The edition · General Surgery
Fluorescence angiography cuts colorectal anastomotic leak by about a third; WSES moves colon trauma further from routine diversion
A trial-sequential meta-analysis of eight RCTs finds ICG angiography prevents one leak for about every 24 colorectal anastomoses, WSES sets out a physiology-led approach to colon and rectal injury, and three analyses cover laparoscopy in severe COPD, Braun enteroenterostomy and missed same-admission cholecystectomy.
The edition in brief
A meta-analysis of eight randomised trials (4712 patients) found indocyanine green fluorescence angiography reduced anastomotic leak after colorectal resection (RR 0.68, 95% CI 0.58 to 0.81; I² = 0%), an absolute reduction of 3.6% and a number needed to treat of about 24. Benefit was clearest for left-sided anastomoses and low-grade leaks; grade C leaks and reoperation did not differ significantly. World Society of Emergency Surgery recommendations on colon and rectal trauma favour primary repair or resection with anastomosis over routine diversion in most stable patients, reserve diversion for persistent vasopressor need, failed fascial closure or compounded physiological derangement, keep diversion as default for extraperitoneal rectal injury, advise against presacral drains and distal washout, and cap prophylactic antibiotics at 24 hours. In a propensity-matched NSQIP cohort of 6038 patients with severe COPD, laparoscopic colectomy was associated with lower 30-day mortality (2.3% vs 3.4%) and fewer pulmonary complications. A meta-analysis of 17 mostly observational studies associated Braun enteroenterostomy with less delayed gastric emptying after pancreatoduodenectomy (OR 0.39), but the four randomised trials showed no difference. In 482,705 US patients with mild or moderate biliary pancreatitis, only 59% had same-admission cholecystectomy, less often in Black patients. The practical message: use perfusion angiography for left-sided colorectal anastomoses where available, and do the cholecystectomy before discharge.
WSES recommends primary repair over routine diversion for most colon injuries
In stable patients with colon injury, repair or anastomose rather than divert; reserve stomas for persistent shock, an open abdomen or extraperitoneal rectal injury.
Laparoscopic colectomy was associated with lower mortality than open surgery in severe COPD
In severe COPD, a laparoscopic approach to elective colectomy was associated with fewer deaths and pulmonary complications than open surgery.
Braun enteroenterostomy after Whipple: benefit in observational data, none in the randomised trials
Braun enteroenterostomy is safe after pancreatoduodenectomy, but randomised trials have not confirmed any benefit.
Four in ten patients with mild biliary pancreatitis leave without their gallbladder removed
Remove the gallbladder before discharge in mild biliary pancreatitis; many units are not doing so.
Reading an ICG perfusion check before you fire the stapler
Image perfusion before transection and move proximally if the planned line fluoresces poorly.
Fluorescence angiography prevents about one colorectal anastomotic leak for every 24 patients
Pooled randomised evidence supports routine fluorescence angiography before left-sided colorectal anastomoses; it prevents about one leak per 24 patients.
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