ocutaneous fistula following stapled bowel anastomosis in patients undergoing radical ... with enterocutaneous fistula in intensive care unit. J Trauma Acute.
216
Bovine Pericardial Strip Buttresses for Bowel Anastomoses in Cystectomy
Editorial Commentaries
The authors report a retrospective analysis of their experience using bovine pericardial strip buttresses to prevent enterocutaneous fistula following stapled bowel anastomosis in patients undergoing radical cystectomy. The BPS group was compared to institutional historical controls. In 301 patients before the use of BPS an ECF developed in 7 patients (2.3%). No cases of ECF were reported in 97 patients using the BPS technique. Rare events such as ECF are difficult to assess in single institution cohorts, as demonstrated in the current analysis where there was no statistically significant difference between study groups. The authors state that ECF may be heavily influenced by patient factors, including nutritional status and use of neoadjuvant chemotherapy. In fact, the BPS group was more likely to receive neoadjuvant chemotherapy. The authors expected neoadjuvant chemotherapy to impair wound healing and increase the probability of ECF. Without an assessment of other patient characteristics known to have a significant impact on patient outcome (nutrition, smoking, Charlson comorbidity etc),1,2 it is impossible to know the baseline health status of the patients in either group. In numerous studies neoadjuvant chemotherapy has been shown to have no impact on patient surgical outcomes.3 We applaud the efforts the authors have made to institute a technique in an attempt to prevent this
Enterocutaneous fistula is a rare but potentially devastating complication following radical cystectomy with urinary diversion (reference 8 in article). Reports in the literature are limited and techniques for avoiding this type of complication have not been well studied. The authors report a true ECF rate of 2.3% in their historical cohort, which is comparable to that in the reported literature. Accurate, prospective reporting of gastrointestinal complications, including functional bowel obstruction and ECF, is essential to current and future efforts to reduce these types of complications. The authors describe a novel technique for urologists performing cystectomy that has been used by bariatric surgeons with some success in preventing ECF and other gastrointestinal complications. Furthermore, gastrointestinal related complications after cystectomy are relatively common and quite costly as they lead to longer hospital stays and increased readmission rates.1 As a result, enhanced recovery after surgery pathways have been developed to reduce gastrointestinal complications.2 Given the low incidence of ECF after radical cystectomy, it is unlikely that all patients would benefit from use of
significant complication. The potential of this technique to diminish bowel complications in patients undergoing radical cystectomy requires further investigation. Hopefully, a larger series with more detailed patient characteristics will be forthcoming. Justin T. Matulay and Mitchell C. Benson Department of Urology Columbia University Medical Center New York, New York References 1. Hu D, Ren J, Wang G et al: Persistent inflammation-immunosuppression catabolism syndrome, a common manifestation of patients with enterocutaneous fistula in intensive care unit. J Trauma Acute Care Surg 2014; 76: 725. 2. Rencuzogullari A, Benlice C, Valente M et al: Predictors of anastomotic leak in elderly patients after colectomy: nomogrambased assessment from the American College of Surgeons National Surgical Quality Program Procedure-Targeted Cohort. Dis Colon Rectum 2017; 60: 527. 3. Grossman HB, Natale RB, Tangen CM et al: Neoadjuvant chemotherapy plus cystectomy compared with cystectomy alone for locally advanced bladder cancer. N Engl J Med 2003; 349: 859.
bovine pericardial strips as buttresses and, thus, caution should be used in drawing conclusions about costeffectiveness. Identifying high risk populations may minimize the cost associated with implementation of this technique and maximize the benefit rendered. Alice Semerjian and Phillip Pierorazio The Brady Urological Institution and Department of Urology Johns Hopkins University School of Medicine Baltimore, Maryland
References 1. Shabsigh A, Korets R, Vora KC et al: Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. Eur Urol 2009; 55: 164. 2. Tyson MD and Chang SS: Enhanced recovery pathways versus standard of care after cystectomy: a meta-analysis of the effect of perioperative outcomes. Eur Urol 2016; 70: 995.
