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Results of postoperative microdialysis intraperitoneal and at the anastomosis in patients developing anastomotic leakage after rectal cancer surgery
Örebro University, School of Medical Sciences. Department of Surgery, Colorectal Unit.ORCID iD: 0000-0003-2789-8001
School of Rudbeck, Örebro, Sweden.
Örebro University, School of Medical Sciences. Örebro University Hospital. Department ofCardiothoracic and Vascular Surgery.ORCID iD: 0000-0003-3912-4732
Department of Vascular Surgery, Institute of Medicine, Gothenburg, Sweden; Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden.
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2019 (English)In: Scandinavian Journal of Gastroenterology, ISSN 0036-5521, E-ISSN 1502-7708, Vol. 54, no 10, p. 1261-1268Article in journal (Refereed) Published
Abstract [en]

Introduction: Anastomotic leakage postoperatively in patients operated with rectum resection and primary anastomosis is a common and feared complication. We have studied seven patients with an anastomotic leakage after surgery and compared them with 13 patients without complications.

Methods: Metabolic measurements with microdialysis were done during the first seven postoperative days, with measurements of glucose, pyruvate, lactate and glycerol. The lactate/pyruvate ratio was calculated. Measurements were performed subcutaneously, intraperitoneally and at the anastomosis. The inflammatory cytokines, IL 6 and IL 10, were measured intravenously and intraperitoneally 48 hours postoperatively.

Results: Intravenous and intraperitoneal IL 6 were higher in the leakage group. Around the small intestine (intraperitoneally), we found that patients developing anastomotic leakage had higher lactate and lactate/pyruvate ratio immediately after surgery. They also showed lower glycerol levels. At the anastomosis, we found higher lactate and lactate/pyruvate ratio in anastomotic leak patients after the fourth postoperative day.

Conclusions: The results indicate that a possible mechanism behind an anastomotic leakage is an impaired circulation and thus insufficient saturation to the small intestine peroperatively. This develops into an inflammation both intraperitoneally and intravenously, which, if not reversed, spread within the gastrointestinal tract. The colorectal anastomosis is the most vulnerable part of the gastrointestinal tract postoperatively and hypoxia and inflammation may occur there, and an anastomosis leakage will be the consequence.

Place, publisher, year, edition, pages
Taylor & Francis, 2019. Vol. 54, no 10, p. 1261-1268
Keywords [en]
Rectal surgery, anastomotic leakage, intraperitoneal microdialysis, lactate pyruvate ratio, intraperitoneal cytokines
National Category
Gastroenterology and Hepatology
Identifiers
URN: urn:nbn:se:oru:diva-77758DOI: 10.1080/00365521.2019.1673476ISI: 000491462900001PubMedID: 31630578Scopus ID: 2-s2.0-85074687398OAI: oai:DiVA.org:oru-77758DiVA, id: diva2:1368020
Note

Funding Agencies:

Research Committee of Region Örebro County at Örebro University Hospital  

Nyckelfonden at Örebro University Hospital 

Available from: 2019-11-05 Created: 2019-11-05 Last updated: 2025-02-11Bibliographically approved
In thesis
1. Anastomotic leakage in colorectal surgery: early diagnosis and treatment with stent
Open this publication in new window or tab >>Anastomotic leakage in colorectal surgery: early diagnosis and treatment with stent
2021 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Every year inn Sweden more than 6000 individuals are diagnosed with colorectal cancer and more than 5000 operations are performed. Anastomotic leakage (AL) is the most dreaded complication in colorectal surgery and has a great impact on postoperative morbidity and mortality. 

In Study I, an iatrogenic rectal perforation was performed on an experimental group of pigs, in order to imitate AL and compared with a control group which had a sham operation over a 10-hours follow-up with intraperitoneal microdialysis (IPM) and cytokines. Glucose levels were lower in the experimental group at 4 hours and lactate and lactate/pyruvate ratios (L/P) were higher in the experimental group at 7 hours. Intraperitoneal (IP) Interleukine 6 (IL6) and Interleukine 10 (IL10) were higher in the experimental group at 10 hours and blood IL6 was higher in the experimental group at 4 hours. IPM and cytokines thus seem to react early after rectal perforation. 

Study II was a prospective observational study in which 7 patients with AL after surgery were compared with 13 patients without complications during the first 7 postoperative days with IPM, and intravenous and IP cytokines. In patients who later developed AL, IP lactate and L/P were higher immediately after surgery, while glycerol levels were lower. At the anastomosis higher L/P in AL patients were found after the fifth postoperative day. Intravenous and IP IL6 was higher in the leakage group. 

In Study III, mRNA expression in blood was analyzed in an animal model designed to imitate AL. Significantly increased levels of 276 genes were found and 11 of the 48 genes which coded for a known protein were highly up-regulated.

In Study IV, the metabolic effects of a fully covered self-expandable metal stent (FCSEMS) over a colorectal anastomosis were investigated with IPM, after laparotomy, colon resection and anastomosis with stent. Lactate and L/P rise at the oral part of the anastomosis were significantly higher, while glucose showed a small tendency toward numerically declining values. At the distal part of the anastomosis glucose decreased significantly after the resection but did not reach zero. Lactate increased significantly while L/P slightly increased. This suggest that hypermetabolism occurs in the intestinal ends next to the resectate, but even a start of hypoxemia cannot be excluded after the placement of a FCSEMS.

Place, publisher, year, edition, pages
Örebro: Örebro University, 2021. p. 76
Series
Örebro Studies in Medicine, ISSN 1652-4063 ; 240
Keywords
anastomotic leakage, colorectal cancer, intraperitoneal microdialysis, cytokines, mRNA analysis, stent
National Category
Surgery
Identifiers
urn:nbn:se:oru:diva-90318 (URN)978-91-7529-388-2 (ISBN)
Public defence
2021-06-09, Örebro universitet, Campus USÖ, hörsal C1, Södra Grev Rosengatan 32, Örebro, 09:00 (Swedish)
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Available from: 2021-03-09 Created: 2021-03-09 Last updated: 2022-08-24Bibliographically approved

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Oikonomakis, IoannisHörer, Tal M.Nilsson, Kristofer F.

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