Establishing the impact, detection and prevention of colorectal surgical complications
File(s)
Author(s)
Nachiappan, Subra
Type
Thesis
Abstract
This dissertation examines the postoperative complications in colorectal surgery with an emphasis on anastomotic complications. Firstly, it investigates the impacts of anastomotic leakage and its subsequent treatment, on overall survival, disease-free survival and timing of adjuvant chemotherapy. Secondly it assesses intraoperative anastomotic testing utilities and novel intraoperative surgical techniques such as the ileo-distal sigmoid anastomosis in prophylactic colectomy patients, and the tube ileostomy, a variant of the loop ileostomy that negates the need for a second reversal operation. Thirdly it interrogates the feasibility of remote patient self-monitoring using tablet computers and Blue-tooth enabled technology to measure physiological parameters after elective colorectal surgery.
A variety of research methodology has been employed to investigate above, including local hospital datasets, national level administrative databases, systematic reviews and pooled analysis, and pilot feasibility studies in the intraoperative and postoperative setting.
This thesis has demonstrated that anastomotic leakage and reoperation to manage it, adversely impacts overall survival and although not statistically significant, it has noted increased recurrence rates in patients who suffered a leakage compared to those that did not. The large administrative database studies have firstly shown that delay in adjuvant chemotherapy reduces overall survival and have secondly identified that patients who receive adjuvant chemotherapy early within eight weeks are conferred a survival benefit, regardless of reoperative status, compared to those who did after eight weeks.
Subsequently it has systematically reviewed intraoperative testing methods and has shown that basic mechanical patency tests reduce postoperative anastomotic leakage in non-randomised studies. It has also shown that Near Infrared-Indocyanine Green autofluorescence anastomotic assessment is safe and feasible in a pilot study. It has also described the initial experience with the IDSA technique in Polyposis patients in a tertiary institution. A further systematic review and subgroup analysis on tube ileostomy reported no significant differences in anastomotic leakage when compared to the established loop ileostomy. Lastly, postoperative patient self-monitoring has been found to be feasible and comparable to nurse-acquired physiological measurements. Both this and the initial experience of IDSA will allow extrapolation into future studies in our local institution.
This thesis has demonstrated the impact of postoperative operative complications, specifically of anastomotic leakage, and the importance of its perioperative prevention, detection and prompt management in minimising them and their sequelae.
A variety of research methodology has been employed to investigate above, including local hospital datasets, national level administrative databases, systematic reviews and pooled analysis, and pilot feasibility studies in the intraoperative and postoperative setting.
This thesis has demonstrated that anastomotic leakage and reoperation to manage it, adversely impacts overall survival and although not statistically significant, it has noted increased recurrence rates in patients who suffered a leakage compared to those that did not. The large administrative database studies have firstly shown that delay in adjuvant chemotherapy reduces overall survival and have secondly identified that patients who receive adjuvant chemotherapy early within eight weeks are conferred a survival benefit, regardless of reoperative status, compared to those who did after eight weeks.
Subsequently it has systematically reviewed intraoperative testing methods and has shown that basic mechanical patency tests reduce postoperative anastomotic leakage in non-randomised studies. It has also shown that Near Infrared-Indocyanine Green autofluorescence anastomotic assessment is safe and feasible in a pilot study. It has also described the initial experience with the IDSA technique in Polyposis patients in a tertiary institution. A further systematic review and subgroup analysis on tube ileostomy reported no significant differences in anastomotic leakage when compared to the established loop ileostomy. Lastly, postoperative patient self-monitoring has been found to be feasible and comparable to nurse-acquired physiological measurements. Both this and the initial experience of IDSA will allow extrapolation into future studies in our local institution.
This thesis has demonstrated the impact of postoperative operative complications, specifically of anastomotic leakage, and the importance of its perioperative prevention, detection and prompt management in minimising them and their sequelae.
Version
Open Access
Date Issued
2017-08
Date Awarded
2018-10
Copyright Statement
Attribution NoDerivatives 4.0 International Licence (CC BY-ND)
Advisor
Faiz, Omar
Phillips, Robin
Publisher Department
Department of Surgery & Cancer
Publisher Institution
Imperial College London
Qualification Level
Doctoral
Qualification Name
Doctor of Philosophy (PhD)