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
| | - Michael Von Papen
- Department of Colorectal Surgery, Gold Coast University Hospital, Gold Coast, Queensland, Australia
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4
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Spagnolo E, Marí-Alexandre J, Di Saverio S, Gilabert-Estellés J, Agababyan C, Garcia-Casarrubios P, López A, González-Cantó E, Pascual I, Hernández A. Feasibility and safety of transvaginal specimen extraction in deep endometriosis colorectal resectional surgery and analysis of risk factors for postoperative complications. Tech Coloproctol 2022; 26:261-270. [PMID: 35091790 DOI: 10.1007/s10151-021-02565-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 12/06/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND The aim of the present study was to demonstrate that transvaginal specimen extraction is a feasible and safe approach in colorectal resection for deep endometriosis (DE) and to assess the risk factors for postoperative complications. METHODS This retrospective cohort study included all the consecutive patients undergoing segmental bowel resection for symptomatic endometriosis at "La Paz" University Hospital (Madrid, Spain) and at "Hospital General Universitario de Valencia" (Valencia, Spain) from January 2014 to December to 2017. Patients were grouped according to specimen extraction approach into those who had transvaginal extraction (Group I) and those who had suprapubic extraction (Group II). Clinic-demographical, surgical and post-surgical data were recorded. Intra- and postoperative complications were classified according to Clavien-Dindo criteria. Postoperative data were compared between groups. Risk factors associated with surgery were investigated. RESULTS Out of 99 female patients included (average age 36.91 ± 5.36 years), 23 patients (23.2%) had transvaginal and 76 (76.8%) had suprapubic specimen extraction. The groups were comparable regarding operative time, nodule size, level of anastomosis, hospital stay and intraoperative complications. We observed no statistically significant differences in postoperative complications and rectovaginal fistula rate between the groups. Binary logistic regression analyses determined that vaginal endometriosis is an independent risk factor for postoperative complications (OR: 2.63, 95% CI [1.10-6.48], p = 0.03). CONCLUSIONS Transvaginal specimen extraction is a safe and feasible technique in DE colorectal surgery and should be taken into consideration whenever vaginal endometriosis exists. Nevertheless, vaginal endometriosis can be an independent risk factor for postoperative complications in DE surgery.
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Affiliation(s)
- E Spagnolo
- Department of Obstetrics and Gynecology, "La Paz" University Hospital, Madrid, Spain
| | - J Marí-Alexandre
- Research Laboratory in Biomarkers in Reproduction, Gynecology and Obstetrics, Fundación Hospital General Universitario de Valencia, Valencia, Spain
| | - S Di Saverio
- General Surgery One, University of Insubria, University Hospital of Varese, Viale Luigi Borri, 57, 21100, Varese, VA, Italy.
| | - J Gilabert-Estellés
- Research Laboratory in Biomarkers in Reproduction, Gynecology and Obstetrics, Fundación Hospital General Universitario de Valencia, Valencia, Spain.,Comprehensive Multidisciplinary Endometriosis Unit, Consorcio Hospital General Universitario de Valencia, Valencia, Spain.,Department of Paediatrics, Obstetrics and Gynaecology, University of Valencia, Valencia, Spain
| | - C Agababyan
- Research Laboratory in Biomarkers in Reproduction, Gynecology and Obstetrics, Fundación Hospital General Universitario de Valencia, Valencia, Spain.,Comprehensive Multidisciplinary Endometriosis Unit, Consorcio Hospital General Universitario de Valencia, Valencia, Spain
| | - P Garcia-Casarrubios
- Department of Obstetrics and Gynecology, "La Paz" University Hospital, Madrid, Spain
| | - A López
- Department of Obstetrics and Gynecology, "La Paz" University Hospital, Madrid, Spain
| | - E González-Cantó
- Research Laboratory in Biomarkers in Reproduction, Gynecology and Obstetrics, Fundación Hospital General Universitario de Valencia, Valencia, Spain
| | - I Pascual
- Department of General Surgery, "La Paz" University Hospital, Madrid, Spain
| | - A Hernández
- Department of Obstetrics and Gynecology, "La Paz" University Hospital, Madrid, Spain.,Department of Obstetrics and Gynaecology, Universidad Autónoma de Madrid, Madrid, Spain
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5
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Abstract
Leaks from anastomoses can be a serious complication of any gastrointestinal resection. Leaks lead to increased morbidity, delayed postoperative recovery, and potential delays in adjuvant treatment in cancer cases. Prevention of anastomotic leak has been an area of ongoing research for decades. Methods of assessing bowel perfusion have been developed that may provide forewarning of anastomotic compromise. Physical reinforcement of the anastomosis with buttressing material is an available method employed with the goal of preventing leaks. Liquid-based sealants have also been explored. Lastly, interactions between the gut microbiome and anastomotic healing have been investigated as a mean of manipulating the microenvironment to reduce leak rates. Though no single technology has been successful in eliminating leaks, an understanding of these developing fields will be important for all surgeons who operate on the gastrointestinal tract.
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Affiliation(s)
- Abhineet Uppal
- Division of Colorectal Surgery, Department of Surgery, University of California at Irvine Medical Center, Orange, California
| | - Alessio Pigazzi
- Division of Colorectal Surgery, Department of Surgery, University of California at Irvine Medical Center, Orange, California
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6
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Wallace B, Schuepbach F, Gaukel S, Marwan AI, Staerkle RF, Vuille-dit-Bille RN. Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery. Gastroenterol Res Pract 2020; 2020:9057963. [PMID: 32411206 PMCID: PMC7199605 DOI: 10.1155/2020/9057963] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 12/04/2019] [Indexed: 02/08/2023] Open
Abstract
Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.
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Affiliation(s)
- Bradley Wallace
- Department of Pediatric Surgery, Children's Hospital Colorado, USA
| | | | - Stefan Gaukel
- Department of Orthopaedics and Traumatology, Cantonal Hospital Winterthur, Switzerland
| | - Ahmed I. Marwan
- Department of Pediatric Surgery, Children's Hospital Colorado, USA
| | - Ralph F. Staerkle
- Clarunis, Department of Visceral Surgery, University Centre for Gastrointestinal and Liver Diseases, St. Clara Hospital and University Hospital Basel, Switzerland
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7
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Prevesical peritoneum interposition to prevent risk of rectovaginal fistula after en bloc colorectal resection with hysterectomy for endometriosis: Results of a pilot study. J Gynecol Obstet Hum Reprod 2019; 49:101649. [PMID: 31760180 DOI: 10.1016/j.jogoh.2019.101649] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2019] [Revised: 10/10/2019] [Accepted: 10/18/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To evaluate the risk of rectovaginal fistula after en bloc hysterectomy and colorectal resection (H-CR) for endometriosis using prevesical peritoneum interposition. STUDY DESIGN A retrospective study conducted at Tenon University Hospital, expert center in endometriosis, from June 2016 to June 2018. Patients undergoing H-CR with prevesical peritoneum interposition without protective defunctioning stoma were included. RESULTS Of the 160 patients who underwent surgery with colorectal resection for endometriosis during the study period, 27 had H-CR (15 with segmental and 12 with discoïd colorectal resection) and were included. The median age (range) was 45 years (41-47.5). Eight patients (13 %) were nulliparous. All procedures were performed by laparoscopy. Parametrial resection was performed in 14 cases (52 %). Associated bowel procedures were ileocecal resection (n = 5) and appendectomy (n = 2). Median follow-up (range) was 14.6 months (10.5-20.2). Nine (33.3 %) patients experienced intra- or postoperative complications including one grade I, four grade II, two grade IIIA and two grade IIIB complications (Clavien-Dindo classification). Seven patients (26 %) experienced postoperative voiding dysfunction. One suspicion of rectovaginal fistula associated with pelvic abscess was diagnosed 4 weeks after surgery but not confirmed during a second operation. CONCLUSION Despite the small sample size, the present pilot study supports the practice of prevesical peritoneum interposition to limit the risk of rectovaginal fistula in patients who undergo H-CR for deep endometriosis.
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8
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Shalaby M, Thabet W, Morshed M, Farid M, Sileri P. Preventive strategies for anastomotic leakage after colorectal resections: A review. World J Meta-Anal 2019; 7:389-398. [DOI: 10.13105/wjma.v7.i8.389] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2019] [Revised: 08/31/2019] [Accepted: 09/03/2019] [Indexed: 02/06/2023] Open
Abstract
Anastomosis is a crucial step in radical cancer surgery. Despite being a daily practice in gastrointestinal surgery, anastomotic leakage (AL) stands as a frequent postoperative complication. Because of increased morbidity, mortality, combined with longer hospital stay, the rate of re-intervention, and poor oncological outcomes, AL is considered the most feared and life-threatening complication after colorectal resections. Furthermore, poor functional outcomes with a higher rate of a permeant stoma in 56% of patients this could negatively affect the patient’s quality of life. This a narrative review which will cover intraoperative anastomotic integrity assessment and preventive measures in order to reduce AL. Although the most important prerequisites for the creation of anastomosis is well-perfused and tension-free anastomosis, surgeons have proposed several preventive measures, which were assumed to reduce the incidence of AL, including antibiotic prophylaxis, intraoperative air leak test, omental pedicle flap, defunctioning stoma, pelvic drain insertion, stapled anastomosis, and general surgical technique. However, lack of clear evidence of which preventive measures is superior over the other combined with the fact that the decision remains based on the surgeon’s choice. Despite the advances in surgical techniques, AL remains a serious health problem associated with increased morbidity, mortality with additional cost. Many preventative measures were employed with no clear evidence supporting the superiority of stapled anastomosis over hand-Sewn anastomosis, coating of the anastomosis, or pelvic drain. Defunctioning stoma, when justified it could decrease the leakage-related complications and the incidence of reoperation. MBP combined with oral antibiotics still recommended.
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Affiliation(s)
- Mostafa Shalaby
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
- Department of General Surgery UOC C, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome 00133, Italy
| | - Waleed Thabet
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
| | - Mosaad Morshed
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
| | - Mohamed Farid
- Department of General Surgery, Mansoura University Hospitals, Mansoura University, Dakahliya, Mansoura 35516, Egypt
| | - Pierpaolo Sileri
- Department of General Surgery UOC C, Policlinico Tor Vergata Hospital, University of Rome Tor Vergata, Rome 00133, Italy
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9
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Impact of omentoplasty on anastomotic leak and septic complications after low pelvic anastomosis: a study from the NSQIP database. Int J Colorectal Dis 2018; 33:1733-1739. [PMID: 30171353 DOI: 10.1007/s00384-018-3151-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/20/2018] [Indexed: 02/04/2023]
Abstract
PURPOSE The role of omentoplasty in the prevention of anastomotic leak (AL) in colorectal surgery is controversial. The aim of this study was to evaluate the impact of omentoplasty on AL and septic complications after low pelvic anastomosis using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database. METHODS The ACS-NSQIP database was queried for patients who underwent segmental colectomy with low pelvic anastomosis by using 2012 targeted colectomy participant use data file. Patients were divided into two groups according to omentoplasty versus no-omentoplasty formation. AL and surgical site infections (SSIs) within postoperative 30 days were compared between the groups. RESULTS A total of 2891 patients (1447 [50.1%] males) with a mean age of 60.2 ± 13.0 years met the inclusion criteria. There were 86 (2.9%) and 2805 (97.1%) patients in the omentoplasty and no-omentoplasty group, respectively. In the multivariate analysis, omentoplasty neither reduced AL (p = 0.83; OR = 0.88, 95% CI, 0.21-2.44) nor organ/space SSIs (p = 0.08; OR = 2.14, 95% CI, 0.91-4.41). Also, this technique did not play any role in reducing AL and organ/space SSI rates regardless of diversion with the exception of its association with higher organ/space SSIs in patients without diverting stoma (9.2% vs 3.8%, p = 0.04). No differences were detected between the groups with respect to the management strategies for AL (p = 0.22). CONCLUSIONS Omentoplasty did not decrease AL and septic complications after low pelvic anastomosis and had no impact on the postoperative management of AL.
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10
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Loriau J, Petit E, Mephon A, Angliviel B, Sauvanet E. [Evidence-based ways of colorectal anastomotic complications prevention in the setting of digestive deep endometriosis resection: CNGOF-HAS Endometriosis Guidelines]. ACTA ACUST UNITED AC 2018. [PMID: 29525185 DOI: 10.1016/j.gofs.2018.02.007] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Management of deep pelvic and digestive endometriosis can lead to colorectal resection and anastomosis. Colorectal anastomosis carries risks for dreaded infectious and functional morbidity. The aim of the study was to establish, regarding the published data, the role of the three most common used surgical techniques to prevent such complications: pelvic drainage, diverting stoma, epiplooplasty. Even if many studies and articles have focused on colorectal anastomotic leakage prevention in rectal cancer surgery data regarding this topic in the setting of endometriosis where lacking. Due to major differences between the two situations, patients, diseases the use of the conclusions from the literature have to be taken with caution. In 4 randomized controlled trials the usefulness of systematic postoperative pelvic drainage hasn't been demonstrated. As this practice is not systematically recommended in cancer surgery, its interest is not demonstrated after colorectal resection for endometriosis. There is a heavy existing literature supporting systematic diverting stoma creation after low colorectal anastomosis for rectal cancer. Keeping in mind the important differences between the two situations, the conclusions cannot be directly extrapolated. In endometriosis surgery after low rectal resection, stoma creation must be discussed and the patient must be informed and educated about this possibility. Even if widely used there is no data supporting the role of epiplooplasty in colorectal anastomotic complication prevention? The place for epiplooplasty in preventing rectovaginal fistula occurrence in case of concomitant resection hasn't been studied.
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Affiliation(s)
- J Loriau
- Service de chirurgie digestive, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France.
| | - E Petit
- Service d'imagerie, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
| | - A Mephon
- Service de gynécologie, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
| | - B Angliviel
- Service de chirurgie digestive, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
| | - E Sauvanet
- Service de gynécologie, GH Paris Saint-Joseph, 185, rue Raymond-Losserand, 75001 Paris, France
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11
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Ledu N, Rubod C, Piessen G, Roman H, Collinet P. Management of deep infiltrating endometriosis of the rectum: Is a systematic temporary stoma relevant? J Gynecol Obstet Hum Reprod 2017; 47:1-7. [PMID: 29097291 DOI: 10.1016/j.jogoh.2017.10.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2017] [Revised: 10/18/2017] [Accepted: 10/24/2017] [Indexed: 12/15/2022]
Abstract
STUDY OBJECTIVE To assess the value of performing a protective stoma in patients operated for rectal endometriosis. MATERIAL AND METHODS From June 2009 to December 2011, 47 patients were operated for rectal endometriosis by segmental or discoid resection in 4 different centers. Two groups were formed: one with protective stoma (group S), n=33 and one without protective stoma (group NS), n=14. Data were collected from the CIRENDO database. MEASUREMENTS AND MAIN RESULTS Postoperative complication rate of group NS was 57% against 48% in group S (P=0.75). There was an increasing trend of the rate of anastomotic leakage in group S as compared to group NS: 21% against 3% (P=0.073). All 3 patients of group NS with an anastomotic leakage were reoperated and the group S patient had medical treatment. In a center, digestive operative time was not necessarily performed in association with a gastrointestinal surgeon. All patients in group S had a restoration of continuity in about 3 months. Two of them had dilation of anastomotic stricture and 3 others showed a transient postoperative ileus during this recovery. Quality of life was assessed by the MOS SF-36 and significantly improved in both groups thanks to the intervention. CONCLUSION Temporary digestive stoma in patients operated for rectal endometriosis has to be considered because in our study, it seems reducing complications such as anastomotic leakage. This must be confirmed with studies with larger numbers.
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Affiliation(s)
- N Ledu
- Clinique de gynécologie, hôpital Jeanne-de-Flandre, université Lille-Nord-de-France, 1, rue Eugène-Avinée, 59037 Lille cedex, France.
| | - C Rubod
- Clinique de gynécologie, hôpital Jeanne-de-Flandre, université Lille-Nord-de-France, 1, rue Eugène-Avinée, 59037 Lille cedex, France
| | - G Piessen
- Service de chirurgie digestive et générale du Pr Mariette, hôpital Huriez, CHRU Lille, place de Verdun, 59037 Lille, France
| | - H Roman
- Clinique gynécologique et obstétricale, centre hospitalier universitaire Charles-Nicolle, 76031 Rouen, France
| | - P Collinet
- Clinique de gynécologie, hôpital Jeanne-de-Flandre, université Lille-Nord-de-France, 1, rue Eugène-Avinée, 59037 Lille cedex, France
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12
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Nasiri S, Mirminachi B, Taherimehr R, Shadbakhsh R, Hojat M. The Effect of Omentoplasty on the Rate of Anastomotic Leakage after Intestinal Resection: A Randomized Controlled Trial. Am Surg 2017. [DOI: 10.1177/000313481708300215] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Anastomotic leakage is a major postoperative complication after intestinal surgery leading to increased risk of morbidity and mortality. Omentoplasty has been evaluated to prevent anastomotic leakage in several studies. However, there is no consensus regarding whether or not omentoplasty should be used to decrease the rate of anastomotic leakage after intestinal resection. A prospective, randomized study was conducted to evaluate the influence of omentoplasty on anastomotic leakage after intestinal resection. A total of 124 patients who underwent intestinal resection were enrolled in this prospective study. Patients were randomly assigned to receive either the omentoplasty or nonomentoplasty. In the omentoplasty group, the omentum was wrapped around the anastomotic region. Age, gender, site and type of anastomosis, duration of hospital stay, and performance of omentoplasty were recorded. This study was registered in Iranian Registry of clinical trial (number: IRCT201412316925N3). The rate of anastomotic leakage was significantly lower in the omentoplasty group (P = 0.04). Patients in the omentoplasty group developed a significantly lower rate of postoperative infection and peritonitis (P < 0.05). There was no significant difference of abscess and fistula formation between the two groups (P > 0.05). The length of hospital stay was longer in the nonomentoplasty group, compared with that for omentoplasty patients (P < 0.05). No death occurred in the omentoplasty subjects, while six nonomentoplasty patients died (P < 0.05). Our data demonstrated that omentoplasty is useful to lower the rate of postoperative complications in patients underwent intestinal surgery.
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Affiliation(s)
- Shirzad Nasiri
- Department of General Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Babak Mirminachi
- Department of General Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Reyhaneh Taherimehr
- Department of General Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Roya Shadbakhsh
- Department of General Surgery, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Hojat
- Department of General Surgery, Tehran University of Medical Sciences, Tehran, Iran
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Vallance A, Wexner S, Berho M, Cahill R, Coleman M, Haboubi N, Heald RJ, Kennedy RH, Moran B, Mortensen N, Motson RW, Novell R, O'Connell PR, Ris F, Rockall T, Senapati A, Windsor A, Jayne DG. A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery. Colorectal Dis 2017; 19:O1-O12. [PMID: 27671222 DOI: 10.1111/codi.13534] [Citation(s) in RCA: 84] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2016] [Accepted: 07/27/2016] [Indexed: 02/06/2023]
Abstract
The reduction of the incidence, detection and treatment of anastomotic leakage (AL) continues to challenge the colorectal surgical community. AL is not consistently defined and reported in clinical studies, its occurrence is variably reported and its impact on longterm morbidity and health-care resources has received relatively little attention. Controversy continues regarding the best strategies to reduce the risk. Diagnostic tests lack sensitivity and specificity, resulting in delayed diagnosis and increased morbidity. Intra-operative fluorescence angiography has recently been introduced as a means of real-time assessment of anastomotic perfusion and preliminary evidence suggests that it may reduce the rate of AL. In addition, concepts are emerging about the role of the rectal mucosal microbiome in AL and the possible role of new prophylactic therapies. In January 2016 a meeting of expert colorectal surgeons and pathologists was held in London, UK, to identify the ongoing controversies surrounding AL in colorectal surgery. The outcome of the meeting is presented in the form of research challenges that need to be addressed.
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Affiliation(s)
- A Vallance
- Royal College of Surgeons of England, London, UK
| | - S Wexner
- Cleveland Clinic Florida, Weston, Florida, USA
| | - M Berho
- Cleveland Clinic Florida, Weston, Florida, USA
| | - R Cahill
- University College Dublin, Dublin, Ireland
| | | | - N Haboubi
- University Hospital of South Manchester, Manchester, UK
| | - R J Heald
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - B Moran
- Basingstoke and North Hampshire Hospital, Basingstoke, UK
| | | | - R W Motson
- The ICENI Centre, Colchester University Hospital, Colchester, UK
| | - R Novell
- The Royal Free Hospital, London, UK
| | | | - F Ris
- Geneva University Hospitals and Medical School, Geneva, Switzerland
| | - T Rockall
- Royal Surrey County Hospital, Guildford, UK
| | | | - A Windsor
- University College Hospital, London, UK
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14
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Does omental pedicle flap reduce anastomotic leak and septic complications after rectal cancer surgery? Int J Surg 2016; 27:53-57. [DOI: 10.1016/j.ijsu.2015.12.070] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2015] [Accepted: 12/21/2015] [Indexed: 11/23/2022]
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15
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McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 2015; 102:462-79. [PMID: 25703524 DOI: 10.1002/bjs.9697] [Citation(s) in RCA: 579] [Impact Index Per Article: 57.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2014] [Revised: 09/09/2014] [Accepted: 10/08/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND Anastomotic leak (AL) represents a dreaded complication following colorectal surgery, with a prevalence of 1-19 per cent. There remains a lack of consensus regarding factors that may predispose to AL and the relative risks associated with them. The objective was to perform a systematic review of the literature, focusing on the role of preoperative, intraoperative and postoperative factors in the development of colorectal ALs. METHODS A systematic review was performed to identify adjustable and non-adjustable preoperative, intraoperative and postoperative factors in the pathogenesis of AL. Additionally, a severity grading system was proposed to guide treatment. RESULTS Of 1707 papers screened, 451 fulfilled the criteria for inclusion in the review. Significant preoperative risk factors were: male sex, American Society of Anesthesiologists fitness grade above II, renal disease, co-morbidity and history of radiotherapy. Tumour-related factors were: distal site, size larger than 3 cm, advanced stage, emergency surgery and metastatic disease. Adjustable risk factors were: smoking, obesity, poor nutrition, alcohol excess, immunosuppressants and bevacizumab. Intraoperative risk factors were: blood loss/transfusion and duration of surgery more than 4 h. Stomas lessen the consequences but not the prevalence of AL. In the postoperative period, CT is the most commonly used imaging tool, with or without rectal contrast, and a C-reactive protein level exceeding 150 mg/l on day 3-5 is the most sensitive biochemical marker. A five-level classification system for AL severity and appropriate management is presented. CONCLUSION Specific risk factors and their potential correction or indications for stoma were identified. An AL severity score is proposed to aid clinical decision-making.
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Affiliation(s)
- F D McDermott
- Centre for Colorectal Disease, St Vincent's University Hospital, Dublin, Ireland
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16
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Improving outcomes and cost-effectiveness of colorectal surgery. J Gastrointest Surg 2014; 18:1944-56. [PMID: 25205538 DOI: 10.1007/s11605-014-2643-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2014] [Accepted: 08/25/2014] [Indexed: 02/08/2023]
Abstract
In order to truly make an impact on improving the cost effectiveness, and most importantly, the outcomes of patients undergoing colorectal surgery, all aspects of care need to be scrutinized, re-evaluated, and refined. To accomplish this, everything from the way we train surgeons to the adoption of a minimally invasive approach for colorectal disease, along with the use of adjunct intraoperative measures to decrease morbidity and mortality, may all need to be incorporated within an ERAS program. Only then will this approach lead the provider to a patient-centric care plan which can successfully reduce metrics such as morbidity, mortality, and length of stay (even with the obligatory readmission rate) and provide it all at a lower cost of care.
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17
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van Vugt JLA, Reisinger KW, Derikx JPM, Boerma D, Stoot JHMB. Improving the outcomes in oncological colorectal surgery. World J Gastroenterol 2014; 20:12445-12457. [PMID: 25253944 PMCID: PMC4168077 DOI: 10.3748/wjg.v20.i35.12445] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2014] [Revised: 03/18/2014] [Accepted: 06/17/2014] [Indexed: 02/06/2023] Open
Abstract
During the last several decades, colorectal cancer surgery has experienced some major perioperative improvements. Preoperative risk-assessment of nutrition, frailty, and sarcopenia followed by interventions for patient optimization or an adapted surgical strategy, contributed to improved postoperative outcomes. Enhanced recovery programs or fast-track surgery also resulted in reduced length of hospital stay and overall complications without affecting patient safety. After an initially indecisive start due to uncertainty about oncological safety, the most significant improvement in intraoperative care was the introduction of laparoscopy. Laparoscopic surgery for colon and rectal cancer is associated with better short-term outcomes, whereas long-term outcomes regarding survival and recurrence rates are comparable. Nevertheless, long-term results in rectal surgery remain to be seen. Early recognition of anastomotic leakage remains a challenge, though multiple improvements have allowed better management of this complication.
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18
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Afors K, Murtada R, Centini G, Fernandes R, Meza C, Castellano J, Wattiez A. Employing Laparoscopic Surgery for Endometriosis. WOMENS HEALTH 2014; 10:431-43. [DOI: 10.2217/whe.14.28] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Endometriosis is a chronic, multifactorial disease, which can impact significantly on a women's quality of life. It is associated with pelvic pain, dyspareunia and intestinal disorders, and can lead to infertility. The use of laparoscopic surgery in the management of endometriosis is well documented; however, the optimal management of women with deep infiltrating disease remains controversial. This review describes the different surgical strategies for the treatment of endometriosis.
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Affiliation(s)
- Karolina Afors
- IRCAD, Hopitaux Universitaires, 1 Place de l'Hopital, 67091 Strasbourg, France
| | - Rouba Murtada
- IRCAD, Hopitaux Universitaires, 1 Place de l'Hopital, 67091 Strasbourg, France
| | - Gabriele Centini
- IRCAD, Hopitaux Universitaires, 1 Place de l'Hopital, 67091 Strasbourg, France
| | - Rodrigo Fernandes
- IRCAD, Hopitaux Universitaires, 1 Place de l'Hopital, 67091 Strasbourg, France
| | - Carolina Meza
- IRCAD, Hopitaux Universitaires, 1 Place de l'Hopital, 67091 Strasbourg, France
| | - Jesus Castellano
- IRCAD, Hopitaux Universitaires, 1 Place de l'Hopital, 67091 Strasbourg, France
| | - Arnaud Wattiez
- IRCAD, Hopitaux Universitaires, 1 Place de l'Hopital, 67091 Strasbourg, France
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Akladios C, Faller E, Afors K, Puga M, Albornoz J, Redondo C, Leroy J, Wattiez A. Totally laparoscopic intracorporeal anastomosis with natural orifice specimen extraction (NOSE) techniques, particularly suitable for bowel endometriosis. J Minim Invasive Gynecol 2014; 21:1095-102. [PMID: 24858985 DOI: 10.1016/j.jmig.2014.05.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2014] [Revised: 03/16/2014] [Accepted: 05/14/2014] [Indexed: 01/31/2023]
Abstract
The objective of this retrospective study was to evaluate the feasibility of natural orifice specimen extraction (NOSE) techniques in 41 patients undergoing bowel resection for treatment of deep infiltrating endometriosis. In all patients laparoscopic treatment of rectovaginal endometriosis with bowel resection had been performed. In 32 patients the classic approach was adopted (group 1), and in 9 a NOSE technique was performed (group 2). Demographic, operative, and postoperative data were compared. Statistical analyses were performed using SPSS software, version 16.0. When needed, qualitative variables were compared using the χ(2) test or the Fisher exact test. Quantitative variables using the t-test were used. The threshold of statistical significance was set at p = .05. No statistically significant difference was observed between the 2 groups. Eight complications (19.5%) were observed, 2 minor (4.8%) and 6 major (14.6%). Of major complications, 2 were observed in the NOSE group (n = 2; 22.2%). It was concluded that the NOSE technique is a feasible approach in patients undergoing bowel resection for treatment of deep infiltrating endometriosis.
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Affiliation(s)
- Cherif Akladios
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France.
| | - Emilie Faller
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France
| | - Karolina Afors
- Institut de Recherche Contre le Cancer de l'Appareil Digestif, Strasbourg, France
| | - Marco Puga
- Institut de Recherche Contre le Cancer de l'Appareil Digestif, Strasbourg, France
| | - Jaime Albornoz
- Institut de Recherche Contre le Cancer de l'Appareil Digestif, Strasbourg, France
| | - Christina Redondo
- Institut de Recherche Contre le Cancer de l'Appareil Digestif, Strasbourg, France
| | - Joel Leroy
- Institut de Recherche Contre le Cancer de l'Appareil Digestif, Strasbourg, France
| | - Arnaud Wattiez
- Department of Obstetrics and Gynecology, Strasbourg University Hospital, Strasbourg, France
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20
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Belghiti J, Ballester M, Zilberman S, Thomin A, Zacharopoulou C, Bazot M, Thomassin-Naggara I, Daraï E. Role of Protective Defunctioning Stoma in Colorectal Resection for Endometriosis. J Minim Invasive Gynecol 2014; 21:472-9. [DOI: 10.1016/j.jmig.2013.12.094] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2013] [Revised: 12/03/2013] [Accepted: 12/04/2013] [Indexed: 10/25/2022]
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21
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Pan RY, Yan QT, Qu JS, Han HL, Xu JM, Xue LX, Zhang YJ, Qu MH. Wrapping digestive tract anastomotic fistula with a pedicled gastrocolic omentum flap to prevent anastomotic leakage in diabetic rats. Shijie Huaren Xiaohua Zazhi 2013; 21:3107-3111. [DOI: 10.11569/wcjd.v21.i29.3107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the effect of wrapping digestive tract anastomotic fistula with a pedicled gastrocolic omentum flap in preventing anastomotic leakage in diabetic rats.
METHODS: Experiments were performed using 6-week-old male Wistar rats (n = 30). All animals were allowed to adapt to their environment for 1 wk (free access to food and water, 12:12-h light/dark cycle) prior to the beginning of study. Type 2 diabetes mellitus (T2DM) was induced by feeding a high-fat diet for two months and then giving a single intraperitoneal injection of low-dose 1% streptozocin (35 mg/kg) after 12 h of fasting. Seven days after model induction, the rats were divided into either a control group to receive a surgery without wrapping anastomotic fistula (n = 11) or an experimental group to receive wrapping anastomotic fistula using a pedicled gastrocolic omentum flap (n = 13).
RESULTS: The incidence of anastomotic leakage was significantly lower in the experimental group than in the control group (3.8% vs 30.8%, P = 0.029). The survival rate was also improved in the experimental group.
CONCLUSION: Wrapping digestive tract anastomotic fistula with a pedicled gastrocolic omentum flap is feasible in preventing anastomotic leakage and can significantly decrease the incidence of anastomotic leakage and improve survival in diabetic rats.
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23
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Okano K, Asano E, Oshima M, Yamamoto N, Yachida S, Nishizawa Y, Akamoto S, Fujiwara M, Deguchi A, Mori H, Masaki T, Suzuki Y. Omental flap wrapping with fixation to the cut surface of the liver for reducing delayed gastric emptying after left-sided hepatectomy. Surg Today 2012; 43:1425-32. [PMID: 23224260 DOI: 10.1007/s00595-012-0446-8] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2012] [Accepted: 10/01/2012] [Indexed: 12/19/2022]
Abstract
BACKGROUND Delayed gastric emptying (DGE) is a common complication following left-sided hepatectomy. The goal of this study was to clarify the clinical implications of an omental flap wrapping procedure that includes fixation to the cut surface of the liver to reduce the incidence of DGE after left-sided hepatectomy. METHODS The study included 50 consecutive patients who underwent left-sided hepatectomy between January 2000 and July 2011. Clinicopathologic risk factors for DGE after left-sided hepatectomy were identified using univariate and multivariate models. The incidence of DGE, digestive symptoms, and postoperative complications were compared between two groups: 25 patients treated with the omental flap wrapping and fixation procedure and 25 patients who did not receive such a flap. RESULTS A univariate analysis revealed that a lack of the omental flap, the lymph node clearance, and use of left hemihepatectomy were associated with postoperative DGE. The multivariate analysis indicated that the lack of the omental flap was the only independent significant factor associated with the DGE (odds ratio, 21.23; p = 0.0002). There was a significant difference in the incidence of DGE between the patients with (4 %) and without an omental flap (36 %). The incidence of gastric distension and the use of prokinetic drugs were also significantly lower in patients with an omental flap than in patients without the flap, and patients with an omental flap resumed a solid diet significantly earlier. CONCLUSIONS This retrospective single-center study revealed that it was possible to reduce the incidence of DGE using a procedure involving omental flap wrapping with fixation to the cut surface of the liver after left-sided hepatectomy.
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Affiliation(s)
- Keiichi Okano
- Department of Gastroenterological Surgery, Faculty of Medicine, Kagawa University, 1750-1 Ikenobe, Miki-cho, Kita-gun, Kagawa, 761-0793, Japan,
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Prevention of gastric stasis by omentum patching after living donor left hepatectomy. Surg Today 2012; 42:816-8. [PMID: 22451247 DOI: 10.1007/s00595-012-0168-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2011] [Accepted: 08/15/2011] [Indexed: 10/28/2022]
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