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Introduction: Laparoscopic pancreaticoduodenectomy (LPD) is a challenging procedure. We investigated the learning curve (LC) for LPD with a multidimensional analysis. Methods: Data of patients undergoing LPD between 2017 and 2021, operated by a single surgeon, were considered. A multidimensional assessment of the LC was performed through Cumulative Sum (CUSUM) and Risk-Adjusted (RA)-CUSUM analysis. Results: 113 patients were selected. Rates of conversion, overall postoperative complication, severe complication and mortality were 4%, 53%, 29% and 4%, respectively. RA-CUSUM analysis showed a LC with three phases: competency (procedures 1–51), proficiency (procedures 52–94), and mastery (after procedure 94). Operative time was lower in both phase two (588.17 vs 541.13 min, p = 0.001) and three (534.72 vs 541.13 min, p = 0.004) with respect to phase one. Severe complication rate was lower in mastery as compared to competency phase (42% vs 6%, p = 0.005). During mastery phase a greater number of lymph nodes was harvested in comparison to proficiency phase. Conclusions: According to our LC analysis, 52 procedures were required to achieve technical competency in LPD. Mastery, which corresponded to a reduction in operative time and surgical failures, was acquired after 94 procedures.

BACKGROUND: The complexity of oesophageal surgery and the significant risk of morbidity necessitates that oesophagectomy is predominantly performed by a consultant surgeon, or a senior trainee under their supervision. The aim of this study was to determine the impact of trainee involvement in oesophagectomy on postoperative outcomes in an international multicentre setting. METHODS: Data from the multicentre Oesophago-Gastric Anastomosis Study Group (OGAA) cohort study were analysed, which comprised prospectively collected data from patients undergoing oesophagectomy for oesophageal cancer between April 2018 and December 2018. Procedures were grouped by the level of trainee involvement, and univariable and multivariable analyses were performed to compare patient outcomes across groups. RESULTS: Of 2232 oesophagectomies from 137 centres in 41 countries, trainees were involved in 29.1 per cent of them (n = 650), performing only the abdominal phase in 230, only the chest and/or neck phases in 130, and all phases in 315 procedures. For procedures with a chest anastomosis, those with trainee involvement had similar 90-day mortality, complication and reoperation rates to consultant-performed oesophagectomies (P = 0.451, P = 0.318, and P = 0.382, respectively), while anastomotic leak rates were significantly lower in the trainee groups (P = 0.030). Procedures with a neck anastomosis had equivalent complication, anastomotic leak, and reoperation rates (P = 0.150, P = 0.430, and P = 0.632, respectively) in trainee-involved versus consultant-performed oesophagectomies, with significantly lower 90-day mortality in the trainee groups (P = 0.005). CONCLUSION: Trainee involvement was not found to be associated with significantly inferior postoperative outcomes for selected patients undergoing oesophagectomy. The results support continued supervised trainee involvement in oesophageal cancer surgery.

In this study, we describe an intrathoracic microsurgical lymphatico-venous anastomosis as an alternative surgical technique for the treatment of refractory chylothorax in an infant. This procedure allowed us to restore enteral nutrition within days of surgery. At 3-year follow-up, there was no recurrence of pleural effusion.

Endoscopic ultrasonography-guided gastrojejunal anastomosis (EUS-GJA) was developed in 2015 using a lumen-apposing metal stent (LAMS) [1] [2]. Its application was described for malignant bowel obstruction and a few cases of benign obstruction [3] [4]. Crohn’s disease is an inflammatory bowel disease that could induce inflammatory or fibrotic bowel strictures, the management of which includes medical therapy, endoscopic dilation or surgical resection [5]. We report a case of duodenal stricture in severe Crohn’s disease and short bowel syndrome. [...]

A perforated peptic ulcer is associated with a 30 % mortality and 50 % morbidity and is usually managed as a surgical emergency [1]. To seal the perforation, applying interrupted sutures with omental apposition is the most commonly used technique [2]. In a few cases, a perforated peptic ulcer may be complicated by a choledochoduodenal fistula, which is managed surgically by laparoscopic digestive resection [3] or medically with a protein pump inhibitor and endoscopic retrograde cholangiopancreatography (ERCP). We present a case of a biliary fistula complicating a perforated peptic ulcer that was managed endoscopically in an original way. [...]

In this study, we describe an intrathoracic microsurgical lymphatico-venous anastomosis as an alternative surgical technique for the treatment of refractory chylothorax in an infant. This procedure allowed us to restore enteral nutrition within days of surgery. At 3-year follow-up, there was no recurrence of pleural effusion.

Background: Many Eastern reports attempted to identify predictive variables for esophago-jejunal anastomosis leakage (EJAL) after total gastrectomy for cancer. There are no definitive answers about reliable risk factors for EJAL. This retrospective study shows the largest Western series focused on this topic. Methods: This is a multicenter retrospective study analyzing patients’ datasets collected by 18 Italian referral Centres of the Italian Research Group for Gastric Cancer (GIRCG) from 2000 to 2018. The inclusion criteria were pathological diagnosis of gastric and esophageal (Siewert III) carcinoma requiring total gastrectomy. The primary end point of risk analysis was the occurrence of EJAL; secondary end points were post-operative (30-day) morbidity and mortality, length of stay (LoS), and survival. Results: Data of 1750 patients submitted to total gastrectomy were collected. EJAL developed in 116 (6.6%) patients and represented the 26.3% of all the 441 observed post-operative surgical complications. EJAL diagnosis was followed by a reoperation in 39 (33.6%) patients and by an endoscopic/radiological procedure in 30 cases (25.9%). In 47 patients (40.5%) EJAL was managed with conservative approach. Post-operative LoS and mortality were significantly higher after EJAL occurrence (27 days versus 12 days and 8.6% versus 1.6%, respectively). At risk analysis, comorbidities (particularly, if respiratory), minimally invasive surgery, extended lymphadenectomy, and anastomotic technique resulted significant predictive factors for EJAL. EJAL did not significantly affect survival. Conclusions: These results were consistent with Asian experiences: the frequency of EJAL and its higher rate observed in patients with comorbidities or after minimally invasive approach were confirmed.

Introduction Postintubation laryngo-tracheal stenosis requires a precise diagnosis and an experienced operator in both endoscopic and surgical treatment. This report presents surgically treated cases of laryngo-tracheal stenosis secondary to long-term intubation/ tracheostomy with review of the literature. Case Reports In this retrospective study, we present 5 cases (23-year-old male, 13 year old male, 22 year old male, 19 year old male and 33 year old female) of post-intubation/tracheostomy laryngo-tracheal stenosis (glottic/subglottic) stenosis in the year 2016 to 2017. Each patient was managed differently. A patient with history of multiple subglottic stenosis dilations and stenting underwent open surgical subglottic stenosis resection and anastomosis, LASER assisted resection of stenosis with stenting was done in a patient with history of dilation, LASER assisted resection and dilation followed by Mitomycin C application was done in another patient with history of poisoning, plain endoscopic dilation was done in one patient with history of head injury and Kashima’s Cordotomy with release of interarytenoid adhesion by LASER was done in one patient. Conclusion Resection of stenotic segment by open surgical anastomosis and laser assisted resection is a safe option for the treatment of subglottic stenosis following intubation without the need for repeated dilation. Endoscopic dilation can be reserved for unfit patients.

Introduction Postintubation laryngo-tracheal stenosis requires a precise diagnosis and an experienced operator in both endoscopic and surgical treatment. This report presents surgically treated cases of laryngo-tracheal stenosis secondary to long-term intubation/ tracheostomy with review of the literature. Case Reports In this retrospective study, we present 5 cases (23-year-old male, 13 year old male, 22 year old male, 19 year old male and 33 year old female) of post-intubation/tracheostomy laryngo-tracheal stenosis (glottic/subglottic) stenosis in the year 2016 to 2017. Each patient was managed differently. A patient with history of multiple subglottic stenosis dilations and stenting underwent open surgical subglottic stenosis resection and anastomosis, LASER assisted resection of stenosis with stenting was done in a patient with history of dilation, LASER assisted resection and dilation followed by Mitomycin C application was done in another patient with history of poisoning, plain endoscopic dilation was done in one patient with history of head injury and Kashima’s Cordotomy with release of interarytenoid adhesion by LASER was done in one patient. Conclusion Resection of stenotic segment by open surgical anastomosis and laser assisted resection is a safe option for the treatment of subglottic stenosis following intubation without the need for repeated dilation. Endoscopic dilation can be reserved for unfit patients.

Introduction Postintubation laryngo-tracheal stenosis requires a precise diagnosis and an experienced operator in both endoscopic and surgical treatment. This report presents surgically treated cases of laryngo-tracheal stenosis secondary to long-term intubation/ tracheostomy with review of the literature. Case Reports In this retrospective study, we present 5 cases (23-year-old male, 13 year old male, 22 year old male, 19 year old male and 33 year old female) of post-intubation/tracheostomy laryngo-tracheal stenosis (glottic/subglottic) stenosis in the year 2016 to 2017. Each patient was managed differently. A patient with history of multiple subglottic stenosis dilations and stenting underwent open surgical subglottic stenosis resection and anastomosis, LASER assisted resection of stenosis with stenting was done in a patient with history of dilation, LASER assisted resection and dilation followed by Mitomycin C application was done in another patient with history of poisoning, plain endoscopic dilation was done in one patient with history of head injury and Kashima’s Cordotomy with release of interarytenoid adhesion by LASER was done in one patient. Conclusion Resection of stenotic segment by open surgical anastomosis and laser assisted resection is a safe option for the treatment of subglottic stenosis following intubation without the need for repeated dilation. Endoscopic dilation can be reserved for unfit patients.

OBJECTIVES: Open-distal anastomosis is the preferred technique over clamp-on technique for surgical repair of acute type A aortic dissection (ATAAD). The aim of this study was to define how outcomes of ATAAD were affected by the use of either technique.METHODS: Nordic Consortium for Acute Type A Aortic Dissection includes 8 academic cardiothoracic hospitals in 4 Nordic countries. The cohort consisted of 1134 patients, 153 clamp-on and 981 open-distal, from 2005 to 2014.RESULTS: Patients who underwent operation with the clamp-on were younger, more frequently had coronary artery disease, bicuspid aortic valve, hypotension/shock or syncope, and a greater PennClass than open-distal patients. Postoperative cerebral vascular accident occurred less frequently in clamp-on (14/153, 10%) compared with the open-distal group (190/981, 20%). Clamp-on had greater 30-day mortality (39/153, 25%) than the open-distal group (158/981, 16%), and 5-year survival was also worse in clamp-on (61.8% ± 4.4%) compared with the open-distal group (73.0% ± 1.6%). The open-distal technique was used more frequently in greater-volume hospitals but was not independently associated with 30-day mortality. Preoperative condition was an independent risk factor whereas hospital volume and later year of operation were beneficial in regard to short-term outcome. Open-distal was independently associated with improved mid-term survival.CONCLUSIONS: Patients who underwent operation with the clamp-on were sicker on presentation and had worse short- and mid-term survival compared with the open-distal group. Patients in the open-distal group had greater rates of cerebrovascular complications. The results support the routine use of open-distal anastomosis as the primary operative strategy for ATAAD, although clamp-on can be performed successfully in select cases.

BACKGROUND AND AIMS: Anastomotic ulceration (AU) is a rare potential life-threatening complication that may occur after intestinal resection. The diagnosis is often delayed after a long-lasting history of refractory anemia. The pathogenesis remains unknown and there are no established therapies. The aim of the study was to analyze the medical history of children with short bowel syndrome (SBS) who were experiencing AU. METHODS: Records of SBS children were retrospectively reviewed. Demographics, baseline characteristics, presentation, diagnosis and treatment of AU cases were analyzed. RESULTS: Eight out of 114 children with SBS were identified as having AU. Mean gestational age was 32.5weeks. Underlying diseases were: 5 necrotising enterocolitis, 2 gastroschisis and 1 multiple intestinal atresia. The mean age at AU diagnosis was 6.5years (diagnosis delay of 35months). All but 2 patients had AU persistency after medical treatment. Endoscopic treatment (2 argon plasma coagulation; 1 platelet-rich fibrin instillation; 2 endoscopic hydrostatic dilations) was effective in 3 out of 5 children. Surgery was required in 3 patients. CONCLUSIONS: Severe bowel ischemic injury, especially in preterm infant, could predispose to AU development. Medical treatment showed discouraging results. We firstly described that different endoscopic treatment could be attempted before resorting to further surgery. LEVEL OF EVIDENCE: IV.

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Advanced microsurgical procedures are currently limited by human precision and manual dexterity. The potential of robotics in microsurgery is highlighted, including a general overview of applications of robotic assistance in microsurgery and its introduction in different surgical specialties. A new robotic platform especially designed for (super) microsurgery is presented. Results of an in vivo animal study underline its feasibility and encourage further development toward clinical studies. Future directions of robotic microsurgery are proposed.

Introduction: Supermicrosurgical lymphatic-venous anastomosis (LVA) can improve limbs lymphedema. We describe a technique that we employ for preoperative lymphatic mapping of the upper limb (UL), when indocyanine green (ICG) lymphography shows only dermal backflow (DB) and no lymphatic vessel is detectable. Patients and methods: Sixteen patients undergoing LVA for unilateral UL lymphedema, showing “stardust” or “diffuse” DB pattern, were included. Demographic, clinical data, and limbs measurements were recorded. LymQoL arm questionnaire was administered. Mean age of patients was 58.8 ± 13.1 years. Fifteen were females and 1 male. Lymphatic anatomy of the healthy limb was investigated by ICG lymphography and reported on the affected limb by a four steps technique: marking the main lymphatic pathway on the healthy limb, measuring of the distances at seven levels between the pathway and a line joining fixed landmarks, reporting these measurements on the affected limb with a correction proportional to the degree of swelling, marking skin incisions at the intersection of this pathway with venules, individuated by near infrared light system. Results were analyzed by postoperative questionnaire and changes of limb measurements. Results: For every limb, we could find 3 ± 0.73 incision sites each containing at least one lymphatic vessel suitable for anastomosis. In every patient, we could perform 3.38 ± 0.62 anastomoses. Mean follow-up was 12.13 ± 2.73 months. After surgery, mean preoperative QoL score increased from 5.5 to 7.9 (P <.001), and mean difference between the mean circumferences of the affected and healthy limbs decreased from 4.3 ± 1.3 to 2.5 ± 1.3 cm, showing improvement of swelling after surgery (P <.01). Conclusion: This technique allowed to preoperatively map UL lymphatics even if diffuse DB was present.

Study Objective: We present a very rare case of focal metastasis of endometrial cancer to the small bowel entirely managed laparoscopically. Design: Case report (Canadian Task Force Classification Study design III). Setting: Tertiary referral centre in Rome, Italy. Patients: A 58 year-old patient with a FIGO Stage IB G2 N0 endometrial cancer was found to have a vaginal cuff recurrence and an isolated distant metastasis to the small bowel 13 months after primary treatment. Intervention: In this video we show a fully laparoscopic management mainly focusing on small bowel resection with intracorporeal anastomosis. A laparoscopic partial colpectomy was also performed. Our institutional review board approved this study. Measurements and main results: Operative time was 180 minutes. Intraoperative blood loss was less than 100 mL. The operation was performed successfully with no intraoperative complications. Pathologic findings showed recurrent disease in the vaginal cuff and in the resected small bowel segment with free resection margins in both specimens and 3 mesenteric local nodes negative for metastasis. The patient was discharged on day 3 and 26 days later started adjuvant chemotherapy. After a 16-month follow-up period, the patient is still disease free and in good general conditions. Conclusions: This case shows a successful laparoscopic management of recurrent endometrial cancer equiring complex surgical procedures.

Background Compression anastomotic ring-locking procedure (CARP) is a novel procedure for creating colonic anastomoses. The surgical procedure allows perioperative quantification of the compression pressure between the intestinal ends within the anastomosis and postoperative monitoring of the anastomotic integrity. We have recently shown that CARP is a safe and effective method for colonic anastomoses in pigs, and the purpose of the present study was to evaluate CARP for colonic anastomoses in humans. Materials and methods This is a prospective study on 25 patients undergoing elective left-sided colonic resection. Time for evacuation of the anastomotic rings, perioperative compression pressure, and adverse effects were recorded. Postoperative blood samples were collected daily, and flexible sigmoidoscopy was performed 8–12 weeks after surgery to examine the anastomoses. Results Fourteen out of 25 patients underwent CARP. CARP was not used in 11 patients due to advanced tumor disease (two cases) and size restrictions (nine cases). No case of anastomotic leakage, bowel obstruction, or stenosis formation was observed. No device-related perioperative adverse events were noted. The surgical device evacuated spontaneously in all patients by the natural route after a median of 10 days. Perioperative compression pressure ranged between 85 and 280 mBar (median 130 mBar). Flexible sigmoidoscopy revealed smooth anastomoses without signs of pathological inflammation or stenosis in all cases. Conclusion Our results indicate that the novel suture-less CARP is a safe and effective method for creating colonic anastomoses. Further studies are warranted in larger patient populations to compare CARP head-on-head with stapled and/or hand-sewn colonic anastomoses., BACKGROUND: Compression anastomotic ring-locking procedure (CARP) is a novel procedure for creating colonic anastomoses. The surgical procedure allows perioperative quantification of the compression pressure between the intestinal ends within the anastomosis and postoperative monitoring of the anastomotic integrity. We have recently shown that CARP is a safe and effective method for colonic anastomoses in pigs, and the purpose of the present study was to evaluate CARP for colonic anastomoses in humans.MATERIALS AND METHODS: This is a prospective study on 25 patients undergoing elective left-sided colonic resection. Time for evacuation of the anastomotic rings, perioperative compression pressure, and adverse effects were recorded. Postoperative blood samples were collected daily, and flexible sigmoidoscopy was performed 8-12 weeks after surgery to examine the anastomoses.RESULTS: Fourteen out of 25 patients underwent CARP. CARP was not used in 11 patients due to advanced tumor disease (two cases) and size restrictions (nine cases). No case of anastomotic leakage, bowel obstruction, or stenosis formation was observed. No device-related perioperative adverse events were noted. The surgical device evacuated spontaneously in all patients by the natural route after a median of 10 days. Perioperative compression pressure ranged between 85 and 280 mBar (median 130 mBar). Flexible sigmoidoscopy revealed smooth anastomoses without signs of pathological inflammation or stenosis in all cases.CONCLUSION: Our results indicate that the novel suture-less CARP is a safe and effective method for creating colonic anastomoses. Further studies are warranted in larger patient populations to compare CARP head-on-head with stapled and/or hand-sewn colonic anastomoses.

BACKGROUND/AIM: Anastomotic leakage remains a frequent and serious complication in gastrointestinal surgery. In order to reduce its incidence, several clinical and experimental studies on anastomotic sealing have been performed. In a number of these studies, the sealing material has been fibrin glue (FG), and the results in individual studies have been varying. The positive effect of anastomotic sealing with FG might be due to the mechanical/physical properties, the increased healing of the anastomoses or both. The aim of this systematic review was to evaluate the existing evidence on the healing effects of FG on gastrointestinal anastomoses.METHODS: PubMed, EMBASE and the Cochrane databases were searched for studies evaluating the healing process of gastrointestinal anastomoses after any kind of FG application. The search period was from 1953 to December 2013.RESULTS: Twenty-eight studies were included in the qualitative synthesis. These studies were all experimental studies, since no human studies used histological or biochemical evaluation of healing. In 7 of the 28 studies, a positive effect of FG on healing was found, while 8 studies reported a negative effect and 11 studies found no effect. Furthermore, 2 studies reported unclear results. The difference in the study outcome was independent of the study design and the type of FG used.CONCLUSION: In the available studies, FG did not consistently have a positive influence on the healing of gastrointestinal anastomoses. It is consequently plausible that the positive effect of FG sealing of gastrointestinal anastomoses, if there is any, may be due to a mechanical sealing effect rather than due to improved healing per se.

Postsurgical subcutaneous lymphocele is caused by accidental lesion of a lymphatic vessel that keeps on flowing lymph under the scar. Traditional treatments include aspiration and compression, with probable recurrence, and sclerotherapy which destroys both lymphatic cyst and vessel, creating risk of lymphedema. We describe the case of a postsurgical subcutaneous lymphocele of the left leg that was treated by supramicrosurgical lympatic-venous anastomosis. A single anastomosis was performed end-to-end, between one lymphatic vessel, individuated through indocyanine green lymphography, and one subcutaneous vein, distally to the lymphocele, under sedation and local anesthesia. Postoperative course was uneventful; the lymphocele completely resolved and never recurred during the nine months followup. This technique may heal the lymphocele with no impairing of lymph drainage function.

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We investigated risk factors and prognostic implications of symptomatic anastomotic leakage after anterior resection for rectal cancer, and the influence of a diverting stoma. Our retrospective review of prospective collected data analyzed 475 patients who underwent anterior resection for rectal cancer. Uni- and multivariate analysis was made between anastomotic leakage and patient, tumor, and treatment variables, either for the overall group (n = 475) and in the midlow rectal cancer subgroup (n = 291). Overall rate of symptomatic leakage was 9 per cent (43 of 475) with no related postoperative mortality. At univariate analysis, significant factors for leak were a tumor less than 6 cm from the anal verge (13.7 vs 6.6%; P = 0.011) and intraoperative transfusions (16.9 vs 4.3%; P = 0.001). Similar results were observed in the midlow rectal cancer subgroup. At multivariate analysis, no parameter resulted in being an independent prognostic factor for risk of leakage. In patients with a leakage, a temporary enterostomy considerably reduced the need for reoperation (12.5 vs 77.8%; P < 0.0001) and the risk of a permanent stoma (18.7 vs 28.5%; P = 0.49). The incidence of anastomotic failure increases for lower tumors, whereas it is not influenced by radiotherapy. Defunctioning enterostomy does not influence the leak rate, but it mitigates clinical consequences.

OBJECTIVE: To investigate the impact of anastomotic leak (AL) on disease recurrence and long-term mortality in patients alive 120 days after curative resection for colonic cancer.BACKGROUND: There is no solid data as to whether AL after colonic cancer surgery increases the risk of disease recurrence.METHODS: This was a nationwide cohort study of 9333 patients, prospectively registered in the database of the Danish Colorectal Cancer Group and merged with data from the Danish Pathology Registry and the National Patient Registry. Multivariable Cox regression analysis was used to adjust for confounding.RESULTS: The incidence of AL was 6.4%, 744 patients died within 120 days. Of the remaining 8589 patients, 861 (10.0%) developed local recurrence with no association to AL [adjusted hazard ratio (HR) = 0.78; 95% confidence interval (CI): 0.55-1.12; P = 0.184]. Distant recurrence developed in 1281 (14.9%) patients and more frequently after AL (adjusted HR = 1.42; 95% CI: 1.13-1.78; P = 0.003). AL was also associated with increased long-term mortality (adjusted HR = 1.20; 95% CI: 1.01-1.44; P = 0.042). In 2841 patients with stage III cancer, AL was associated with both decreased likelihood of receiving adjuvant chemotherapy (adjusted HR = 0.58; 95% CI: 0.45-0.74; P < 0.001) and a delay to initial administration (16 days; 95% CI: 12-20 days; P < 0.001).CONCLUSIONS: AL was significantly associated with increased rates of distant recurrence and long-term all-cause mortality. Cancelled or delayed administration of adjuvant chemotherapy may partly account for these findings.

OBJECTIVE: To investigate the impact of anastomotic leak (AL) on disease recurrence and long-term mortality in patients alive 120 days after curative resection for colonic cancer.BACKGROUND: There is no solid data as to whether AL after colonic cancer surgery increases the risk of disease recurrence.METHODS: This was a nationwide cohort study of 9333 patients, prospectively registered in the database of the Danish Colorectal Cancer Group and merged with data from the Danish Pathology Registry and the National Patient Registry. Multivariable Cox regression analysis was used to adjust for confounding.RESULTS: The incidence of AL was 6.4%, 744 patients died within 120 days. Of the remaining 8589 patients, 861 (10.0%) developed local recurrence with no association to AL [adjusted hazard ratio (HR) = 0.78; 95% confidence interval (CI): 0.55-1.12; P = 0.184]. Distant recurrence developed in 1281 (14.9%) patients and more frequently after AL (adjusted HR = 1.42; 95% CI: 1.13-1.78; P = 0.003). AL was also associated with increased long-term mortality (adjusted HR = 1.20; 95% CI: 1.01-1.44; P = 0.042). In 2841 patients with stage III cancer, AL was associated with both decreased likelihood of receiving adjuvant chemotherapy (adjusted HR = 0.58; 95% CI: 0.45-0.74; P < 0.001) and a delay to initial administration (16 days; 95% CI: 12-20 days; P < 0.001).CONCLUSIONS: AL was significantly associated with increased rates of distant recurrence and long-term all-cause mortality. Cancelled or delayed administration of adjuvant chemotherapy may partly account for these findings.

INTRODUCTION: In colorectal surgery, the most feared complication is anastomotic leakage (AL), which is associated with a high morbidity and mortality. In this study, we focus on treatment of perianastomotic abscess following AL after low anterior resection (LAR) of rectal cancer. In the literature, conservative irrigation regimes are reported to perdure for months and some even years and to be associated with a poor stoma closure rate. In the present paper, we evaluated endoscopic vacuum treatment of the perianastomotic abscess.MATERIAL AND METHODS: Patients who had LAR due to rectal cancer with total mesorectal excision (TME) performed in Slagelse and Næstved Hospitals in the 2008-2012 (1st February) period were identified in the Danish Colorectal Cancer Group database. We included patients who had AL and who did not require emergency reoperation and were treated with endoscopic vacuum in the study period. Patients who initiated treatment more than one month after the leakage were excluded. All patients had primary ileostomy.RESULTS: A total of 13 patients were included. All patients had successful closure of the perianastomotic abscess for a median of 18 (3-40) days in a median of eight (1-18) sessions. The median length of hospital stay was 25 (7-39) days. Mortality was zero, and the stoma closure rate was 12/13 (97%).CONCLUSION: Our data support the positive findings previously reported by other studies. Endoscopic vacuum treatment seems to be a safe approach for selected patients in the treatment of perianastomotic abscess after LAR with TME of rectal cancer.FUNDING: not relevant.TRIAL REGISTRATION: not relevant.

INTRODUCTION: In colorectal surgery, the most feared complication is anastomotic leakage (AL), which is associated with a high morbidity and mortality. In this study, we focus on treatment of perianastomotic abscess following AL after low anterior resection (LAR) of rectal cancer. In the literature, conservative irrigation regimes are reported to perdure for months and some even years and to be associated with a poor stoma closure rate. In the present paper, we evaluated endoscopic vacuum treatment of the perianastomotic abscess.MATERIAL AND METHODS: Patients who had LAR due to rectal cancer with total mesorectal excision (TME) performed in Slagelse and Næstved Hospitals in the 2008-2012 (1st February) period were identified in the Danish Colorectal Cancer Group database. We included patients who had AL and who did not require emergency reoperation and were treated with endoscopic vacuum in the study period. Patients who initiated treatment more than one month after the leakage were excluded. All patients had primary ileostomy.RESULTS: A total of 13 patients were included. All patients had successful closure of the perianastomotic abscess for a median of 18 (3-40) days in a median of eight (1-18) sessions. The median length of hospital stay was 25 (7-39) days. Mortality was zero, and the stoma closure rate was 12/13 (97%).CONCLUSION: Our data support the positive findings previously reported by other studies. Endoscopic vacuum treatment seems to be a safe approach for selected patients in the treatment of perianastomotic abscess after LAR with TME of rectal cancer.FUNDING: not relevant.TRIAL REGISTRATION: not relevant.

Laser-based repairing techniques offer several advantages respect to standard suturing in microsurgery. In this work we evaluate the applicability and feasibility of two innovative laser-based approaches for microvascular repair and anastomoses: (1) laser-assisted vascular repair (LAVR); (2) laser-assisted end-to-end vascular anastomosis (LAVA). All these procedures have been executed by the use of diode laser irradiation and chitosan-patches infused with Indocyanine Green (ICG).

Prolonged left-to-right shunting in piglets does not further aggravate pulmonary vasculopathy, but is a cause of RV failure, which appears related to an activation of apoptosis and inflammation.

Three-month chronic systemic-to-pulmonary shunting in growing piglets has been reported as an early pulmonary arterial hypertension (PAH) model with preserved right ventricular (RV) function. We sought to determine whether prolonged shunting might be associated with more severe PAH and RV failure., Journal Article, Research Support, Non-U.S. Gov't, SCOPUS: ar.j, info:eu-repo/semantics/published

Three-month chronic systemic-to-pulmonary shunting in growing piglets has been reported as an early pulmonary arterial hypertension (PAH) model with preserved right ventricular (RV) function. We sought to determine whether prolonged shunting might be associated with more severe PAH and RV failure., Journal Article, Research Support, Non-U.S. Gov't, SCOPUS: ar.j, info:eu-repo/semantics/published

Prophylactic (procto-) colectomy is the treatment of choice to reduce the risk of colorectal cancer in FAP patients with multiple adenomas. Because patients present at young age, rectum-sparing surgery is sometimes advocated, so that there is no pelvic dissection with impact on quality of life, preserved pelvic innervation and sexual function and fertility. The main disadvantage of a total colectomy with an ileorectal anastomosis (IRA) is a rectal cancer risk of 50% at the age of 50 years and a cumulative risk of 25.8% after 25 years of follow-up. Therefore, this procedure should be reserved for patients with an unaffected rectum. There should be no discussion to perform a primary IPAA in patients with multiple rectal adenomas (> 20) or those with a severe dysplastic or large (> 3 cm) rectal adenoma or a cancer elsewhere in the colon. A patient with an IRA should undergo yearly follow-up by rectoscopy.

The intravascular stenting (IVaS) method was published by Narushima and Koshima in 2008. This method involves using a monofilament nylon stent to make the anastomosis of small vessels easier. The aim of this study was to explore the IVaS technique to determine its advantages, disadvantages, and usefulness for inexperienced microsurgeons and also for more experienced practitioners during difficult anastomoses. The study was approved by the Catholic University of Louvain Animal Experimentation Ethics Committee. The study was done on 20 Wistar rats; each rat acting as his own control. Group 1 had an anastomosis done with the IVaS technique on the femoral artery. Group 2 had a classic end-to-end anastomosis without a stent. All anastomoses were performed by the same trainee surgeon with 4 months experience in microsurgery. The diameter of the external artery, distance between the double clamp forceps, stent length, number of sutures, stent preparation, and installation time and suture time were all measured. Anastomotic patency was verified using O'Brien's Patency test. The rats were anesthetized 1 week later to reassess the patency of the vessels. While the anastomotic time was shorter in the stent group, the preparation time was longer and so the total time to perform the anastomosis in both groups was the same. All vessels were patent at the completion of the anastomosis. At 1 week, patency rates were identical (83.3%) in both groups. The study shows an improvement in suturing time in the IVaS group. The time saved is equivalent to the time required for preparation and installation of the stent. At 7 days, the Patency test was identical for the two groups (83.3%). IVaS technique is a useful method of vessels anastomosis especially for junior surgeons. The reason why the patency rate was not 100% at 1 week may be because of excessive manipulation of the stent causing thrombosis in the IVaS group and imperfections in suturing technique by a trainee surgeon. Different a

Restorative coloproctectomy (RCP) with ileal pouch-anal anastomosis (IPAA), is one of the surgical responses to the crucial question of prophylactic treatment in familial adenomatous polyposis (FAP). No consensus has been reached, until now, to choose between IPAA and ileo-rectal anastomosis (IRA), the rectal sparing prophylactic colectomy. This paper aims to review the latest issues related to IPAA and highlights its specificities compared to IRA., Journal Article, Review, SCOPUS: re.j, info:eu-repo/semantics/published

Prophylactic (procto-) colectomy is the treatment of choice to reduce the risk of colorectal cancer in FAP patients with multiple adenomas. Because patients present at young age, rectum-sparing surgery is sometimes advocated, so that there is no pelvic dissection with impact on quality of life, preserved pelvic innervation and sexual function and fertility. The main disadvantage of a total colectomy with an ileorectal anastomosis (IRA) is a rectal cancer risk of 50% at the age of 50 years and a cumulative risk of 25.8% after 25 years of follow-up. Therefore, this procedure should be reserved for patients with an unaffected rectum. There should be no discussion to perform a primary IPAA in patients with multiple rectal adenomas (> 20) or those with a severe dysplastic or large (> 3 cm) rectal adenoma or a cancer elsewhere in the colon. A patient with an IRA should undergo yearly follow-up by rectoscopy., Journal Article, Review, SCOPUS: re.j, info:eu-repo/semantics/published

Restorative coloproctectomy (RCP) with ileal pouch-anal anastomosis (IPAA), is one of the surgical responses to the crucial question of prophylactic treatment in familial adenomatous polyposis (FAP). No consensus has been reached, until now, to choose between IPAA and ileo-rectal anastomosis (IRA), the rectal sparing prophylactic colectomy. This paper aims to review the latest issues related to IPAA and highlights its specificities compared to IRA.

INTRODUCTION: This was a pilot project performed prior to full implementation of early loop ileostomy closure (within two weeks) following low anterior resection of the rectum in a group of patients selected according to previously recommended criteria for safe, early ileostomy closure.MATERIAL AND METHODS: Retrospective review of medical records. Patients undergoing loop ileostomy closure between December 2009 and October 2010 were analyzed. Data were collected on demographics, tumour characteristics, information about the perioperative period, operative details, postoperative complications, closure operation, the postoperative closure period and follow-up.RESULTS: Eleven patients were included (men, n = 4) with a median age of 58 years (range 47-79 years). Ileostomy closure was performed at a median of ten days (range 8-13 days) following rectum resection. The median hospital stay was 16 days (range 14-24 days). No re-laparotomies were performed. One patient developed a pelvic pus collection ten days post closure and was treated conservatively. One patient died 32 days after closure for reasons not related to surgery.CONCLUSION: The results of this small retrospective study show morbidity rates associated with early loop ileostomy closure that are probably acceptable. Safety, feasibility, timing and selection criteria should be clarified in large randomized studies.FUNDING: not relevant.TRIAL REGISTRATION: not relevant.

The aim of this study was to evaluate whether oxidized regenerated cellulose (ORC), applied to "dirty" surgical wounds, is able to reduce the microbial load and, consequently, the infection rate as compared to conventional local wound treatment.

The laser welding of biological tissues is a particular use of lasers in surgery. The technique has been proposed since the 1970s for surgical applications, such as repairing blood vessels, nerves, tendons, bronchial fistulae, skin and ocular tissues. In vascular surgery, two procedures have been tested and optimized in animal models, both ex vivo and in vivo, in order to design different approaches for blood vessels anastomoses and for the repair of vascular lesions: the laser-assisted vascular anastomosis (LAVA) and the laser-assisted vessel repair (LAVR). Sealing tissues by laser may overcome the problems related to the use of conventional closuring methods that are generally associated with various degrees of vascular wall damage that can ultimately predispose to vessel thrombosis and occlusion. In fact, the use of a laser welding technique provides several advantages such as simplification of the surgical procedure, reduction of the operative time, suppression of bleeding, and may guarantee an optimal healing process of vascular structures, very similar to restitutio ad integrum. Despite the numerous preclinical studies performed by several research groups, the clinical applications of laser-assisted anastomosis or vessel repair are still far off. Substantial breakthrough in the laser welding of biological tissues may come from the advent of nanotechnologies. Herein we describe the present status and the future perspectives in laser welding of vascular structures.

INTRODUCTION: This was a pilot project performed prior to full implementation of early loop ileostomy closure (within two weeks) following low anterior resection of the rectum in a group of patients selected according to previously recommended criteria for safe, early ileostomy closure.MATERIAL AND METHODS: Retrospective review of medical records. Patients undergoing loop ileostomy closure between December 2009 and October 2010 were analyzed. Data were collected on demographics, tumour characteristics, information about the perioperative period, operative details, postoperative complications, closure operation, the postoperative closure period and follow-up.RESULTS: Eleven patients were included (men, n = 4) with a median age of 58 years (range 47-79 years). Ileostomy closure was performed at a median of ten days (range 8-13 days) following rectum resection. The median hospital stay was 16 days (range 14-24 days). No re-laparotomies were performed. One patient developed a pelvic pus collection ten days post closure and was treated conservatively. One patient died 32 days after closure for reasons not related to surgery.CONCLUSION: The results of this small retrospective study show morbidity rates associated with early loop ileostomy closure that are probably acceptable. Safety, feasibility, timing and selection criteria should be clarified in large randomized studies.FUNDING: not relevant.TRIAL REGISTRATION: not relevant.

Restorative coloproctectomy (RCP) with ileal pouch-anal anastomosis (IPAA), is one of the surgical responses to the crucial question of prophylactic treatment in familial adenomatous polyposis (FAP). No consensus has been reached, until now, to choose between IPAA and ileo-rectal anastomosis (IRA), the rectal sparing prophylactic colectomy. This paper aims to review the latest issues related to IPAA and highlights its specificities compared to IRA., Journal Article, Review, SCOPUS: re.j, info:eu-repo/semantics/published

Prophylactic (procto-) colectomy is the treatment of choice to reduce the risk of colorectal cancer in FAP patients with multiple adenomas. Because patients present at young age, rectum-sparing surgery is sometimes advocated, so that there is no pelvic dissection with impact on quality of life, preserved pelvic innervation and sexual function and fertility. The main disadvantage of a total colectomy with an ileorectal anastomosis (IRA) is a rectal cancer risk of 50% at the age of 50 years and a cumulative risk of 25.8% after 25 years of follow-up. Therefore, this procedure should be reserved for patients with an unaffected rectum. There should be no discussion to perform a primary IPAA in patients with multiple rectal adenomas (> 20) or those with a severe dysplastic or large (> 3 cm) rectal adenoma or a cancer elsewhere in the colon. A patient with an IRA should undergo yearly follow-up by rectoscopy., Journal Article, Review, SCOPUS: re.j, info:eu-repo/semantics/published

INTRODUCTION: This was a pilot project performed prior to full implementation of early loop ileostomy closure (within two weeks) following low anterior resection of the rectum in a group of patients selected according to previously recommended criteria for safe, early ileostomy closure.MATERIAL AND METHODS: Retrospective review of medical records. Patients undergoing loop ileostomy closure between December 2009 and October 2010 were analyzed. Data were collected on demographics, tumour characteristics, information about the perioperative period, operative details, postoperative complications, closure operation, the postoperative closure period and follow-up.RESULTS: Eleven patients were included (men, n = 4) with a median age of 58 years (range 47-79 years). Ileostomy closure was performed at a median of ten days (range 8-13 days) following rectum resection. The median hospital stay was 16 days (range 14-24 days). No re-laparotomies were performed. One patient developed a pelvic pus collection ten days post closure and was treated conservatively. One patient died 32 days after closure for reasons not related to surgery.CONCLUSION: The results of this small retrospective study show morbidity rates associated with early loop ileostomy closure that are probably acceptable. Safety, feasibility, timing and selection criteria should be clarified in large randomized studies.FUNDING: not relevant.TRIAL REGISTRATION: not relevant.

Microvascular free tissue transfer in head and neck reconstruction requires suitable recipient vessels which are frequently compromised by prior surgery or radiotherapy to the neck. This article details a new technique of arterial free flap pedicle anastomosis to the internal carotid artery in a vessel-depleted neck. A 63-year-old female was referred because of recurrence of squamous cell carcinoma of the tongue, which involved the left-sided tongue base and pharynx with circumferential involvement of the homolateral external carotid artery. This artery and its branches were excluded as potential recipients. To close the defect after tumor excision, a free vertical rectus abdominis muscle arterial flap pedicle was anastomosed to the homolateral internal carotid artery with the help of a Pruitt-Inahara outlying carotid shunt. The venous anastomosis was performed to the internal jugular vein. The VRAM flap survived without complications. This procedure is to be considered an alternative rescue technique for salvage reconstruction in vessel depleted necks.

Biliary plastic stenting plays a key role in the endoscopic management of benign biliary diseases. Complications following surgery of the biliary tract and liver transplantation are amenable to endoscopic treatment by plastic stenting. Insertion of an increasing number of plastic stents is currently the method of choice to treat postoperative biliary strictures. Benign biliary strictures secondary to chronic pancreatitis or primary sclerosing cholangitis may benefit from plastic stenting in select cases. There is a role for plastic stent placement in nonoperative candidates with acute cholecystitis and in patients with irretrievable bile duct stones.

Duodenal fistula (DF) after gastrectomy continues to be a life-threatening problem. We performed a retrospective multicenter study analyzing the characteristics of DF after elective gastrectomy for malignant disease.

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INTRODUCTION: European System for Cardiac Operative Risk Evaluation (EuroSCORE) has been used to predict the postoperative mortality rate for patients undergoing open-heart surgery. The contributions of EuroSCORE in off-pump coronary artery bypass grafting (CABG) has not yet clearly elucidated. METHODS: Consecutive patients of isolated off-pump CABG performed from 2000 when we start performing 'routine' off-pump procedures were stratified using the additive EuroSCORE. Incidence of postoperative mortality, morbidity, and recovery were assessed, and compared to an historical cohort of on-pump procedures performed between 1991 until 1998 when CABG had been routinely performed under on-pump. RESULTS: There were 1318 patients in the off-pump and 1162 patients in the on-pump group. EuroSCORE of the off-pump group was significantly higher than that of the on-pump group. In both the on- and off-pump groups, mortality, total incidence of major complications, heart failure, and renal failure, and three parameters of recovery time were well correlated with EuroSCORE; however, the discriminatory power of the EuroSCORE model was always better in the on-pump group than in the off-pump group. Stroke was correlated with EuroSCORE only in the on-pump group. Pneumonia, mediastinitis postoperative myocardial infarction, or mediastinitis was not correlated with EuroSCORE in either group. In the off-pump group, postoperative major complication was reduced and postoperative recovery was shortened significantly, compared to those in the on-pump group. CONCLUSION: In off-pump CABG, EuroSCORE can, but not as good as in on-pump CABG, predict mortality, certain major postoperative complications, and postoperative recovery. This suggests off-pump technique appears to modify the risk stratification of the patients undergoing CABG.

Although full bowel preparation, including mechanical washout and non-absorbable antibiotherapy, has been considered for decades as a prerequisite to any elective colorectal surgery, recent literature has suggested that this habit was perhaps unjustified. The aim of this study was to assess the safety of ileocolic, colocolic and colorectal anastomosis in the absence of pre-operative mechanical bowel preparation., Journal Article, SCOPUS: ar.j, info:eu-repo/semantics/published

Although full bowel preparation, including mechanical washout and non-absorbable antibiotherapy, has been considered for decades as a prerequisite to any elective colorectal surgery, recent literature has suggested that this habit was perhaps unjustified. The aim of this study was to assess the safety of ileocolic, colocolic and colorectal anastomosis in the absence of pre-operative mechanical bowel preparation., Journal Article, SCOPUS: ar.j, info:eu-repo/semantics/published

The serial transverse enteroplasty (STEP) procedure appears beneficial clinically, but the mechanism(s) underlying these effects remains unclear. The present study evaluated the nutritional, hormonal, and morphologic effects of the STEP procedure in a rodent model of short bowel syndrome.