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BACKGROUND Consensus agreements regarding laparoscopic sleeve gastrectomy (LSG) advise against using staple loads less than 1.5 mm in closed staple height. However, few data exist to support this recommendation. We hypothesized that using staples with a shorter closed height would actually decrease incidence of intraoperative and postoperative bleeding during LSG, while not increasing the incidence of leak. METHODS All LSG cases for a single institution from 1/1/2014 to 12/31/2019 were exported for analysis. Two cohorts were established: 1. 'Green/Blue' group was cases in which no white cartridges were used and 2. 'White' group was cases in which any white cartridges were used. Demographic variables, procedural characteristics, hospital length of stay, and postoperative outcomes were compared between groups. RESULTS The study populations included 1710 patients, 974 in the green/blue group and 736 in the white cartridge group. There were no significant differences in postoperative leak, bleed, stricture, readmission, or death while using white staple loads as compared with the standard combination of blue and green loads. CONCLUSION Using staples with a shorter closed height during LSG did not impact the postoperative bleeding or leak rate. The impact from selection of shorter staples to achieve more tissue compression may be limited.

Laparoscopic sleeve gastrectomy (SG) continues to grow in popularity as a primary bariatric procedure. The purpose of this study is to determine if leak rates and need for subsequent interventions are changed by the standardized use of a closed suction calibration system (CSCS) at a high-volume urban hospital. A retrospective review was conducted between January 1, 2016, and December 31, 2018, on SG patients. All cases performed in 2018 were completed with a closed suction calibration system. Patient demographics, comorbidities, operative variables, and outcomes were collected. Descriptive statistics and chi-squared test were used to compare the two groups. Logistic regression models were adjusted for patient- and procedure-specific factors. Four hundred ninety cases were performed before and 195 after institution of the CSCS. Groups were similar in most characteristics, including median body mass index (BMI) (46.4 vs 45.8 kg/m2, p = 0.79). Those in the closed suction cohort were more likely to have OSA requiring therapy (32.4% vs 46.6%, p

Once a common bariatric procedure, laparoscopic adjustable gastric band (LAGB) is more frequently the subject of conversion procedures, particularly to laparoscopic sleeve gastrectomy (LSG), due to failure of weight loss, weight regain, and band intolerance. Staple line reinforcement (SLR) in primary LSG has been studied extensively, but has not been evaluated in revision procedures. The aim of this study is to investigate commonly used SLR techniques and their effects on morbidity and mortality in single-stage bands converted to sleeves. The Metabolic and Bariatric Surgery Accreditation Quality and Improvement Program (MBSAQIP) Participant Use Data Files (PUF) for 2015–2016 were utilized to assess data for single-stage bands converted to sleeves based on CPT codes, and records were stratified by technique of staple line reinforcement. The database contained all the defined variables utilized for analysis with the exception of leak rate and overall morbidity, which had to be derived. Thirty-day outcomes were analyzed using multiple bivariate analyses and Bonferroni corrections were applied. Of the 6,286 patients who underwent single-stage bands converted to sleeves for whom SLR data is available, 56.9% of surgeons utilized SLR only, 21.3% chose no reinforcement technique (No SLR), 13.4% chose SLR plus over-sewing of the staple line (SLR+OSL), and 8.4% chose OSL alone. There were no statistically significant differences in rates of death, reoperation, readmission, reintervention, number of bleeding events, and staple line leaks across groups. Choice of SLR does not affect number of bleeding events or staple line leak rate.

OBJECTIVE To assess the impact of reconstructive technique on the incidence of cerebrospinal fluid (CSF) leak following retrosigmoid approach to acoustic neuroma resection. STUDY DESIGN Retrospective case series. SETTING Academic medical center. PATIENTS A total of 1,200 patients with acoustic neuromas presented to our institution from 2005 to 2018. Of these, 196 patients underwent surgical resection via a retrosigmoid approach. INTERVENTION At our institution, internal auditory canal (IAC) reconstruction following a retrosigmoid approach was performed with bone wax and muscle plug or Norian hydroxyapatite bone cement from 2005 to 2013. Starting in 2014, a newer model of bone cement, Cranios hydroxyapatite, was used exclusively for reconstruction. MAIN OUTCOME MEASURES Rates of CSF leak were evaluated across different methods of IAC reconstruction and types of bone cement. Patients whose leaks were attributable to the craniectomy site were excluded from analysis. RESULTS The postoperative CSF leak rate among patients who did not receive bone cement for IAC reconstruction was 15.6% (n.5). The leak rate amongst patients who received Norian bone cement was 6.3% (n.4). After introduction of Cranios bone cement, the total leak rate decreased to 1% (n.1). Compared with all other types of closure, Cranios had a significantly reduced rate of postoperative CSF leak (p

Objectives At least partially technically related, a cervical esophagogastric anastomosis has a 12% to 14% leak rate, which is theoretically reducible with simulator practice. Preliminary development and testing of a cervical esophagogastric anastomosis simulator are described. Methods A portable, low-cost, scale reproduction of the cervical esophagogastric anastomosis operative site was engineered around a 19 × 11 × 6-cm plastic box. Silicone "esophageal" and "gastric tip" castings permitted construction of a stapled side-to-side cervical esophagogastric anastomosis guided by an illustrated curriculum. In a 2-phase pilot study, the simulator and curriculum were evaluated. Phase 1: Seven faculty evaluated fidelity using a 5-point, 24-item survey of (1) physical attributes, (2) realism of materials, (3) realism of experience, (4) value, and (5) relevance, and (6) ability to perform tasks. Overall impression of the simulator was also measured. Phase 2: Eight thoracic surgical trainees similarly evaluated the simulator and the quality of the curriculum. Faculty and trainee ratings were compared using a Rasch model, and inter-rater agreement was estimated. Results There were no overall fidelity differences across faculty and resident ratings. Combined observed averages ranged from 4.52 (Realism of Materials) to 5.00 (Relevance). Lifelike feel of esophagus had the lowest ratings (observed average = 4.40). Residents rated interrupted outer layer of anterior closure to be more difficult (observed average = 4.13) than faculty (observed average = 4.86; P = .016, d = 1.99). Global ratings (observed average = 3.33/4.00) indicated participants believed the simulator could be used for cervical esophagogastric anastomosis training now, but could be improved slightly. Conclusions Preliminary evidence suggests the novel cervical esophagogastric anastomosis simulator is valuable as a surgical training tool.

Background Laparoscopic gastrectomy (LG) for cancer has been introduced in institutions worldwide in an effort to minimize surgical trauma, while aiming to provide comparable oncological outcomes to conventional open gastrectomy (OG). The aim of this study was to present our results during the period of implementation of the laparoscopic technique. Materials and methods In 2012, LG for the treatment of gastric cancer was introduced at our institution. The results presented are based on a retrospective analysis of data from a cohort of all patients treated with curative intent over the period 2010-2018. Results During the study period, 206 patients underwent surgery for gastric cancer: 129 patients (62.6%) had an OG and 77 patients (37.4%) an LG. The conversion rate due to technical reasons was 2.6%. LG was associated with significantly less intraoperative blood loss [mean (mL), OG 544 versus LG 176] and shorter hospital stay than OG [mean (d), OG 12 versus LG 8], fewer severe complications (Clavien-Dindo grade ≥ IIIb) [OG 29 (22.5%) versus LG 9 (11.7%), P = 0.081], significantly lower anastomotic leak rate [OG 18 (14.0%) versus LG 1 (1.3%)] and no 90-day mortality. The percentage of R0 resections was similar between the two groups (OG 82.2% versus LG 85.7%, P = 0.507), while the mean number of resected lymph nodes was significantly higher in the laparoscopic group [OG 34 versus LG 39, P = 0.030]. Conclusions Our data suggest that similar and, in some aspects, better short-term outcomes can be achieved with LG with maintained oncological quality.

Aims Anastomotic leak and chylothorax are serious complications of cardio-oesophagectomy. The application of a tissue sealant to the anastomosis and ligated thoracic duct could be beneficial in protecting against leaks. We aimed to determine if using Tisseel, a fibrin-based tissue sealant, had any impact on anastomotic or chyle leak rates following cardio-oesophagectomy. Methods All elective cardio-oesophagectomys performed in a tertiary upper GI centre between 01/01/2013 and 01/01/2018 were identified. Patient records were retrospectively analysed to assess basic demographics; whether Tisseel was used; whether anastomotic or chyle leak occurred and if so whether this was managed conservatively or surgically. Results 245 records were available, Tisseel was used in 151 cases (61.6%). Patient demographics were similar between the Tisseel and no Tisseel groups (82.7% vs 77.7% male, mean age 66 vs 65 years). There was no significant difference in anastomotic leak (4.0% vs 7.4%, p = 0.24) or chyle leak (6.6% vs 4.3%, p = 0.44) rates. For patients who had an anastomotic leak there was a significantly lower rate of re-thoracotomy when Tisseel was used (16.7% vs 85.7%, p = 0.021). There was no significant difference in re-thoracotomy rates for chyle leak (40% vs 100%, p = 0.085). Conclusion Our data does not show any significant difference in leak rates when Tisseel is used. However, it does show that Tisseel use is associated with lower rate of re-thoracotomy in patients with anastomotic leak. This could possibly be due to smaller contained leaks. Further work is needed to determine the true benefit of Tisseel use in cardio-oesophagectomy.

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: in patient with Whipple's procedure which anastomotic technique has lower leak rate pancreaticogastostomy (PG) or pancreatojejunostomy (PJ)? Using the reported search, 38 articles were found; out of this six studies were deemed to be suitable to answer the question. The outcomes assessed were incidence of anastomotic leaks (pancreatic fistula) in both techniques PG and PJ. In conclusion, the best evidence showed that PG anastomosis has lower incidence of pancreatic fistula in comparison to PJ anastomosis., Highlights • Aim: Comparison of pancreatic fistula rate among pancreaticogastostomy (PG) vs pancreatojejunostomy (PJ) anastomosis. • Result: Six randomized controlled trials were included. • Conclusion: The best evidence showed that PG anastomosis has lower incidence of pancreatic fistula than PJ anastomosis.

Background Exposure to inhalation of anticancer drugs is frequent in anticancer drug handling. Using an activated carbon mask with the ability to remove particulates and vapors of anticancer drugs may be effective. Mask fitting performance is important, because low fitting performance leads to inhalation via bypassing the mask filter (leak). This study evaluated the leak rate of multiple-shaped masks. Methods Activated carbon and nonactivated carbon masks of the pleated-type (like surgical mask) and cup-type were used. Four pharmacists wore the masks and a fitting tester was employed. The particle reduction rate of particles in ambient air was calculated using: particle count (outside - inside)/outside × 100 (%). Leak rate was calculated as the difference in the particle reduction rate due to the presence or the absence of a seal in the mask surroundings. Results Reduction rates of the pleated-type nonactivated carbon mask and the pleated-type activated carbon mask were 14.8% and 34.8% (mean). These values significantly increased to 85.6% and 83.3% upon sealing the mask surroundings. Particle reduction rates of the cup-type nonactivated carbon mask and activated carbon mask were 99.3% and 33.6%. When mask surroundings were sealed, these values were 99.6% and 39.2%. Leak rates of pleated-type nonactivated carbon mask, pleated-type activated carbon mask, cup-type nonactivated carbon mask, and cup-type activated carbon mask were 70.8%, 48.5%, 0.3%, and 5.6%, respectively. Conclusion A difference was found in the leak rate between masks used in anticancer drug handling. Based on the low leak rate, the cup-type activated carbon mask was thought to be effective.

To explore the role of one anastomosis (Mini) gastric bypass (OAGB) for the super-obese patients. Literature review was performed in March 2019 as per PRISMA guidelines. A total of 318 patients were identified. Mean age was 31.8 years. Mean body mass index (BMI) was 57.4 kg/m2. The mean operative time was 93.1 min with median length of stay of 4.5 days. The biliopancreatic limb (BPL) varied from 190 to 350 cm(median 280 cm). Early mortality was 0.31% with seven complications (including 1 revisional surgery). Leak rate was 0%. Mean %excess weight loss (EWL) at 12, 18–24 and 60 months was 67.7%, 71.6% and 90.75%, respectively. OAGB is a safe and effective option for management of super and super-super obese patients with tailoring of the BPL. Larger comparison, follow-up and randomised trials are necessary to validate these findings.

Several authors have reported advantages of the purely endoscopic (PE) approach over traditional purely microscopic (PM) techniques for many sinus and anterior skull base procedures. However, in pituitary surgery, the PE approach carries a number of limitations. Experienced microscopically-trained neurosurgeons are required to master the endoscopic technique which has a steep learning curve due to its one-handed nature and optically-distorted 2-dimensional view. We describe our novel technique, the sequential endoscopic and microscopic pituitary procedure (SEMPP) which does not require microscopically-trained neurosurgeons to alter their technique. We compare SEMPP with the PE approach in terms of outcome and safety. Retrospective chart review of consecutive SEMPP cases performed at our institution between January 2010 and December 2013 was conducted. Operative time, gross total resection rate, resolution of endocrine and visual dysfunction, hospital length of stay, cerebrospinal fluid (CSF) leak rate and revision rates were recorded. 32 patients were identified (50% female, mean age 53.0 years), and 33 SEMPP cases. Mean operating time was 132 min (range 90–200). 69% of patients experienced gross total resection. Most patients (81.3%) with preoperative visual deficit either experienced complete resolution or improved symptoms. The remainder experienced no change in vision. 12.5% (n = 4) of patients experienced intraoperative CSF leaks. All were repaired intraoperatively or with conservative management. Two patients (6.3%) experienced epistaxis managed with conservative measures. The SEMPP technique demonstrates comparable outcomes, complication rates and operative time to PE and PM techniques described in the literature.

A room temperature liquid metal-based microvalve has been proposed in this work. The microvalve has the advantages of easy fabrication, high flexibility, and a low leak rate. By designing a posts array in the channel, the liquid metal can be controlled to form a deformable valve boss and block the flow path. Besides, through adjustment of the pressure applied to the liquid metal, the microvalve can perform reliable switching commands. To eliminate the problem that liquid metal is easily oxidized, which causes the microvalve to have poor repeatability, a method of electrochemical cathodic protection has been proposed, which significantly increases the number of open/close switch cycles up to 145. In addition, this microvalve overcomes the shortcomings of the traditional microvalve that requires an alignment process to assemble all the parts. When the valve is closed, no leak rate is detected at ≤320 mbar, and the leak rate is ≤0.043 μL/min at 330 mbar, which indicates it has good tightness. As an application, we also fabricate a chip that can control bubble flow based on this microvalve. Therefore, this microvalve has great prospects in the field of microfluidics.

INTRODUCTION The incidence of CSF leak following endoscopic transsphenoidal surgery remains the most important measure in the success of any repair. The nasoseptal flap (NSF) has played a pivotal role in reconstructing defects. However, morbidity associated with the NSF includes bleeding, septal injury, altered smell and crusting. Tachosil® is an absorbable fibrin sealant patch that promotes haemostasis and wound healing. The purpose of this study was to evaluate the effectiveness of Tachosil® to repair intraoperative defects during an endoscopic transsphenoidal approach. MATERIALS AND METHODS All patients who underwent an endoscopic transsphenoidal approach with the use of Tachosil® at the Queen Elizabeth Hospital Birmingham, between January 2013 and June 2020 were retrospectively analysed. Tachosil® was used as an overlay patch over of the bony defect, in a multi-layered repair depending on the defect and grade of CSF leak. The primary outcome measure was post-operative CSF leak. RESULTS A total of 52 primary procedures where Tachosil® was used as the overlay were analysed. There were 23 (44.2%) intraoperative CSF leaks. The overall post-operative CSF leak rate was 7.8% (n = 4), with all cases having had a Tachosil® overlay reconstruction with no NSF. A formal NSF was harvested in only five cases alongside the Tachosil® patch, where a grade 2 or more leak was identified at the time of the primary procedure, none of which developed a post-operative leak. No patient had any post-operative adverse outcomes that were attributed to Tachosil®. CONCLUSIONS We believe this to be the largest case series evaluating the endoscopic use of Tachosil® in skull base reconstruction. Our data show that in endoscopic transsphenoidal approach, Tachosil® may be used safely in a multi-layered approach as an effective alternative to the NSF in low flow CSF leak cases, or alongside a NSF in higher flow leaks.

Objective Presently, there are no standards for reporting outcomes of endoscopic endonasal skull base reconstruction (ESBR). This is problematic as a lack of consistent reporting makes synthesizing findings in systematic reviews and meta-analysis challenging. Thus, the aim of this study was to systematically review and describe the patterns of reporting outcomes in ESBR as a foundation for developing reporting guidelines. Study Design Present study is a systematic review. Methods Embase, PubMed, CINAHL, Cochrane Library, and Web of Science were searched for all publications with ≥25 patients and a focus on ESBR. The reporting patterns of each study's variables and outcomes were assessed. Results A total of 112 studies were included in the review. The most commonly reported demographic variables were the number of included patients (n = 112, 100%) and types of pathologies treated (n = 104, 92.9%). Meanwhile, the most routinely described preoperative variable was history of prior treatment (n = 48, 42.9%). Type of reconstruction was a commonly reported intraoperative variable (n = 110, 98.2%), though the rate of intraoperative cerebrospinal fluid (CSF) leak was noted in only 76 studies (67.9%). With regard to postoperative outcomes, postoperative CSF leak rate was routinely provided (n = 101, 90.2%), but reporting of other surgical complications was more inconsistent. Ultimately, of the 43 variables and outcomes reviewed, a median of 12 (range: 4–22) was reported in each study. Conclusion There is significant heterogeneity in the outcomes reported in studies relating to ESBR. This highlights the need for the development of standard reporting guidelines to minimize bias and improve interstudy comparability.

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: is ileocolic anastomotic leak rate higher in handsewn or stapler's anastomosis? Using the reported search, 150 papers were found. 6 studies were deemed to be suitable to answer the question. The outcomes assessed were anastomotic leaks rate in hands Sewn and stapler's ileocolic anastomosis. The evidence does not provide an agreed consensus for which modalities of anastomosis have higher anastomotic leaks rate. Until a high quality randomized control trial is performed, the authors recommend an individual approach in a term of selection of which anastomotic modalities to be used.

Simple Summary One of the most severe postoperative complications after a transthoracic esophagectomy for esophageal cancer is a leakage of the anastomosis created between the remnant esophagus and the stomach. There is substantial debate on which surgical technique and which stapler are the best. The aim of this study was to retrospectively analyze whether the stapler diameter had an impact on postoperative anastomotic leak rates during a 4-year time frame from 2016 to 2020. A total of 632 patients (open, hybrid, and totally minimally invasive esophagectomy) met the inclusion criteria. A total of 214 patients underwent an anastomosis with a 25 mm stapler vs. 418 patients with a 28 mm stapler. Anastomotic leak rates were 15.4% vs. 10.8%, respectively. Stapler size should be chosen according to the individual anatomical situation of the patient and may be of higher relevance in patients undergoing totally minimally invasive reconstruction. Abstract Anastomotic leak is one of the most severe postoperative complications and is therefore considered a benchmark for the quality of surgery for esophageal cancer. There is substantial debate on which anastomotic technique is the best for patients undergoing Ivor Lewis esophagectomy. Our standardized technique is a circular stapled anastomosis with either a 25 or 28 mm anvil. The aim of this study was to retrospectively analyze whether the stapler diameter had an impact on postoperative anastomotic leak rates during a 4-year time frame from 2016 to 2020. A total of 632 patients (open, hybrid, and totally minimally invasive esophagectomy) met the inclusion criteria. A total of 214 patients underwent an anastomosis with a 25 mm stapler vs. 418 patients with a 28 mm stapler. Anastomotic leak rates were 15.4% vs. 10.8%, respectively (p = 0.0925). Stapler size should be chosen according to the individual anatomical situation of the patient. Stapler size may be of higher relevance in patients undergoing totally minimally invasive reconstruction.

Background The insertion of inappropriately sized uncuffed endotracheal tubes (ETTs) with a tight seal or presence of air leakage may be necessary in children. This study aimed to analyze the frequency of the requirement of inappropriately sized uncuffed ETT insertion, air leakage after the ETT was replaced with one of a larger size, and factors associated with air leakage after ETT replacement. Methods Patients under 2 years of age who underwent oral surgery under general anesthesia with uncuffed ETTs between December 2013 and May 2015 were enrolled. The ETT size was selected at the discretion of the attending anesthesiologists. A leak test was performed after intubation. The ETT was replaced when considered necessary. Data regarding the leak pressure (PLeak) and inspiratory and expiratory tidal volumes were extracted from anesthesia records. We considered a PLeak of 10 Leak ≤ 30 cmH2O to be appropriate. The frequencies of the requirement of inappropriately sized ETTs, absence of leakage after ETT replacement, ETT size difference, and leak rate were calculated. A logistic regression was performed, with PLeak, leak rate, and size difference included as explanatory variables and presence of leakage after replacement as the outcome variable. Results Out of the 156 patients enrolled, 109 underwent ETT replacement, with the requirement of inappropriately sized ETTs being observed in 25 patients (23%). ETT replacement was performed in patients with PLeak ≤ 10 cmH2O; leakage was absent after replacement (PLeak 2O) in 52% of patients (25/48). In the multivariate logistic model, the leak rate before ETT replacement was significantly associated with the presence of leakage after replacement (p = 0.021). Conclusions Inappropriately sized ETTs were inserted in approximately 23% of the patients. The leak rate may be useful to guide ETT replacement.

Background Laparoscopic sleeve gastrectomy (LSG) has become a dominant bariatric procedure. In the past, significant leak rates prompted the search for staple line reinforcement (SLR) techniques. Previous analysis of the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program (MBSAQIP) database for all LSG suggested a detrimental influence of SLR on leak rates and overall morbidity. Objective To investigate the relationship between various SLR techniques and bougie size with 30-day outcomes. Setting Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program–accredited bariatric surgery hospitals. Methods Using the Metabolic and Bariatric Surgery Accreditation and Quality Improvement Program 2015 to 2016 Participant Use File data, primary LSG cases were divided into study groups based on surgical techniques. All variables were reported in the Participant Use File except leak rate and overall morbidity, which had to be derived. Multiple bivariate analyses were used to analyze the 30-day outcomes. Results A total of 198,339 primary LSG operations were included and grouped into No SLR (23.0%), SLR (54.2%), oversewn staple line (9.5%), and a combination of SLR + oversewn staple line (13.3%). There were no statistical differences between study groups in mortality, overall morbidity, or leak rate. Bleeding and reoperation rates were statistically higher in the No SLR group. Bougie size was not associated with change in leak rates. Conclusion Primary LSG is a safe procedure with low morbidity and mortality rates. SLR is associated with decreased rates of bleeding and reoperations but does not affect leak rates. The selection of SLR technique should be left to the surgeon's discretion with an understanding of the associated risks, benefits, and costs.

The One Anastomosis (Mini) Gastric Bypass is rapidly gaining acceptance. This review reports cumulative results of 12,807 procedures in obese patients with a mean age of 41.18 years and BMI of 46.6 kg/m2. The overall mortality was 0.10% and the leak rate was 0.96%. The follow-up duration ranged from 6 months to 12 years. A marginal ulceration rate of 2.7% and an anaemia rate of 7.0% were reported. Approximately 2.0% of patients reported postoperative gastro-oesophageal reflux and 0.71% developed malnutrition. Excess weight loss at 6, 12, 24 and 60 months was 60.68, 72.56, 78.2 and 76.6% respectively. Type 2 diabetes mellitus and hypertension resolved in 83.7 and 66.94% respectively. We conclude that there is now sufficient evidence to include MGB-OAGB as a mainstream bariatric procedure.

Gastrointestinal complications are the main source of severe morbidity after cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC), mainly in the form of anastomotic leak. Reducing the rate of anastomotic leaks is of paramount importance and should be approached both through risk factor understanding and reduction, as well as optimization of surgical team performance. We performed a study that describes the details of a technical protocol for the creation of anastomoses after colorectal resections in CRS and HIPEC and the anastomotic outcomes associated with its systematic application in a high-volume peritoneal surface malignancy center. An extremely low, near-zero anastomotic leak rate (0.85% in colorectal anastomoses, 1% in ileo-colic anastomoses, and 0% in ileo-rectal anastomoses) was observed among 1172 patients. Extremely low, near-zero rates of anastomotic leak after colorectal resections in CRS and HIPEC could be achievable in high-volume peritoneal malignancy centers. The described techniques could be adopted and validated in other high-volume peritoneal malignancy centers.

Introduction: Post operative leaks of esophageal anastomosis after esophagectomy is a risky event associated with poor postoperative evolution. Its frequency and severity will depend mainly on surgical technical aspects. Objectives: To analyze the frequency, management and prognosis of leakage of esophageal anastomosis after esophagectomy for esophageal cancer. Material and Method: Analysis of our prospective oncologic database of patients with esophageal cancers submmitted to esofagectomy. Statistical analysis with Fisher’s exact test. Results: 34 out of 37 esophageal cancer patients were included submitted to completely invasive mini esophagectomy. Cervical anastomosis was performed in 79.4% of patients, in the remaining 20.6%, a distal esophagectomy with intrathoracic anastomosis was performed. The leak rate was 38.2% (13/34), of these, 69.2% (9/13) correspond to grade Clavien - Dindo I - II complications. The leak rate was 54.5% (6/11) for retro-sternal gastric ascensus and 43.7% (7/16) for mediastinal route, without significative difference (p = 1.0). The reoperation rate was 11.7%, being a 100% secondary to mediastinal ascensus, 3 of them were submitted to thoracoscopic toilets and an innominate vein repair. Postoperative mortality rate was 5.8%, all concentrated in the group of patients with posterior mediastinal ascensus, but without statistical difference (p = 0.26). Conclusion: Leaks are frequent in patients operated on for esophageal cancer, especially after cervical esophago-gastro-anastomosis with anterior route for ascensus. However, retro-sternal ascensus did not require re-operations, nor postoperative mortality compared to gastric ascensus through posterior mediastinum

The cervical anastomotic leak is a major complication of transhiatal esophagectomy and results in chronic strictures in up to half of patients. A change in postoperative protocol to delaying initiation of oral intake was made with the goal of reducing anastomotic leak rate and associated sequelae. A postoperative protocol change was applied to all patients undergoing elective transhiatal esophagectomy. Rate of anastomotic leak and anastomotic stricture, defined as defect in the esophagogastric anastomosis and narrowing of the anastomosis, respectively, were compared between pre- and post-change groups. Between 2004 and 2013, 203 patients underwent transhiatal esophagectomy with cervical anastomosis. Historically, oral intake was resumed on postoperative day 3, and during the course of the study, a change was made to the protocol to delay oral intake until 15 days postoperatively. Eighty-three patients were in the early oral feeding group (postoperative day 3), and 120 were in the delayed oral intake group (postoperative day 15). There was a statistically significant decrease in the rate of anastomotic leak from 14.5% to 4.2% between the early and delayed intake groups, respectively (P = 0.0089). There was also a trend (P = 0.05) towards a lower rate of anastomotic stricture in all patients in the delayed intake group (15.8%) compared with those in the early feeding group (27.7%). By increasing the time to postoperative oral feeding, we have noted an associated improvement in both immediate and long-term outcomes of elective transhiatal esophagectomy patients.

Background: Esophagectomy remains the gold standard in the curative intent treatment of resectable esophageal cancer. However, this procedure is complex and associated with high risk of complications. In an effort to reduce the postoperative morbidity associated with open esophagectomy various minimally invasive techniques have been introduced and developed during the recent years. The aim of the current study was to present our 4.5-year experience of the gradual implementation of various minimally invasive esophagectomy (MIE) techniques in our tertiary referral center Methods: From May 2012 a transitional period from conventional open esophagectomy to MIE was initiated. This period was preceded by fellowships and visits to expert centers abroad. Thereafter, a gradual implementation and refinement of the new techniques followed. Technique related data were collected prospectively. Results: Between January 1 st 2011 and December 31 st 2016 a total of 249 patients underwent an esophagectomy in our unit. Seventy-six cases were performed through a conventional open esophagectomy and 173 by some type of MIE. An increasing utilization of MIE over this time period was seen and finally reached 100% of treatment intentions, during the last 2 years. Ten cases (5.7%) where converted to open approach. A decrease in leak rate, operating time, peroperative bleeding and hospital stay as well as an increasing number of harvested lymph nodes was observed during the implementation period. Conclusions: The transition from conventional open esophagectomy to MIE was successful at our center. The implementation was overall safe with good postoperative outcomes, although changes in results required technical modifications over time.

PURPOSE The purpose of this paper is to study the causes of leaks following sleeve gastrectomy (SG). MATERIALS AND METHODS Pubmed was searched during January 2016 for publications reporting leak after SG. A total of 205 publications were identified, of which 17 papers were selected. RESULTS In about 3018 patients, reinforcement was used compared with 4595 patients, in whom no reinforcement was applied; both groups were representing matched bariatric populations. The use of reinforcement/buttressing has resulted in different rates of leaks ranging from 0% to 3.9%; whereas with no reinforcement/buttressing, the leak rate was 0.16% to 3.5%. The use of reinforcement/buttressing did not result in reduction of leak to a statistical significance although the trend was suggesting so (P=0.06), whereas no reinforcement/buttressing did not statistically increase the leak rate (P=0.10). CONCLUSIONS No statistical significant difference of leak with or without reinforcement. This mean case complexity and surgical technique and experience are the sole factors for leaks following SG.

The objective of this study is to investigate the long-term performance of a typical CANDU® 1 containment structure. A three-dimensional nonlinear finite element model was built to realistically evaluate the performance of the structure under service load as well as a hypothetical beyond-design level internal pressure. Consideration is given to the time-dependent effects, such as shrinkage, creep, and relaxation of prestressing tendons, over a 60-year timeframe. In addition, the sensitivity of the response of the containment structure against support condition, internal temperature profile and temporary construction openings was also investigated. The accuracy of the numerical model was validated against structural measurements made during a routine leak rate test. The analysis results show that the containment structure would develop a ductile mechanism if the internal pressure significantly exceeded the design pressure. The pressure-deformation relationship of the structure is sensitive to the considered time-dependent parameters.

Decreased blood perfusion at the anastomotic site increases the risk of anastomotic leakage (AL) following colorectal surgery. Indocyanine green near-infrared fluoroangiography (NIRF/ICG) is a technique that allows for the assessment of intestinal perfusion before and after the formation of an anastomosis. We aimed to compare the rate of AL after colorectal surgery conducted with NIRF/ICG assessing vascular anastomotic perfusion and without this support. The data of patients who underwent colorectal surgery from November 2014 to February 2019 were reviewed retrospectively. Left-sided hemicolectomy, sigmoid resection, and anterior rectal resection were included. Emergency resections were excluded. Procedures conducted with NIRF/ICG and without NIRF/ICG (no-NIRF/ICG) support were compared using Fisher’s and Mann–Whitney U test. Overall, 196 procedures were included, 98 were carried out with no-NIRF/ICG and 98 with NIRF/ICG. Patients’ clinical and intraoperative characteristics were similar in the two groups. In the NIRF/ICG, fluorescence was detected in 100% of the cases; following NIRF/ICG the planned site of transection was changed in eight cases, whereas in one case the anastomosis was re-performed. Overall, six patients (3%) developed an AL, 0% in the NIRF/ICG and 6% (n = 6) in the no-NIRF/ICG group (p = 0.029). Median hospital length of stay was shorter in the NIRF/ICG group [6 days (IQR 6–7) vs. 7 days (IQR 6–9), p

SUMMARY Centralization of care has improved outcomes in esophagogastric (EG) cancer surgery. However, specialist surgical centers often work within clinical silos, with little transfer of knowledge and experience. Although variation exists in multiple dimensions of perioperative care, the differences in operative technique are rarely studied. An esophageal anastomosis workshop was held to identify areas of common and differing practice within the operative technique. Surgeons showed videos of their anastomosis technique by open and minimally invasive surgery. Each video was followed by a discussion. Surgeons from 10 different EG cancer centers attended. Eight key technical differences and learning points were identified and discussed: the optimum diameter of the gastric conduit; avoiding ischemia in the gastric conduit; minimizing esophageal trauma; the use of an esophageal mucosal collar; omental wrapping; intraoperative leak testing; ideal diameter of the circular stapler and the growing use of linear stapled anastomoses. The workshop received positive feedback from participants and on 2 years follow-up, 40% stated that they believed that the learning of tips and techniques during the workshop has contributed to lowering their anastomotic leak rate. Many differences exist in surgical technique. The reasons for, and crucially the significance of, these differences must be discussed and examined. Workshops provide a forum for peer-to-peer collaborative learning to reflect on one’s own practice and improve surgical technique. These changes can, in turn, generate incremental improvements in patient care and postoperative outcomes.

AIM to assess results of stapling anastomosis in colorectal surgery. PATIENTS AND METHODS. The results of surgical treatment of 427 patients with rectal cancer and 458 patients with colon cancer (T1-4N0-2M0-1) were analyzed. A circular stapler was used to perform end-to-end (347patients) and side-to-end (80 patients) anastomosis. 164 patients underwent stapling colonic anastomosis. RESULTS. Anastomotic leak rate after stapled colorectal anastomosis was 8,7% (n=37) and was lower after side-to-end anastomosis 3,8% (n=3). Anastomotic leakage developed in only 2 (1,2%) patients after colon anastomosis. CONCLUSION. Proper use of stapling devices and proper surgical technique allow to create reliable anastomosis which safety is comparable the manual one.

Hydroxyapatite cement (HAC) is an osteoconductive material that serves as a scaffold over and inside which bone can grow without intervening fibrous tissue. With micropore diameters of 2–5 nm, HAC is highly resistant to infection. Whether it should be used as the sole bone substitute during cranioplasty or as an adjunct to other materials, it is still a matter of debate, and no direct answer really exists. At our institution, bone flap is always repositioned and fixed with titanium screws prior to layering the HAC. As reconstructive retrosigmoid cranioplasty was combined with an underlay hourglass-shaped autologous pericranium duraplasty, no postoperative wound infections or meningitis were observed nor were clinically significant cerebrospinal fluid (CSF) leaks reported. In the perspective of reducing the postoperative CSF leak rate as much as possible, it is advisable to focus the upcoming research not only on cranioplasty but also on the combination duraplasty-cranioplasty, which yielded very good results in our experience.

Objective The optimal management of dural closure is unclear; therefore, we aimed to survey current common practices among Italian practitioners. Methods The Delphi method was used to achieve a consensus on dura mater closing techniques in Italy. A steering committee decided 3 major topics to be investigated: pre- and postoperative conditions associated with cerebrospinal fluid (CSF) leak, indications to perform watertight dural closure, and dural closure technique. A questionnaire containing 12 statements was then submitted to Italian neurosurgeons. Results The response rate was 60%. Among 60 items, 36 reached a positive consensus, 5 reached a negative consensus, and 19 did not reach consensus. Intrathecal hypertension, arachnoid opening, previous treatments, spinal incidental durotomy, wide size of osteo-dural defect, and lack of nasoseptal flap were considered major risk factors for CSF leak. Early mobilization, avoidance of stress maneuvers, and use of CSF external drainage were considered to reduce CSF leak rate. Italian neurosurgeons always attempt watertight dural closure, ideally with monofilament nonabsorbable sutures. Both autologous and heterologous dural grafts are used. Among dural sealants, fibrin glues are preferred, which are used most commonly in transsphenoidal surgery. Conclusions This study elucidates the areas of consensus and uncertainty on dural closure management among a group of Italian neurosurgeons. It provides reliable and comparable data for the investigation of the departments' daily practice in dural closure. Given the lack of solid evidence, there is a need for further comparative studies of dural repair strategies.

Esophagogastrostomy leakage is a severe complication after esophagectomy for esophageal cancer. Cervical anastomosis usually has a higher leak rate than intrathoracic anastomosis. Esophageal stents will be considered in the management or prevention of esophagogastrostomy leaks. Previously we have used an externally fixed silicone tube in the treatment of cervical esophagogastrostomy leaks. Recently, we started to use anchoring silicone stent for managing or preventing esophagogastrostomy leaks. In the management of one patient with anastomotic leakage, the stent was kept in place for 27 days. In three patients who had a high risk of esophagogastrostomy leaks, the anchoring silicone stents were kept in place for 1 week to protect the anastomosis.

Background Obesity is becoming a worldwide health problem. Recently, bariatric surgeries are developing to combat with this problem. However, these surgical methods themselves have risks. Objectives The present study investigated the preventive effect of routine leak test of both gastrojejunal and jejunojejunal anastomoses immediately after laparoscopic Roux-en-Y gastric bypass (LRYGB) surgery against post-operative leak by inexperienced surgeons. Methods In a prospective interventional study, this research enrolled 52 morbid obese patients with LRYGB from September 2014 to October 2016. After anastomoses, methylene blue and air leak tests were performed and the section line and both anastomosis sites for patency and inspected for air and dye leaks were examined. Results Mean body mass index of patients was 48.84 ± 6.8 kg/m2. Twelve patients had positive leak test and the anastomoses were reinforced by additional sutures. All patients were discharged with no leak and no patient had leak during the routine follow-up period. Conclusions Intraoperative leak test of both gastrojejunal and jejunojejunal anastomoses is a valuable test in the assessment of leak during LRYGB surgery, especially in unskilled surgeons.

This paper reviews design validity before manufacturing HCVT prototype through simulation. The component part is being devided, modeled and checked if it works well to an designer`s original intent about some active modes. Also, the dynamic characteristic is examined how it changes according to alteration of pressure, friction and leak rate. Finally, HCVT design plan is being confirmed if it could be materialized through those analysis.

Wolsong Unit 2,3&4 has been performing a containment integrity test during power operation. This test could impact to the safe operation during test. If an accident occurs during pressure dropping phase, reactor trip can be delayed because of the increased pressure difference which causes a time delay to reach the trip set-point. On the contrary, if an accident occurs during pressure increasing phase, reactor trip could be accelerated because the pressure difference to the trip set-point decrease. Point Lepreau nuclear power plant, which installed GCLMS (Gross Containment Leakage Monitoring System) in 1990, has discontinued the test since 1992 due to these adverse effects. Therefore, we evaluated the risk to obviate the GCLMS test based on PWR's ILRT (Integrated Leak Rate Test) extension methodologies. The results demonstrate that risk increase rate is not high in case of performing only ILRT test at every 5 years instead of doing GCLMS test at every 1.5 years. In addition, the result shows that GCLMS test can be removed on a risk-informed perspective since risk increasement is in acceptable area of regulatory acceptance criteria.

Background Left-sided colonic pathologies requiring emergency resection are commonly encountered on an acute surgical unit. Subspecialist colorectal (CR) management of these patients may result in decreased morbidity, mortality and stoma rates. This study is the first of its kind comparing outcomes between CR surgeons and general surgeons on an acute surgical unit. Methods This is a retrospective review of 196 consecutive patients who underwent emergency left colonic resection on an acute surgical unit between January 2009 and July 2014. Patients were divided into two groups dependent on whether their surgery was managed by a CR specialist or general surgeon. Primary outcome measures were 30-day mortality, rate of primary anastomosis and overall stoma rate. Results Patients in the two groups were comparable for age, sex, American Society for Anesthesiologists score as well as CR POSSUM scores. Rates of primary anastomosis were significantly higher in the CR group compared with the acute surgical unit group (85.5 versus 28.7%, P ≤ 0.001). Overall stoma rates were significantly lower in the CR group (40.4 versus 88.8%, P = 0.0001). Thirty-day mortality was similar in both groups. Other secondary markers of morbidity including length of stay, return to theatre, anastomotic leak rate, wound problems and systemic complications had no significant difference between the two groups. Conclusion Subspecialist CR management of patients undergoing emergency left-sided colonic resection on an acute surgical unit is associated with a similar level of morbidity and mortality while safely achieving significantly higher rates of primary anastomosis and lower stoma rates.

We present our technique for a totally robot-assisted laparoscopic Roux-en-Y gastric bypass. Moreover, data are presented in relation to a single-surgeon experience with use of the robotic platform in bariatric surgery. We reviewed a single surgeon's console and room time from 2009 to 2013 for all robot-assisted Roux-en-Y gastric bypasses (RARYGBs). Revision operations were excluded. There were in total 168 robotic bariatric operations in this time frame. The number of cases performed each year and the cumulative number of each operation were considered as well. The change in console time as related to the number of cases and the change in room time as related to the console time and number of cases were investigated. Complications during this time and their frequency were noted and described. The console time for RARYGB ranged from 131 ± 46 minutes in 2010 to 94 ± 29 minutes in 2013 (P