Search

Anastomotic recurrence after intestinal resection is one of the main embarrassing problems encountered during Crohn's disease (CD) management. This complication is often associated with an expected consequence, mainly a multiple intestinal resection. This systematic review evaluates published evidence on surgical features to reduce surgical recurrence after bowel resection and provide surgeons with recommendations based on published evidence. We conducted bibliographic research on September 05, 2020, through PubMed, Cochrane database, and Google scholar. We retained meta-analysis, randomized clinical trials, and controlled clinical trials. The strength of clinical data and subsequent recommendations were graded according to the Oxford Centre for Evidence-Based Medicine. Fourteen articles were retained. Early resection reduces surgical relapse and the need for additional medical treatment. There was no difference between conventional and laparoscopic bowel resection. Mesenteric excision seems to reduce surgical recurrence. Stapled side-to-side anastomosis reduces surgical recurrence. However, no difference was observed between Kono-S anastomosis ensure at least similar anastomotic recurrence rate compared to conventional anastomosis. Surgical recurrence was reduced after bowel resection when compared to stricturoplasty. There was no difference between the one and two steps resection. Several surgical features have been investigated. Some of them were unanimously found to be effective in lengthening the disease-free relapse. However, others are still controversial. [ABSTRACT FROM AUTHOR]

Aim: Benign anastomotic strictures following colorectal surgical resection are a commonly under‐reported complication in up to 30% of patients, with a significant impact upon quality of life. In this systematic review, we aim to assess the utility of endoscopic techniques in avoiding the need for surgical reintervention. Method: A literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases. Additional papers were found by scanning the references of relevant papers. Results: A total of 34 papers were included, focusing upon balloon dilatation, endoscopic stenting, electroincision, stapler stricturoplasty and cortiocosteroids alone and in combination, with success rates varying from 20% to 100%. The most challenging strictures were reported as those with a narrow lumen, frequently observed following neoadjuvant chemoradiotherapy or an anastomotic leak. Endoscopic balloon dilatation was the most commonly used first‐line method; however, repeated dilatations were often required and this was associated with an increased risk of perforation. Although initial success rates for stents were good, patients often experienced stent migration and local symptoms. Only a small number of patients experienced endoscopic management failure and progressed to surgical intervention. Conclusion: Following identification of an anastomotic stricture and exclusion of underlying malignancy, endoscopic management is both safe and feasible as a first‐line option, even if multiple treatment exposures or multimodal management is required. Surgical resection or a defunctioning stoma should be reserved for emergency or failed cases. Further research is required into multimodal and novel therapies to improve quality of life for these patients. [ABSTRACT FROM AUTHOR]

After surgical resection for Crohn's disease (CD) endoscopic recurrence is noted within few weeks and almost 80% of patients will have evidence of endoscopic recurrence at the anastomosis after ileocolic resection at 1 year. With time and if left untreated surgical recurrence will be detected at the preanastomotic segment or at the anastomosis in the vast majority of cases. It has become progressively apparent also based on these historical data that anastomotic configuration plays a major role in the subsequent recurrence of CD in surgically induced remission. In this article, we will review the evidence in the literature to support the different anastomotic configurations and we will discuss the principles of surgical prophylaxis of CD recurrence. [ABSTRACT FROM AUTHOR]

Infantile intracranial aneurysms (IAs) are extremely rare. IA clipping and embolization have been the most common treatment options. Infantile giant IAs treated by surgical resection and in situ anastomosis have rarely been reported. A 43-day-old female infant was admitted to our hospital because of abnormal crying and vomiting. Multimodal images showed a right temporal hematoma and a giant dissecting IA. With comprehensive preoperative management, IA resection and in situ anastomosis were successfully performed. Furthermore, intraoperative and postoperative multimodal images demonstrated that the parent vessel was patent. Pathological examination showed chronic inflammation of this IA wall. The infant had a favorable outcome during the 3-month follow-up period. Infantile giant IAs are extremely rare. Chronic inflammation might be involved in the pathogenesis of infantile dissecting IAs. IA resection and in situ anastomosis could be a reasonable choice in the management of infantile giant IAs that cannot be completely clipped or embolized. [ABSTRACT FROM AUTHOR]

A 17-year-old, female cockatiel (Nymphicus hollandicus) was presented for a 1-week history of respiratory distress. The clinical signs were consistent with tracheal obstruction; therefore, an air sac cannula was placed to reduce respiratory compromise. Radiographic images of the patient revealed a round, intraluminal, soft tissue opacity in the trachea. The obstruction could be visualized via transtracheal illumination, but tracheoscopy was not feasible because of the size of the patient. Attempts to manually extirpate the obstruction were unsuccessful, and the trachea subsequently avulsed in the midcervical region. Tracheal resection and anastomosis was performed, and the obstruction was removed with the associated tracheal ring. The patient recovered uneventfully and was doing well at follow-up evaluations at 9 days, 24 days, and 10 months after the surgical procedure. The histologic diagnosis was ossifying myelolipoma arising from bone marrow within the tracheal ring. [ABSTRACT FROM AUTHOR]

Intra-arterial embolization of juvenile nasopharyngeal angiofibroma (JNA) prior to surgical resection is the preferred approach to minimize blood loss during surgical resection of the tumor. However, the presence of external carotid artery-internal carotid artery (ECA-ICA) anastomoses may hinder complete tumor embolization due to the associated risk for embolic complications. Here, we evaluate the use of a balloon-assisted embolization (BAE) technique in the treatment of JNA. We conducted a retrospective review of JNA patients who underwent tumor embolization with injection of Onyx in a single session between 2013-2018. All cases displayed tumor arterial supply from ECA and ICA circulations on 2-D catheter angiograms. Procedural and surgical outcome data were analyzed. Results are given as mean±- standard deviation (range). Among 9 patients with JNA, all were males and mean age was 14.1±6.3 years (range, 9-29 years). The mean tumor volume embolization was 84.4±12.4% (range, 60-100%) and in 89% patients =80% of tumor volume embolization was achieved. There were no embolization-related complications reported. During surgical resection of the tumor there was a low average surgical blood loss of 722±651.5 mL (range, 50-2,000 mL) and the mean procedure time was 282.6±85.4 mins (range, 151-403 mins). In this series, the BAE technique showed to be a safe and effective approach to achieve successful tumor embolization while avoiding embolic complications and effectively reducing the risk for blood loss during surgical resection. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to examine and describe the efficiency of endoscopic balloon and bougie dilatation techniques applied to anastomotic strictures developed in patients who underwent a low anterior resection (LAR) and ileostomy. Methods: A total of 167 patients underwent an LAR with an ileostomy due to rectal cancer between July 2014 and December 2017. Nineteen (%11.4) cases with anastomosis stricture were retrospectively evaluated and included in the study. Patients were classified according to the dilation time. Group 1 patients received dilatation within the first 3 months postoperatively, and Group 2 patients received dilatation after 3 months. Demographic data, the dilatation technique, the number of dilatation applications, the level of the stricture, the success rate, and the stoma closure time were evaluated. Results: In Group 1, the mean number of dilatation procedures was 1.8 (range: 1-3), whereas in Group 2, the mean was 3.8 (range: 2-5). The success rate was 100% in Group 1 and 66.6% in Group 2. There was a statistically significant difference between the groups in the requirement for dilatation and the success rate (p=0.022, p=0.028, respectively). Conclusion: It was concluded that dilatation techniques are most successful when applied within 3 months after surgery in cases with stenotic anastomoses. The risk of strictures and the number of repeated dilatations was lower and the success rate was significantly higher in these cases. [ABSTRACT FROM AUTHOR]

Abstract: Aim: An airtight anastomosis on intra‐operative leak testing has been previously demonstrated to be associated with a lower risk of clinically significant postoperative anastomotic leak following left‐sided colorectal anastomosis. However, to date, there is no consistently agreed upon method for management of an intra‐operative anastomotic leak. Therefore, we powered a noninferiority study to determine whether suture repair alone was an appropriate strategy for the management of an intra‐operative air leak. Method: This is a retrospective cohort analysis of prospectively collected data from a tertiary care referral centre. We included all consecutive patients with left‐sided colorectal or ileorectal anastomoses and evidence of air leak during intra‐operative leak testing. Patients were excluded if proximal diversion was planned preoperatively, a pre‐existing proximal diversion was present at the time of surgery or an anastomosis was ultimately unable to be completed. The primary outcome measure was clinically significant anastomotic leak, as defined by the Surgical Infection Study Group at 30 days. Results: From a sample of 2360 patients, 119 had an intra‐operative air leak during leak testing. Sixty‐eight patients underwent suture repair alone and 51 underwent proximal diversion or anastomotic reconstruction. The clinically significant leak rate was 9% (6/68; 95% CI: 2–15%) in the suture repair alone arm and 0% (0/51) in the diversion or reconstruction arm. Conclusion: Suture repair alone does not meet the criteria for noninferiority for the management of intra‐operative air leak during left‐sided colorectal anastomosis. Further repair of intra‐operative air leak by suture repair alone should be reconsidered given these findings. [ABSTRACT FROM AUTHOR]

A 24-year-old female secretary bird ( Sagittarius serpentarius) was presented with acute, mild dyspnea occurring only during feeding times. Despite initial conservative therapy consisting of antibiotics and antifungal, antiparasitic, and anti-inflammatory drugs, the dyspnea worsened progressively, resulting in severe respiratory distress. Radiographs of the trachea suggested stenosis in the caudal one-third of the trachea. Tracheal endoscopy revealed an obstruction of approximately 90% of the tracheal lumen, in addition to mild suspected aspergillosis of the air sacs. Tracheal resection and anastomosis were performed, during which 1.5 cm of abnormal trachea was removed. Histopathologic examination showed severe granulomatous tracheitis, most likely induced by foreign body material. Respiratory signs resolved immediately postoperatively. Antibiotic and anti-inflammatory therapy continued for another 7 days and the bird was treated with antifungals for a total of 45 days. The bird recovered uneventfully. We encourage tracheal resection and anastomosis for severe tracheal stenosis even in aged, large birds of prey that are managed in large aviaries. [ABSTRACT FROM AUTHOR]

Aim Colorectal resection is frequently performed during cytoreductive surgery for gynaecological malignancy. The aim of this study was to assess the safety of colorectal anastomosis, and especially low rectal anastomosis, in the absence of a protective stoma in patients with gynaecological cancer and peritoneal metastasis. Method Patient data were retrospectively collected from a database for gynaecological cancer procedures carried out between January 2013 and July 2015. All patients who underwent a colorectal resection during cytoreduction were included in the study. The primary outcome was anastomotic leakage in the presence or absence of a diverting stoma. Secondary outcome parameters were complications and reoperations. Results In the period of study, 43 major colorectal procedures were performed on 37 women. The most common colorectal procedure was low rectal resection ( n = 22; 59%) followed by anterior rectal resection ( n = 7; 19%) and sigmoid resection ( n = 4; 11%). Five (14%) patients underwent Hartmann's procedure. In three (8%) patients, a diverting loop ileostomy was created. Conclusion Low rectal resection during debulking procedures for gynaecological cancers with peritoneal carcinomatosis can safely be performed by an experienced surgeon without a diverting stoma. [ABSTRACT FROM AUTHOR]

Background: Laparoscopic left colectomy (LLC) became the standard of care for treating distal transverse and descending colon cancer in many centers. Most centers use laparoscopic-assisted colectomy with extracorporeal anastomosis (LAC/EA). A totally laparoscopic colectomy with intracorporeal anastomosis (TLC/IA) has been proposed. The purpose of our study is to compare these two techniques.Methods: A series of 52 patients undergoing LLC for left-sided colon cancer was retrospectively evaluated. Thirty-three patients underwent TLC/IA, and 19 underwent LAC/EA. The following data were collected: gender, age, body mass index, American Society of Anesthesiologists risk class, operation duration, conversion to laparotomy, intraoperative complications, postoperative complications, postoperative course (duration of stay, time to first flatus), number of excised lymph nodes, readmission, and reoperation rates. Data were prospectively recorded in a colorectal cancer database and retrospectively analyzed.Results: The only demographic parameter that differed significantly between the groups was age (64.2 ± 12.4 years for the TLC/IA group, vs. 72.7 ± 2.1 years for LAC/EA, p = 0.0116). The mini-laparotomy incision was significantly shorter in the TLC/IA than in the LAC/EA group (5.8 ± 0.9 vs. 8.2 ± 0.9 cm, respectively, p < 0.00001). Hospital stay duration was shorter in the TLC/IA group (4.2 ± 1.2 vs. 6.3 ± 1.9, p = 0.0001). The average number of harvested lymph nodes did not differ significantly between the groups (12.9 ± 5.7 in TLC/IA vs. 11.2 ± 4.2 in LAC/EA, p = 0.2546). No significant differences between the groups were observed in any other perioperative or surgical outcome parameters.Conclusions: TLC/IA in LLC for the treatment of left colon cancer is technically feasible and can be performed with a low complication rate, favorable cosmetics, and possibly shorter hospital stay, without significantly lengthening operative duration or compromising oncologic radicality principles. Although further prospective randomized studies are needed to determine its role and limitations, we encourage using it as an alternative to LAC/EA in LLC. [ABSTRACT FROM AUTHOR]

Necrotising enterocolitis (NEC) is a neonatal surgical emergency. At its early stages, the management of NEC is largely medical using broad-spectrum antibiotics, gut rest and total parental nutrition. The only absolute indication for surgery is an intra-abdominal perforation. There are several relative indications for surgery based on clinical, biochemical and radiological parameters. Once the decision to intervene is made, several approaches may be taken. Peritoneal lavage can be used as a salvage procedure or definitive management in some cases. The most common approach taken is bowel resection with enterostomy formation. There is a role for primary anastomosis of bowel in limited NEC. In severe, multi-focal NEC a high diverting jejunostomy or "clip and drop technique" can be used. Laparoscopy has a limited role and is not widespread. The surgical complications of NEC include stoma related morbidity, anastomotic leak/stricture and short-bowel syndrome. Long-term data on neurodevelopmental outcomes is sparse but the present literature is suggestive of a negative impact in cases of surgically managed NEC. [ABSTRACT FROM AUTHOR]

We describe a case of intra-abdominal fibromatosis, which occurred in a 44-year-old woman who had a previous history of gastrointestinal stromal tumor (GIST) of the sigmoid mesocolon, which was treated with imatinib and resection. A mass was detected at the site of ileocolic anastomosis of the previous small bowel resection and sigmoid colectomy, nearly 3 years later. Clinically, this was suspected to represent recurrent GIST and was excised, but histology and mutational analysis showed desmoid-type fibromatosis with a mutation in codon 41 of exon 3 of the CTNNB1 (β-catenin) gene. The occurrence of fibromatosis at the site of excision of GIST is very rare, but its recognition is important as the treatment of the two neoplasms differs significantly. As imaging cannot reliably distinguish between these 2 entities, histological diagnosis is crucial for correct clinical management. [ABSTRACT FROM AUTHOR]

Transanal total mesorectal excision (TaTME) is a novel approach pioneered to tackle the challenges posed by difficult pelvic dissections in rectal cancer and the restrictions in angulation of currently available laparoscopic staplers. To date, four techniques can be employed in order to create the colorectal/coloanal anastomosis following TaTME. We present a technical note describing these techniques and discuss the risks and benefits of each. [ABSTRACT FROM AUTHOR]

Background: Failure of the pancreatic remnant anastomosis to heal following pancreato-duodenectomy is a major cause of significant and life-threatening complications, notably a post-operative pancreatic fistula. Recently, non-randomized trials have shown superiority of a most intuitive anastomosis (Blumgart technique), which involves both a duct-to-mucosa and a full-thickness pancreatic "U" stitch, in effect a mattress stitch, over a standard duct-mucosa technique (Cattell-Warren). The aim of this study is to examine if these findings remain within a randomized setting.Methods/design: The PANasta trial is a randomized, double-blinded multi-center study, whose primary aim is to assess whether a Blumgart pancreatic anastomosis (trial intervention) is superior to a Cattell-Warren pancreatic anastomosis (control intervention), in terms of pancreatic fistula rates. Patients with suspected malignancy of the pancreatic head, in whom a pancreato-duodenectomy is recommended, would be recruited from several UK specialist regional centers. The hypothesis to be tested is that a Blumgart anastomosis will reduce fistula rate from 20 to 10 %. Subjects will be stratified by research site, pancreatic consistency and diameter of pancreatic duct; giving a sample size of 253 per group. The primary outcome measure is fistula rate at the pancreatico-jejunostomy. Secondary outcome measures are: entry into adjuvant therapy, mortality, surgical complications, non-surgical complications, hospital stay, cancer-specific quality of life and health economic assessments. Enrolled patients will undergo pancreatic resection and be randomized immediately prior to pancreatic reconstruction. The operation note will only record "anastomosis constructed as per PANasta trial randomization," thus the other members of the trial team and patient are blinded. An inbuilt internal pilot study will assess the ability to randomize patients, while the construction of an operative manual and review of operative photographs will maintain standardization of techniques.Discussion: The PANasta trial will be the first multi-center randomized controlled trial (RCT) comparing two types of duct-to-mucosa pancreatic anastomosis with surgical quality assurance.Trial Registration: ISRCTN52263879 . Date of registration 15 January 2015. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Background: Minimally invasive techniques are being used increasingly more in pancreatic surgery. Compared to resections of the pancreatic head and tail, total pancreatectomy is rarely performed. As no pancreatic anastomosis has to be made and open resection usually needs a wide laparotomy, a laparoscopically assisted technique seems desirable. Aim: The objective of this article is to report the initial results of laparoscopically assisted total pancreatectomy in three patients. Material and methods: This series included two patients with a main duct type intraductal papillary mucinous neoplasm (IPMN) and one patient with pancreatic metastases from a renal carcinoma. Results: All three resections were achieved laparoscopically. Reconstruction was performed through the retrieval incision. Operative time, blood loss, intermediate care and hospital stay were similar to a control group of open resections in seven patients. Conclusion: In this small group of selected patients laparoscopic total pancreatectomy is feasible when carried out in centers with high expertise in laparoscopy and pancreatic surgery. [ABSTRACT FROM AUTHOR]

Oesophageal atresia is a common malformation in which the survival rate in developed countries is around 90%, while its mortality remains very high in developing countries. Oesophageal stricture post-oesophageal atresia repair is traditionally treated by non-surgical approach. However, surgical resection of the oesophageal stricture may be necessary after the failure of dilations. We report one case of refractory oesophageal stricture post-EA repair in a 3-year-old girl, who underwent oesophageal atresia Type III repair at 11-day-old. We performed an end-to-end oesophageal anastomosis with tracheal oesophageal fistula closure by extra-pleural approach. The patient was lost to follow-up for 3 years. She was seen later for anastomotic oesophageal stricture with the failure of oesophageal dilatations. Surgical resection of oesophageal stricture was performed with end-to-end oesophageal anastomosis. [ABSTRACT FROM AUTHOR]

The objective of this study was to determine the morbidity and mortality after gut resection and anastomosis in a tertiary centre in Kenya. To do this a retrospective, hospital-based study, cohort study of patients who underwent resection and anastomosis in the period 2002 - 2006, both years inclusive. The general surgical wards of Moi Teaching and Referral Hospital (MTRH), a 750 teaching and referral hospital in the Western region of Kenya was used for the study. Two hundred and twenty patients of all ages underwent gut resection and anastomosis for various reasons over the period of study. The primary outcome measures were morbidity and mortality in this group of patients. Morbidity was considered in terms of postoperative complications and hospital length stay. The secondary outcome measures were the patient demography, vital signs at admission and delay in surgery. The morbidity rate was 22.7 % while the mortality rate was 15.9 %. The principal indicators of morbidity were the intra-abdominal pathology, the duration from onset of symptoms to surgery and the type of anastomosis. The patient's age, type of anastomosis and postoperative complications were key determinants of mortality. In conclusion, pre-operative resuscitation in patients who underwent gut resection and anastomosis influenced morbidity and mortality. Delay in surgery and the type of anastomosis done were determinants of post-operative complications which in turn influenced the outcome of treatment. [ABSTRACT FROM AUTHOR]

Laparoscopic right hemicolectomy represents an effective therapeutic approach for right colon cancer (RCC). The primary aim of this study was to evaluate bowel function recovery, length of hospital stay, operative time, and the number of general and anastomosis-related postoperative complications from intracorporeal anastomosis (ICA) vs. extracorporeal anastomosis (ECA); the secondary outcome was the number of lymph nodes retrieved. This observational study was conducted on 108 patients who underwent right hemicolectomy for RCC; after surgical resection, 64 patients underwent ICA and 44 underwent ECA. The operative time was slightly longer in the ICA group than in the ECA group, even though the difference was not significant (199.31 ± 48.90 min vs. 183.64 ± 35.80 min; p = 0.109). The length of hospital stay (7.53 ± 1.91 days vs. 8.77 ± 3.66 days; p = 0.036) and bowel function recovery (2.21 ± 1.01 days vs. 3.45 ± 1.82 days; p < 0.0001) were significantly lower in the ICA group. There were no significant differences in postoperative complications (12% in ICA group vs. 9% in ECA group), wound infection (6% in ICA group vs. 7% in ECA group), or anastomotic leakage (6% in ICA group vs. 9% in ECA group). We did not observe a significant difference between the two groups in the number of lymph nodes collected (19.46 ± 7.06 in ICA group vs. 22.68 ± 8.79 in ECA group; p = 0.086). ICA following laparoscopic right hemicolectomy, compared to ECA, could lead to a significant improvement in bowel function recovery and a reduction in the length of hospital stay in RCC patients. [ABSTRACT FROM AUTHOR]

Objective: This study was performed to compare stapled and hand sewn techniques for esophagogastric anastomosis on esophagus cancer surgery. The study was focused on to the effect of esophagogastric anastomosis techniques on mortality, morbidity, median operation and hospitalization time. Material and Methods: A retrospective study was undertaken in 60 patients with eosophagial cancer who underwent resection and anastomosis. Twenty eight patients were operated with transhiatal (48%) and others with transthoracic (54%) approach. Patients were classified to perform stapled anastomosis (Group 1) and hand sewn anastomosis (Group 2). Hand sewn anastomosis technique was performed in 43 (72%) and stapled anastomosis technique was performed in 17 cases (% 28). Results: The groups were similar regarding age, sex, ASA scores, tumor localization and stage, for the operative approach. Major morbidity was present in 5 patients (30%) in Group 1 and 19 patients (44%) in Group 2. The number of anastomosis leaks was 4 in Group 1 (23%) and 6 in Group 2 (14%). Mortality was encountered in 1 patient in Group 1 (6%) and 5 patients in Group 2 (11%). The mean hospital stay was determined to be 18.4 ± 11.8 days for Group 1 and 16.33 ± 8.1 days for Group 2. No statistically significant difference was found between the groups regarding major morbidity, mortality and mean hospital stay (p>0.05). Conclusion: In our study, the techniques of anastomosis via hand sewn or stapled were not found to be superior to one another. The practice and skill of the surgeon should be determinant about the application of the methods. [ABSTRACT FROM AUTHOR]

Aim: The aim of this experimental study is the assessment of the effects of the immediate post-operative intraperitoneal administration of 5-fluorouracil and irinotecan on the healing process of large bowel anastomoses in rats. Materials and methods: Sixty male Wistar rats were divided into 4 groups of 15 rats each. The rats underwent large bowel resection and anastomosis, followed by the intraperitoneal administration of normal saline (group 1), 5-fluorouracil (group 2), irinotecan (group 3) or the combination of 5-fluorouracil and irinotecan (group 4). All animals were killed on the eighth post-operative day. During post-mortem examination, the anastomoses were assessed macroscopically for a possible anastomotic leak and the extent of adhesion formation. Subsequently, the anastomotic bursting pressure was measured, and the anastomoses were assessed histologically. Results: No anastomotic dehiscence was observed in the rats of group 1. In groups 2 and 3, we observed 3 anastomotic leaks in each group, and in group 4, we observed 5 leaks ( P = 0.111). The mean bursting pressure of the anastomoses in group 1 was significantly higher compared to groups 2, 3 and 4 ( P < 0.001). The least inflammatory cell infiltration score was observed in group 1 ( P < 0.001). The lowest neoangiogenesis score was observed in group 2 and the highest in group 4. The collagen formation in group 1 was significantly higher compared to the other 3 groups ( P < 0.001). Similar results were observed for the fibroblast activity, where group 1 revealed significantly higher fibroblast scores compared to groups 2, 3 and 4 ( P < 0.001). Finally, groups 2, 3 and 4 showed significantly lower hydroxyproline levels compared to the control group ( P < 0.001). Conclusion: The immediate, post-operative intraperitoneal administration of 5-fluorouracil or irinotecan had a negative effect on the healing process of the large bowel anastomoses in rats. The negative effects of the combination of 5-fluorouracil and irinotecan were statistically more significant compared to the single use of 5-fluorouracil or irinotecan. [ABSTRACT FROM AUTHOR]

Aim: This study was designed to determine the effects of intraperitoneally or orally administered N-acetylcysteine (NAC) on anastomotic healing of irradiated rats. Methods: Thirty-two male Wistar albino rats were randomized into four groups containing 8 rats each: I; standard resection plus anastomosis, II; radiation plus standard resection plus anastomosis, III; radiation plus standard resection plus anastomosis plus oral NAC, IV; radiation plus standard resection plus anastomosis plus intraperitoneal NAC. Four types of assessment were performed: bursting pressure, hydroxiproline (OHP) content, histopathology, and biochemical evaluation, including serum malondialdehyde (MDA), advanced oxidation protein products (AOPP), reduced glutathione (GSH) and superoxide dismutase (SOD) activities. Results: Group comparisons demonstrated that bursting pressure was significantly higher in NAC treated rats. The mean tissue OHP concentration in the anastomotic tissue was significantly lower in irradiated rats (group II) than in the other groups. NAC treatment caused increased activity of SOD and GSH. In contrast, MDA levels were found to be decreased in groups III and IV. Histopathological analysis revealed that NAC administration, either orally or intraperitoneally, leads to a better anastomotic healing in terms of reepithelialization, perianastomotic fibrosis, ischemic necrosis, and muscle layer destruction. Conclusion: The present study supports the hypothesis that NAC administration alleviates the negative effects of radiotherapy on anastomotic healing. Nevertheless, the underlying mechanisms responsible for this protective effect is unknown today. [ABSTRACT FROM AUTHOR]

Anastomotic leakage after low anterior resection may incompletely resolve, resulting in sinus tracts that persist on repeated contrast studies. This case series evaluated the factors that may contribute to sinus healing or to safe reversal of the defunctioning ileostomy. All patients ( n = 8) who developed an anastomotic sinus after low anterior resection over an 8-year period were identified from a prospective database. All patients had been treated with low anterior resections with defunctioning stomas for rectal carcinoma [median follow up 43.5 (13-84) months]. Two patients with an unhealed subclinical leak had the stoma reversed successfully. Of the six patients with clinical leakage, two healed spontaneously, one healed after application of fibrin glue, one developed an anastomotic stricture that was successfully treated by dilatation with subsequent stoma reversal, and one developed recurrent cancer and was not reversed. One patient underwent reversal, despite persistence of the sinus, followed by rectal perforation requiring laparotomy and faecal diversion. Bowel function was satisfactory where the sinus healed spontaneously, but poor where reversal was carried out without sinus healing. Tracks that persist for longer than 1 year are unlikely to heal, but the stoma can be reversed if there had been a subclinical leak previously. A persistent anastomotic sinus leading to a cavity may not be suitable for stoma closure. [ABSTRACT FROM AUTHOR]

INTRODUCTION This study investigates if body fat parameters, including visceral adipose tissue (VAT), subcutaneous adipose tissue (SAT), total adipose tissue (TAT) and body mass index (BMI), are correlated with increased risk of complications following surgery for colorectal cancer. METHODS Retrospective study of 54 consecutive patients undergoing elective resectional surgery for colorectal cancer with curative intent. A consultant radiologist reviewed all pre-operative CT scans and calculated body fat parameters using GE software. Primary outcomes were anastomotic leakage and 30 day mortality. Secondary outcomes included length of operation, number of lymph nodes retrieved, medical complications and duration of hospital stay. RESULTS There were 5 leaks (93%) and 3 deaths (5.6%). Out of the four fat parameters, only VAT was significantly associated with an increased risk of developing anastomotic leakage (P=0.0341). The fat parameters were not significantly associated with any other outcome. Although male sex was associated with higher VAT (p=0.001), it was not an independent risk factor for leakage (p=0380). CONCLUSION Increased VAT is associated with a greater risk of anastomotic leakage following resection surgery for colorectal cancer. Further studies are warranted to investigate if pre-operative radiology may be used to stratify high-risk patients who may benefit from a temporary diverting stoma. [ABSTRACT FROM AUTHOR]

Background. The outcomes after different low rectal resection types applied for rectal cancer treatment are still uncertain. The aim of the investigation was to evaluate longterm functional results, the rate of complications and post-operative lethality after rectum low resection operations (connection with J-pouch group: coloplasty - group 2 and "straight" anastomosis - group 3). Patients and methods. In 2003, a randomized study was started and completed on December 2007. The study included 82 patients (38 females and 44 males). The patients were randomized into three groups. They were suffering from cancer stage I-III. Results. There were no postoperative deaths after 82 resections with total mesorectal excision (TME) and low connection. The overall rate of postoperative complications was 28%, and the rate of anastomosis suture leakage was 11%. The rate of postoperative complications was 20.7% (6 patients) in group 1, 28.6% (6 patients) in group 2, 34.3% (11 patients) in group 3. The rate of complications was substantially higher in groups 2 and 3; however, this difference was statistically not significant (p = 0.2636). The functional results after 3, 6, 9, 12 and 24 months showed no statistical difference among the groups; moreover functional results after 24 months in all groups were similar (p = 0.046). Anastomosis with or without pouch does not influence postoperative lethality. The incidence of complications and suture leakage is higher in cases of straight anastomosis; however, this finding is not statistically significant. Necrosis was observed only in patients for whom anastomosis with pouches were performed. Conclusion. Comparison of functional results after 3, 6, 9, 12 and 24 months showed no statistically significant differences among the groups.The necrosis of pulleddown bowel was observed only in the pouch groups. [ABSTRACT FROM AUTHOR]

The impact of anastomic leakage (AL) on the oncological outcome after anterior resection (AR) for rectal cancer is still controversial. We explored the impact of AL regarding local recurrence (LR), distant metastasis and overall recurrence (OAR). Overall and cancer-specific survival was analysed. Patients undergoing AR for rectal cancer with a registered AL between 1995 and 1997 and a control group were identified in the Swedish Rectal Cancer Registry. The medical records were retrieved for additional data and validation. Differences in the oncological outcome at 5-year follow-up were analysed with multivariate methods. After validation, 114 patients with AL and 136 control patients with locally radical surgery for tumours in tumour-node-metastasis stages I-III were analysed. There was no difference detected between patients with AL and control patients regarding rates of LR [8% (9 of 114) vs 9% (12 of 136); P = 0.97], distant metastasis [18% (20 of 114) vs 23% (31 of 136); P = 0.37] and OAR [19% (22 of 114) vs 28% (38 of 136); P = 0.15]. The 5-year cancer-specific survival was almost 80% in both groups. In multivariate analysis, AL was not a risk factor of LR, distant metastasis or OAR and had no impact on 5-year overall or 5-year cancer-specific survival. Irrespective of the occurrence of AL, preoperative radiotherapy ( P = 0.055) and rectal washout ( P = 0.046) reduced the LR rate, but did not influence survival. Anastomotic leakage was not proved to be a risk factor of worse oncological outcome. Hence, additional adjuvant treatment or extended follow-up on the basis of the occurrence of AL after AR might not be justified. [ABSTRACT FROM AUTHOR]

Purpose: Up to 19% of all colorectal resections develop clinically apparent insufficiencies. Insufficient perfusion of the anastomosis is recognized as an important risk factor. As tissue perfusion can be objectified intraoperatively using laser fluorescence angiography (LFA), its effect on the rate of anastomotic complications was evaluated in a retrospective matched-pairs analysis. Methods: Between 2003 and 2008, all anastomosis or resection margins in colorectal cancer resections were investigated intraoperatively using LFA (LFA group). Patients with colorectal cancer resections between 1998 and 2003 without LFA served as the control group. Four hundred two patients were matched for age, T-stage, type of resection and anastomosis, defunctioning stoma, administration of blood, emergency conditions, and body mass index. Statistical analysis was performed using the Fisher and the Wilcoxon tests. Results: Twenty-two surgical revisions were necessary due to anastomotic leakage, seven (3.5%) in the LFA group and 15 (7.5%) in the control group. Subgroup analysis revealed that in elective resections the rate of revision was 3.1% (LFA group) and 7.7% (control group) ( p = 0.04, risk of revision (ROR) reduced by 60%). In patients older than 70 years, the rate of revision was 4.3% (LFA group) compared to 11.9% (control group) ( p = 0.04, ROR reduced by 64%). After hand-sewn anastomosis, the rate of revision was 1.2% (LFA group) and 8.5% (control group) ( p = 0.03, ROR reduced by 84%). Hospital stay was significantly reduced in the LFA group (Wilcoxon test; p = 0.01). Conclusion: There was an overall reduction in the absolute revision rate of 4% in the LFA group and a significantly reduced rate of revision in the subgroup analysis of patients undergoing elective colorectal resections, in patients older than 70 years and in patients with hand-sewn anastomosis. This demonstrates that LFA is a method that may significantly reduce not only the rate of severe complications in colorectal surgery but also the hospital length of stay. [ABSTRACT FROM AUTHOR]

There is still controversy about the necessity of a diverting stoma after deep anterior resection with total mesorectal excision for rectal cancer. Recent results of randomized controlled trials and from systematic reviews have improved the currently available data. A significant benefit was shown for patients with diverting stoma in terms of clinically relevant anastomotic leakage and re-operation rates. The influence on mortality is not as clear. However, analysis of the data of 19 prospective studies within a systematic review including more than 9,000 patients, revealed a significant benefit for stoma creation. Furthermore, the rate of patients with stoma 5 years after primary resection was lower in the group of patients with diverting stoma. The purpose of this manuscript is to show the necessity of a diverting stoma based on the currently available data. [ABSTRACT FROM AUTHOR]

Objective Experimental studies suggest that matrix metalloproteinase (MMP) enzymes mediate the early tissue breakdown that leads to a decrease in intestinal anastomotic strength. Patients with upregulation of MMPs in intestinal biopsies have an increased rate of anastomotic leakage. We measured MMPs and their inhibitors [tissue inhibitors of metalloproteinases (TIMPs)] in postoperative intraperitoneal fluid after rectal cancer surgery, and hypothesized that they would be elevated in patients who later would develop anastomotic leakage. Method Twenty-nine patients with rectal carcinoma underwent low anterior resection of the rectum for cancer. Intraperitoneal fluid was collected via a pelvic drain at a median of 4 h postoperatively. MMP-1, -2, -3, -7, -8, -9 and -13 were determined using particle-based multiplex flow-cytometry. TIMP-1 and -2 were measured by enzyme-linked immunosorbent assays. MMP-9 was considered the main outcome variable. Results Ten patients developed anastomotic leakage. These patients had increased intraperitoneal MMP-9 [median difference (m.d.) 29%; P = 0.03] and MMP-8 (m.d. 58%; P = 0.02), compared with patients who did not develop leakage. There were no differences between the groups for other MMPs and TIMPs. Conclusion Matrix metalloproteinase-8 and -9 appear to have an important role in the development of anastomotic leakage and may be promising pharmacological targets to protect anastomotic integrity. We suggest further investigation of MMPs as markers for anastomotic leakage. [ABSTRACT FROM AUTHOR]

A leaking intestinal anastomosis is typically regarded as a devastating post-operative complication. The reported incidence of anastomotic leakage is highly variable and depends on the definitions used and the anatomical location involved. Early leaks are usually readily diagnosed and aggressive management is warranted. Late leaks may be unrecognised and are likely to be underreported in the literature; diagnosis and treatment in this setting requires a thoughtful, individualised approach. [ABSTRACT FROM AUTHOR]

Background: Tracheal stenosis and dehiscence of anastomosis due to excessive tension are well-known problems after long-segment tracheal resections. The aim of this study was to evaluate the efficacy of the W-plasty technique to prevent these two complications. Methods: Animals were divided into a study and a control group. Each group consisted of 6 animals. In the control group, we performed a 5-cm tracheal segment resection, and then reconstruction was performed with an interrupted technique with 6/0 Prolene sutures. In the study group, we used the W-plasty technique with 6/0 Prolene interrupted sutures. The animals were sacrificed on the 30th day postoperatively and tracheal resection including the entire anastomosis site was performed. The traction and pullout test was applied to each specimen and all the specimens were analysed histopathologically. The intraluminal diameter and the thickness of the tracheal wall at the level of anastomoses were measured by using a micrometer. The pattern of the reaction and localization were recorded. Results: The traction and pullout test results were 131.6 ± 4.3 g and 187.5 ± 6.4 g in the control and the study group, respectively, which was a significant difference (p = 0.004). The intraluminal diameters were 3.3 ± 1.2 mm and 4.3 ± 0.9 mm in the control and study group, respectively (p = 0.134). In contrast to the control group, early inflammatory and late fibroblastic reactions were negative in the study group. Conclusion: Considering the outcomes of this study, we think that the W-plasty technique has much more advantages than the standard techniques in terms of anastomosis durability and development of stenosis. Copyright © 2008 S. Karger AG, Basel [ABSTRACT FROM AUTHOR]

Background: After bowel resection, Crohn's disease (CD) recurs frequently in the site of the anastomosis. Alteration of normal healing processes may play a role in this phenomenon. Transforming growth factor beta (TGF-beta) and insulin-like growth factor (IGF-1) are involved in wound healing mechanisms with pro-fibrogenic properties. The aim of this study was to assess the expression of TGF-beta1 and insulin-like growth factor 1 (IGF-1) in the different zones of the bowel wall to understand why side-to-side anastomosis are associated to a lower recurrence rate compared to end-to-end ones.Patients and Methods: Seventeen patients affected by CD who underwent ileo-colonic resection from 2004 to 2005 were enrolled in this study. Full-thickness tissue samples were obtained from the mesenteric, the lateral, and the anti-mesenteric sides of the macroscopically diseased and healthy ileum for each patient. TGF-beta1 and IGF-1 messenger RNAs (mRNAs) were quantified by real-time polymerase chain reaction. Myeloperoxidase activity and histological disease activity were assessed to quantify the ileal inflammation. Vimentin, desmin, and alpha-smooth muscle actin were stained with immunohistochemistry to assess the fibroblast, smooth muscle cell, and myofibroblasts populations. Comparisons and correlations were carried out with nonparametric tests.Results: In diseased ileum, TGF-beta1 mRNA transcripts in the antimesenteric side were significantly lower than those of the mesenteric side (p = 0.05), and a significant correlation between TGFbeta-1 levels in diseased bowel and the sampling site was observed (tau = 0.36, p = 0.03). On the contrary, neither the IGF-1 mRNA transcripts nor the distribution of fibroblast, smooth muscle cell, and myofibroblasts populations showed any relation with the sampling site.Conclusion: TGF-beta1 mRNA expression was lower in the anti-mesenteric side of the diseased ileum, and this was consistent with the success of side-to-side anastomosis in preventing CD recurrence. Since high expression of TGF-beta1 was associated to early recurrence, it seems rationale to construct the anastomosis on the anti-mesenteric side of the bowel. [ABSTRACT FROM AUTHOR]

Rectal cancer was initially considered a contraindication for the laparoscopic approach to low rectal resection due to the greater difficulty of deep pelvic dissection, but several studies have demonstrated its potential clinical advantages. The currently accepted technique for this intervention includes total mesorectal excision, which entails complete dissection of the mesorectum followed by low transection of the rectum. The laparoscopic approach provides good visualization and magnification of the operative field, but transection of the rectum may be more difficult. This is illustrated by the conversion rate of around 15% in most series, mainly due to technical difficulties. Contour™ placement may overcome these difficulties. Two key points support the interest in the use of devices with the features of the Contour™. First, the current feeling and evidence indicate that with presently available laparoscopic devices, the section of the low rectum in selected patients (males and mid-third rectal tumors) is often difficult. Secondly, allthough the Contour™ device was designed for open surgery, surgeons have the intuitive perception that it perfectly accomplishes the functions an ideal laparoscopic stapler should include. There is clearly a need for more appropriate laparoscopic instruments for low rectal transection. The Contour™ device could be considered a prototype because it meets the surgeon's requirements when operating on the low rectum, providing one shot, simultaneous sewing and cutting function and a symmetric rectum section. However, a number of technical modifications would enhance the utility of the instrument in this setting. [ABSTRACT FROM AUTHOR]

Objective Anastomotic leak after colorectal surgery is a serious event associated with significant morbidity and mortality. There is little consensus regarding ‘acceptable’ rates of leakage, however. This study describes the experience of anastomotic leakage after both elective and emergency colorectal surgery in a district general hospital. Method A prospectively collected database of all patients with a diagnosis of colorectal cancer in a single hospital formed the basis of the study. Leak was defined as breakdown of the anastomosis contributing to death or requiring reoperation or reintervention. Results A total of 949 patients underwent surgery with an anastomosis between 1996 and 2004, including 331 patients treated with anterior resection. Anastomotic leaks requiring reoperation occurred in eight patients (0.8%). Thirty-day and in-hospital mortality was 4%. Conclusion A very low rate of anastomotic leakage after colorectal surgery is possible in a district general hospital setting. Given the impact of anastomotic leakage on function, tumour recurrence and long-term survival, it should be considered as a marker of surgical quality when evaluating surgical performance. [ABSTRACT FROM AUTHOR]

Laparoscopic surgery is increasingly being applied to gastric cancer surgery, including proximal gastrectomy for the resection of cancer located in the upper gastric body. Despite the ease of use of stapling devices for end-to-end anastomosis, esophagogastric anastomosis is complicated by the narrow laparoscopic space, making the placement of an esophageal purse-string suture and anvil insertion into the fragile and contracted esophagus difficult. The aim of this study was to employ a novel esophagogastric anastomosis technique for laparoscopic surgery which may avoid esophageal breakdown. Eleven patients with early gastric cancer within the upper gastric body underwent laparoscopic proximal gastrectomy. The anvil of the stapler was introduced into the esophagus through a small gastrostomy, before transection of the esophagus. The esophageal-to-anterior gastric wall anastomosis was performed using a double-stapling technique, without the need to apply a purse-string suture. The mean operation time was 237 ± 15 min and estimated blood loss was 39 ± 21 ml. The postoperative course was uneventful in all 11 patients, with no anastomotic leakage observed. Two patients needed endoscopic balloon dilation of an anastomotic stricture 24 to 28 days postoperatively. This modified procedure of laparoscopic esophagogastric anastomosis after proximal gastrectomy for the resection of cancer is a simple, rapid, and atraumatic technique which reduces the risk of anastomotic insufficiency. [ABSTRACT FROM AUTHOR]

To determine the safety and feasibility of primary resection and anastomosis with or without a diverting stoma, as compared to Hartmann’s procedure, for patients with acute complicated sigmoid diverticulitis. MEDLINE was searched for studies and trials conducted between 1966 and December 2003. This search revealed trials comparing primary resection and anastomosis to Hartmann’s procedure. The term “diverticulitis, colonic” with the sub-heading “surgery” was used and the search was limited to human studies and clinical trials. Additional studies were found using the MeSH terms: “surgical procedures, operative”, “surgical anastomosis”, and “Hartmann procedure”, combined with the term “diverticulitis, colonic”. The author also searched EMBASE and the Cochrane database for clinical trials using similar terminology. No language restrictions were applied. Eighteen studies met the inclusion criteria and reported 884 patients with acute complicated diverticulitis. None of these studies were randomised; it is likely that there was a significant degree of selection bias. No significant differences were found between primary resection with anastomosis and Hartmann’s procedure with respect to mortality, morbidity, sepsis, wound complications and duration of procedure and anti-biotic treatment. Some studies found that primary anastomosis and a protecting stoma, with or without intra-operative colonic lavage, have more favourable results than Hartmann’s procedure. This review suggests that surgical resection and primary anastomosis in acute diverticulitis with peritonitis compares favourably with Hartmann’s procedure in terms of peri-operative complications. The need for revision of Hartmann’s procedure could be subsequently avoided. Some articles showed that patients with severe peritonitis, who had a diverting stoma, in the setting of resection and primary anastomosis, had the lowest complication rate. However, the quality of these studies was poor with the presence of selection bias. [ABSTRACT FROM AUTHOR]

Abstract: Background: Single-stapled double-pursestring technique for colorectal anastomosis to the mid-rectum or upper rectum is the most commonly used technique in the single institution reported here. The investigators evaluate single-stapled double-pursestring anastomosis after anterior resection of the rectum performed at a single institution. Methods: Medical records of patients who underwent single-stapled double-pursestring anastomosis between January 2000 and May 2005 were analyzed to identify postoperative anastomotic complications. Patients with previous radiation, diverting stoma, coloanal, and hand-sewn and double-stapled anastomoses were excluded. The primary goal was to identify postoperative anastomotic complications. Results: Of 160 patients, 153 (96%) no septic complications. One patient (.6%) developed anastomotic leak requiring diversion. Of the 4 patients with pelvic abscesses (2.5%), 2 were treated with antibiotics and 2 with computed axial tomography–guided drainage. Conclusions: Single-stapled double-pursestring anastomosis is reliable, with very low rates of leak, subsequent diversion, and pelvic abscess (.6%, .6%, and 2.5% respectively). [Copyright &y& Elsevier]

Background There is evolving interest in auditing and credentialling the performance of surgeons. The incidence of anastomotic leakage has been proposed as a measure of performance following colorectal surgery. The aim of this study was to evaluate the incidence and risk factors associated with anastomotic leakage in patients undergoing resections of the colon and rectum. Methods A prospective database was developed for all patients undergoing colorectal surgery. Anastomotic leakage was defined prior to the commencement of the study. A logistic regression analysis was performed to determine independent predictors of leakage. The variables analysed included age, sex, American Society of Anesthesiology (ASA) score, anatomical location, pathology, emergency surgery, type of anastomosis, a covering stoma and radiotherapy. Significance was defined as the probability of a type 1 error of < 5%. The results are presented as odds ratios (ORs) and 95% confidence intervals (95% CIs). Results There were 1598 patients who underwent 1639 anastomoses. Their mean age was 63 years, 34% of patients were ASA 3 or 4, and 16% of the operations were emergencies. Anastomotic leaks occurred in 2.4% (40/1639) of anastomoses. The leak rate for intraperitoneal anastomoses was 1.5% (19/1283) vs 6.6% for extraperitoneal anastomoses (21/316). Half of these leaks (20/40) were managed with re-operation or percutaneous drainage procedures. Ultra-low anterior resections were associated with the highest leak rate (8%, 18/225). A logistic regression analysis identified a covering stoma ( P = 0.0001, OR 5.078, 95% CI 2.527–10.23) and diverticular disease ( P = 0.037, OR 2.304, 95% CI 1.053–5.042) as independent predictors of a leak. Conclusions Within this surgical unit, the incidence of leaks from intraabdominal anastomoses was relatively low. However, leaks in patients undergoing extraperitoneal anastomoses continue to be a major cause of morbidity and mortality. [ABSTRACT FROM AUTHOR]

Objectives: Tension is the limiting factor in long tracheal resection with end-to-end anastomosis. Complications such as dehiscence and restenosis are well correlated with the degree of anastomotic tension. The objective of our study was to investigate the effects of patches of auricular cartilage glued craniocaudally along a tracheal anastomosis. Methods: Rupture tests were performed on sheep tracheas collected from a slaughterhouse. In group A (n = 5), 3 patches of auricular cartilage of 0.5 × 5 cm were glued with albumin-glutaraldehyde tissue adhesive (BioGlue) craniocaudally along the left, right, and anterior borders of the transected tracheas. In group B (n = 10), the patches were fixed with 2 transparietal intercartilaginous stitches without adhesive. In group C (n = 10), adhesive and stitches were used. Results: Three patches of cartilage glued along the tracheal anastomosis held tension as high as 11.1 N. Adhesive maintained the tracheal extremities in closer contact than did stitches alone. It increased the anastomotic resistance strength (50.8 N in group C versus 29.6 N in group B). This increase was statistically significant. Conclusions: Gluing auricular cartilage patches along ex vivo tracheal anastomoses strengthened them and helped diminish tension on the suture line. [ABSTRACT FROM AUTHOR]

Background: The development of anastomotic strictures following colorectal surgery is a frequent problem, but commonly used treatments (e.g. dilatation or revisional surgery) are often ineffective. This study assessed the efficacy of self-expanding metallic stents (SEMS) and endoscopic transanal resection of strictures (ETARS) in managing high-grade benign colorectal anastomotic strictures after the failure of first-line therapies. Methods: All patients with biopsy-proven benign anastomotic strictures (luminal diameter < 7 mm) following colorectal surgery, seen in the period April 1995-October 2004, were treated with either SEMS or ETARS. Results: In the study period, we treated 10 patients (7 men) of median age 71 years. Ten ETARS procedures were performed in six patients, with a mean operating time of 42 minutes and a median hospital stay of 1 day. Early complications of ETARS included: re-operation for bleeding, asymptomatic anastomotic perforation and technical failure in an acutely angulated stricture. SEMS were successfully inserted into five patients (including two with failed ETARS) without any early complications. Overall, nine patients have had satisfactory long-term outcomes (median follow-up, 29 months; range, 3-75 months). Conclusions: SEMS and ETARS are simple, safe and effective methods in treating high-grade anastomotic strictures. [ABSTRACT FROM AUTHOR]

Intra-operative colonic lavage is a widespread procedure introduced to decompress and clean the colon of its faecal load during emergency surgery of the left colon in order to perform a safe anastomosis. This type of lavage is never performed at our institution. The aim of this study was to evaluate the safety and acceptability of emergency left-sided colectomy without colonic lavage in a consecutive series of patients admitted at our department for perforation and obstruction of the left colon.All 44 patients (29 with obstruction and 15 with perforation) on whom a one-stage left-sided colon resection was performed without colonic lavage between January 1998 and June 2004 were evaluated in a retrospective review. During this period all patients with acute disease of the left colon underwent a one stage resection without colonic lavage. The only exclusion criteria for anastomosis were: haemodynamic instability, ASA > 3, unresectable tumour. Death, anastomotic leakage and wound infection were main outcome measures.The leak rate was 4.5% and mortality 2.3% due to one case of postoperative myocardial infarction. A 16% morbidity rate was recorded due to 4 wound infections and 3 minor complications.The procedure is safe. The low morbidity and mortality of one stage resection without colonic lavage can justify future prospective studies enrolling a large number of patients to compare its results with those obtained by one stage resection with colonic lavage. [ABSTRACT FROM AUTHOR]

Objective The anal sphincters, neorectal capacity and motility may be affected by injury to the autonomic nerves during rectal resection. Anorectal function also depends on the method used for restoration of intestinal continuity, and colonic reservoir reconstruction has been recommended in ultralow anastomosis. This study was undertaken to evaluate the results after nerve preserving mesorectal excision and colorectal anastomosis without a reservoir. Patients and methods Thirty-five consecutive patients who underwent low anterior resection with primary healing of the anastomosis, were included. Anal manometry with stationary pull through technique, rectal volumetry and symptom scoring (written questionnaires with visual analogue scales) were performed prior to and 12 months after surgery. Anal sphincter function was evaluated in all patients, but five patients with a colonic reservoir were excluded from the other evaluations. Thirty patients entered the main study; 14 patients having a total mesorectal excision (TME) and a low anastomosis (LA) (4–6 cm) and 16 patients a partial mesorectal excision (PME) and a high anastomosis (HA) (7–11 cm from the anal verge). Results Anal resting and squeeze pressure and rectal sensibility (threshold volume) were unchanged after the operation. The rectal volume eliciting urge to defecate was reduced from median 95 ml to 70 ml (P < 0.01), and the maximum tolerable rectal volume was reduced from 200 to 135 ml (P < 0.01) after the operation. The maximum tolerable volume was significantly lower in patients with LA than in patients with HA (P < 0.01). Overall functional results were good. The patients reported problems with complete bowel emptying (median VAS-score reduction from 90 to 60, P < 0.01), and minor incontinence problems (median VAS-score reduction from 100 to 90, P = 0.03). The reduction of VAS-scores was more pronounced in LA than HA patients (without reaching statistical significance). Conclusions Anal... [ABSTRACT FROM AUTHOR]

Objective: To compare complication rates after rectal resection using a conventional surgical technique (1983-1992) and mesorectal excision (1993-2000), and to find out whether the rate of complications changed with time after the introduction of mesorectal excision. Design: Prospective, observational study. Setting: University hospital, Norway. Patients: All patients who had rectal resections for cancer in the period 1983-2000. Interventions: In the conventional surgery period 217, and in the mesorectal excision period 176, patients had rectal resections. The mesorectal excision period was split in two, the early and the late mesorectal excision period, 88 rectal resections being performed in each period. Total mesorectal excision was done in 118 patients, and partial mesorectal excision in 58 Main outcome measures: Major surgical complications in both periods; intraoperative bleeding, transfusions during the hospital stay, and cardiovascular complications in the mesorectal excision period. Results: 23/217 (11%) developed major surgical complications in the conventional surgery period, compared with 17/88 (19%) in the early mesorectal excision period (p = 0.04). This was caused by an increased incidence of anastomotic leaks after low anterior resection, being 11/122 (9%) in the conventional surgery period and 12/52 (23%) in the early mesorectal excision period (p = 0.01). The incidence of anastomotic leaks declined to 5/61 (8%) in the late mesorectal excision period (p = 0.03). Multiple regression analysis identified a low anastomosis, major bleeding, and age over 75 years as significant risk factors for the development of anastomotic leaks. Major intraoperative bleeding occurred in 36/84 (43%) of the patients in the early and 22/82 (27%) in the late mesorectal period (p = 0.04). Blood transfusions were given to 61/84 (74%) in the early mesorectal period and 41/82 (50%) in the late period (p < 0.01). Conclusions: The incidence of surgical complications increased significantly after the introduction of mesorectal excision, but declined with time. [ABSTRACT FROM AUTHOR]

Objective We evaluated the prognostic validity of preoperative risk scores in the surgical management of patients with diverticular perforation and diffuse peritonitis. Patients and methods From 1988 to 1998, 82 patients, mean age 72 ± 15 years, underwent urgent surgery for perforated diverticulitis with generalized peritonitis. They were operated either with the Hartmann technique or with resection and primary anastomosis. ASA Classification and Mannheimer Peritonitis Index (MPI) were documented as risk scores at time of surgery and used as guidelines to decide for one of both procedures. Results A Hartmann resection (HA) was performed in 62 patients (76%) and resection with primary anastomosis (PA) in 20 (24%). Seventy-one percent of patients in the HA group corresponded to ASA IV/V, compared with 35% in the group with primary anastomosis (P < 0.001). Patients with Hartmann resection had also a higher MPI (23 ± 8) vs those with primary anastomosis (18 ± 7; P < 0.004). However, differences between the HA group and the PA group due to post-operative morbidity (21% vs 35%) and mortality (35% vs 20%) did not reach statistical significance. Nevertheless, multivariate analysis of the whole series revealed a significant relationship between MPI and mortality (P < 0.0043), independent of ASA class, age and operative procedure. Conclusion Patients assigned to Hartmann procedure had more co-morbidities and more advanced peritonitis as assessed by increased ASA and higher MPI. The Mannheimer Peritonitis Index proved to be an independent prognostic index in estimating mortality with respect to peritonitis extension and septic status of the patient. [ABSTRACT FROM AUTHOR]

Abstract: Metastasis from lung cancer, often found in the adrenal glands, bone, liver, brain, and kidneys, have been thought to be rare in the digestive system. When a metastatic tumor is found in the intestine, it is most commonly metastatic melanoma or carcinoma of the cervix uteri, ovary, or breast. Yet, intestinal metastases have been described in 11% of lung cancers at autopsy. These metastases may induce gastrointestinal perforation, obstruction, or bleeding. Patients with bleeding from small intestinal metastases secondary to lung cancer almost uniformly have poor prognoses. The lung cancer metastasized to the gastrointestinal site or location where a first primary cancer was once resected is never reported in the literature. We report the case of a 76-year-old man with a history of gastric adenocarcinoma treated by subtotal gastrectomy seventeen years ago who presented with lung cancer metastatic to the bone. One month later, he developed persistent melena due to duodenal metastases. Upper gastrointestinal endoscopy showed an ulcerative duodenal mass with bleeding. The pathohistological and immunohistochemical examinations of tissue from the pathologic fracture and the endoscopic biopsy specimen revealed metastatic poorly differentiated adenocarcinoma consistent with lung origin. The diagnosis of metastatic lung cancer can be rendered based on pathologic examination and immunohistochemical analysis, even without access to the primary lung tumor. In this case, the anastomosis site where a gastrectomy for gastric cancer was once performed might be a good niche or microenvironment for cancer cells or tumor stem cells to metastasize to. [Copyright &y& Elsevier]

Background: A dehisced colorectal anastomosis complicated by a sinus, especially after preoperative radiation for colorectal cancer, may not heal. We describe our experience in the management of such a condition using the endoscopic surgical stapler. Methods: Patients who underwent low anterior resection for rectal cancer after preoperative chemoradiation and who developed a dehisced anastomosis complicated by a chronic posterior sinus underwent the procedure. After exclusion of cancer recurrence, the common wall between the sinus and the rectal lumen was stapled using the endoscopic surgical stapler. Results: Four patients received the day-surgery treatment. Healing of the sinus was confirmed in all patients using a contrast enema. Median time to healing was 10 weeks. All patients had a diverting ileostomy which was eventually closed. No complications were noted. Conclusion: Stapling the common wall between the sinus and the rectal lumen after a dehisced anastomosis is a viable option in the treatment of chronic posterior sinuses when coupled with fecal diversion. [ABSTRACT FROM AUTHOR]

Esophageus or gaster resection in patients with malignant disease is still a treatment of choice. It is obvious that each surgical procedure in these patients carries some possibility of complications. Esophageo-gastric or esophageo-jejuno anastomosis has a 4–27% frequency of fistula occurrence. All these result in 65% mortality in cases of poorer prognosis. The aim of this paper is not to present all types of complications but to objectively analyse the usefulness of the covered stent placement in the treatment of anastomotic fistulas. We present six patients who were treated for postoperative fistula of esophageo-gastric anastomosis (1 case) or esophageo-jejuno anastomosis (5 cases). All patients were treated with stapler suture for digestive tract reconstruction after malignancy removal during the primary surgical procedure. Signs and symptoms of suture leak between 5–8 days post-surgery were observed. Conservative therapy was not effective. Thus a new method of treatment was employed – covered stent placement. The procedure was performed under X-ray control. In all treated patients there was change for the better and quick reduction of secretion from the fistulas was observed. All patients were discharged from the department after several days and all had survived at 30 days follow-up. Covered esophageal stent placement seems to be a safe and promising method of treatment for patients with anastomotic fistula which significantly reduces mortality and improves quality of live. Our experiences confirms that of other investigators. [ABSTRACT FROM AUTHOR]

An ideal operation for necrotising enterocolitis (NEC) would be quick and reliable, remove all nonviable bowel, minimise the loss of intestinal length, permit early restoration of intestinal continuity, and minimise the need for secondary operations. No operation currently meets all these needs. In this study we review our experience with the Santulli enterostomy in NEC. From 1992 to 1998, 19 patients (16 males, three females) underwent a Santulli enterostomy for Bell grade III NEC. The median gestational age at birth (GA) was 26 weeks (range 23-30), and the median birth weight 755 g (range 600-1095). The median patient age at operation was 10 days (range 3-59), and the median operative time was 55 min (range 25-90). Sixteen (84%) patients survived. Complications included leakage of the Santulli anastomosis in four cases, stomal necrosis in two cases, additional intestinal necrosis in two cases, leakage of a concurrent intra-abdominal anastomosis in two cases, and intestinal obstruction in four cases. Twelve patients underwent relaparotomy. Enteral feeding was started at a median of 5 days postoperatively (range 2-9), with full oral feeding possible at a median of 21 days (range 10-128). The median time until closure of the enterostomy was 48 days and the median hospital stay 87 days (range 19-197). After stomal closure, obstructive symptoms necessitated a new Santulli enterostomy in two patients and a revision of the anastomosis in one patient. Santulli enterostomy can be used to treat NEC even in very small premature babies. It enables rapid recovery of intestinal continuity and early stomal closure. However, the operation is technically demanding and carries significant morbidity. [ABSTRACT FROM AUTHOR]

Fixation of the chin to the anterior chest wall is the most commonly used method of reducing anastomotic tension following a segmental resection of the trachea and reconstruction with primary anastomosis. However, the sutures required for this method may lead to various organic and psychological problems. In five patients who underwent tracheal resection and primary anastomosis, retention sutures were placed on the proximal and distal-lateral edges of the anastomotic line rather than placing a Guardian chin stitch. All patients were mobilised in the early postoperative period and were able to perform their routine daily activities without restrictions. During their average 14.4 months of follow-up, no complications were found in their anastomotic lines during their clinical, radiological, and bronchoscopic assessments. The placement of tracheal retention sutures proved an inexpensive and reliable method to reduce anastomotic tension without additional surgical burden, and was effective in terms of patient comfort. [ABSTRACT FROM AUTHOR]