Search

A 58-year-old woman with a prior radical cystectomy and ileal conduit underwent a living-related donor renal transplant for end-stage renal disease secondary to autoimmune glomerulonephritis. She subsequently developed an ischaemic stricture of the transplant ureter. A successful ureteropyelostomy was performed with the native right ureter anastomosed to the pelvis of the renal transplant. She presented to the emergency department 18 months later feeling unwell and with raised inflammatory markers. Imaging demonstrated a large soft tissue mass over the right psoas muscle and hydronephrosis of the native right kidney. A nephrostomy and nephrostogram of the native right kidney diagnosed a urine leak from the native right kidney and she underwent an open right native nephrectomy. She recovered well postoperatively and continues to have excellent graft function. Renal transplantation in an abnormal urinary tract carries a high risk of complications. A multidisciplinary team approach is essential in offering the most appropriate treatment and ensuring good graft function is preserved.

Endoscopic procedures are the front-runner of the management of bleeding duodenal ulcer. Rarely, surgical intervention is sought for acute bleeding, not amenable to endoscopic procedures. Oversewing of the gastroduodenal artery at ulcer crater by transduodenal approach is the most acceptable and recommended method of treatment. We describe a case of an intraoperative duodenal injury that occurred during an attempt to oversew the gastroduodenal artery after a duodenotomy, leading to an unsatisfactory and meagre duodenal stump. This case will highlight the intraoperative turmoil, postoperative complications and management of a series of anticipated but unfortunate events that have rendered us wiser in terms of surgical management of a bleeding duodenal ulcer.

The advent of free flaps has made it possible to undertake increasingly complex reconstructive surgeries. Many of the patients have already undergone extensive prior surgery, primary free flap reconstruction and/or cervical irradiation. These treatments strongly impact anatomy and tissue quality. The reconstructive surgeon may be faced with a situation where the choice of recipient vessels is limited; in 7% of cases, no cervical vessels are available at all. For venous anastomosis, branches of the internal and external jugular vein are preferentially used, but may have been ligated or be unusable. Venous congestion is one of the most common causes of failure in these situations. The cephalic vein has been described as an alternative for second anastomosis in first line, but is rarely used for early free-flap salvage. Based on a case study, the technique of cephalic vein transposition is illustrated for early salvage of a double free flap for head-and-neck reconstruction. This technique is simple, reliable and rapid. It should be part of the armamentarium of the head and neck reconstructive surgeon.

Although modified Blumgart anastomosis (MBA) in robotic pancreaticoduodenectomy has been accepted as a simple and safe procedure that provides non-inferior surgical outcomes compared to open MBA, the details of the standardization of robotic MBAs have never been established. In this report, we detail the technical tips to reproduce MBA in the robotic environment.From January to December in 2021, 16 patients underwent our novel robotic MBA technique, which included clipless Blumgart suture and duct-to-mucosa anastomosis. To simplify the manipulation of sutures in robotic environment, short double-armed sutures in 15 cm length were created and used for Blumgart suture. Duct-to-mucosa anastomosis were done by 5-0 monofilament of 6 cm length. These tips enabled clipless anastomosis and minimized the burden of the patient-side assistant. Surgical and short-term outcomes were compared between patients with robotic MBA (Robo group) and those who underwent open MBA during 2021 (32 patients, Open group).The median operation time was significantly longer in the Robo group than in the Open group (551 vs. 485.5 min, P = 0.0027). Estimated blood loss was significantly lower in the Robo group than in the open group (95 vs. 355 mL, P 0.0002). The median duration of clipless MBA in the Robo group was 56 (46-68) min. The incidence of POPF (grade B or C) was not significantly different among the groups (19% vs. 22%, P = 0.71). The mean length of hospital stay was significantly shorter in the Robo group than in the Open group (18 vs. 24 days, P = 0.019).Clipless MBA in a robotic environment was safely performed with acceptable short-term outcomes and can be proposed as a standard technique for robotic pancreatojejunostomy.

Background Microvascular hepatic artery reconstruction (MHAR) is associated with decreased rates of hepatic artery thrombosis (HAT) in living donor liver transplantation (LDLT). There is a paucity of literature describing the learning points and initiation of this technique at the institutional level. The objective of this study is to report our institutional experience using MHAR in adult LDLT with a focus on technique and outcomes. Methods A retrospective review of adult patients who underwent LDLT from January 2012 to December 2020 was conducted. Patients were divided into two groups, those who underwent LDLT without MHAR and with MHAR. We analyzed cases for technical data including donor and recipient artery characteristics, anastomotic techniques, intraop events, and postop complications. A Mann–Whitney test was performed to compare outcomes between non-MHAR and MHAR patients. Results Fifty non-MHAR and 50 MHAR patients met inclusion criteria. Median age at transplantation was 58 (interquartile range [IQR] 11.8) and 57.5 years (IQR 14.5), respectively. Median follow-up for MHAR patients was 12.8 months (IQR 11.6). The most common recipient arteries were the right hepatic artery (HA) (58%) and left HA (20%). Median size of recipient and donor arteries were 3.3 mm (IQR 0.7) and 3.1 mm (IQR 0.7), resulting in a median mismatch size of 0.3 mm (IQR 0.4). Median microanastomosis time was 44 minutes (IQR 0). HAT, graft failure, and mortality rates were higher in the non-MHAR cohort (6% vs. 0%, 8% vs. 0%, and 16% vs. 6%, respectively); however, these did not reach statistical significance. Conclusion This study found lower rates of HAT and graft failure after implementing MHAR, though statistical significance was not achieved. Larger cohort studies are needed to further assess the potential benefit of MHAR in adult LDLT. From our experience, MHAR requires cooperation between the transplant and microsurgical teams, with technical challenges overcome with appropriate instrumentation and planning.

Current clinical dogma favors universal inpatient admission after colorectal resection particularly in the presence of an anastomosis.We evaluate the feasibility and safety of ambulatory surgery in carefully selected patients undergoing colorectal resection/anastomosis.Between October 2020 and October 2021, all patients undergoing colorectal resection/anastomosis meeting specific criteria {no major comorbidity [American Society of Anesthesiologist (ASA)4], not on therapeutic anticoagulation, compliant patient/family} were counseled preoperatively for ambulatory surgery (discharge24 h postsurgery). Complicated surgery (ileoanal pouch, enterocutaneous fistula repair, reoperative pelvic surgery, multiple resections) and/or ostomy creation (loop/end ileostomy, Hartmann's, abdominoperineal resection) were exclusions. Discharge was at 6 to 8 hours postoperatively if all predetermined factors (no ostomy teaching needed, ambulating comfortably, tolerating diet, stable vitals, and blood-work) were met and patients were willing, or was postponed to the next day at patient request. All discharged patients received phone checks the next day with the option also given for voluntary readmission if inpatient care was preferred by patient. Patients discharged24 hours postop (AmbC) were compared to those staying on as inpatients admitted (InpC) and also to a comparable historical (October 2019-October 2020) group when ambulatory surgery was not offered (HistC).Of 184 abdominal colorectal surgery patients, 97 had complicated colorectal resection and/or ostomy. Of the remaining 87, 29 (33.3%) were discharged24 hours postoperatively [7 (24%) patients at 8 h]. Of these 29 AmbC patients, 4 were readmitted30 days (ileus: 1, rectal bleeding: 2, nausea/vomiting: 1), 1 readmission was on first postdischarge day, none were voluntary post phone-check. AmbC and InpC (n=58) had similar age, sex, race, body mass index, and comorbidity. InpC had greater estimated blood loss (109 vs 34 mL, P0.001) while length of stay was expectedly significantly longer (109 vs 17 hours, P0.001). There was no mortality in either group. AmbC and InpC had similar readmission, reoperation, anastomotic leak, ileus, and surgical site infection. Mean length of stay for HistC was 83 hours. AmbC and HistC had similar age, sex, race, body mass index, and ASA class. Complications including readmission, reoperation, anastomotic leak, ileus, and surgical site infection were also similar for AmbC and HistC.With careful patient selection, preoperative education, perioperative management, and postoperative follow-up, ambulatory surgery is feasible in up to a third of patients undergoing colorectal resection/anastomosis and can be performed with comparable safety to the time-honored practice of routine inpatient hospitalization. Refinements in inclusion/exclusion criteria and postoperative outpatient follow-up will allow a paradigm shift in how such patients are managed, which has huge implications for patient experience, care-giver workload and health care finances.

Purpose A diverting stoma is commonly formed to reduce the rate of anastomotic leak following anterior resection with anastomosis, although some studies question this strategy. The aim of this study was to assess the leak rates and overall complication burden after anterior resection with and without a diverting stoma. Methods A 5-year national cohort with prospectively registered data of patients who underwent elective anterior resection for rectal cancer located Results Some 1018 patients were included of whom 567 had a diverting stoma and 451 had not. Rate of reoperation for anastomotic leak was 13 out of 567 (2.3%) for patients with diverting stoma and 35 out of 451 (7.8%) (p > 0.001) for patients without. In multivariable analyses not having a diverting stoma (aOR 3.77, c.i 1.97–7.24, p Conclusion Diverting stoma formation after anterior resection is protective against reoperation for anastomotic leak but does not affect overall rates of reoperation or complications within 30 days.

Despite advances in medical therapy, surgery continues to play a vital role in the management of Crohn's disease and its complications. Continuing from Part I of this series (small intestine/ileal disease), we focus next on colonic Crohn's disease and associated neoplasms. We will first review the surgical management of medical-refractory Crohn's colitis and its complications and then examine cancer risk, surveillance, and surgical management of Crohn's-associated colorectal dysplasia and malignancy. We conclude with a discussion of restoration of gastrointestinal continuity following colonic surgery for Crohn's disease.

In our institution, patients with intractable slow transit constipation (STC) have undergone single-incision clipless laparoscopic total colectomy (SCLTC) with ileorectal anastomosis (IRA) since 2011. We aimed to examine the feasibility and usefulness of SCLTC with IRA for patients with intractable STC.From January 2011 to December 2018, twenty-two patients with intractable STC underwent SCLTC with IRA at Kashiwa Hospital, Jikei University, by a single surgeon, were retrospectively registered in this study. They consisted of the first 12 consecutive patients undergoing the double stapling technique (DST) with IRA (DST group) and the last 10 consecutive patients undergoing functional end-to-end anastomosis (FEEA) with IRA (FEEA group).The median surgical time was 185 (150-249) min for the FEEA group and 230 (180-266) min for the DST group. A significant difference was identified between the two groups (0.035). There were no significant differences between the groups with respect to the median age, sex, body mass index, constipation type, intraoperative blood loss, postoperative hospital stay, or no use of laxatives daily stool frequency 1 month after surgery. No postoperative complications, such as anastomotic leakage, bowel obstruction, or bleeding related to vessel sealing device, were encountered in either group more than 3 years after surgery.Our results suggest that SCLTC with IRA is feasible and safe for patients with intractable STC. SCLTC with IRA using FEEA is especially preferred to that using DST for patients with intestinal contents in the rectum that cannot be completely removed by pre- and intraoperative preparation.

Microsurgery allows complex reconstruction of tissue defects after oncological resections or severe trauma. Performing these procedures may be limited by human tremor, precision, and manual dexterity. A new robot designed specifically for microsurgery with wristed microinstruments and motion scaling may reduce human tremor and thus enhance precision. This randomized controlled preclinical trial investigated whether this new robotic system can successfully perform microsurgical needle driving, suturing, and anastomosis.Expert microsurgeons and novices completed six needle passage exercises and performed six anastomoses by hand and six with the new robot. Experienced microsurgeons blindly assessed the quality of the procedures. Precision in microneedle driving and stitch placement was assessed by calculating suturing distances and angulation. Performance of microsurgical anastomoses was assessed by time, learning curves, and the Anastomosis Lapse Index score for objective performance assessment.Refined precision in suturing was achieved with the robot when compared with the manual technique regarding suture distances (p = 0.02) and angulation (p 0.01). The time required to perform microsurgical anastomoses was longer with the robot, however, both expert and novice microsurgeons reduced times with practice. The objective evaluation of the anastomoses performed by novices showed better results with the robot.This study demonstrated the feasibility of performing precise microsutures and anastomoses using a new robotic system. Compared to standard manual techniques, robotic procedures were longer in time, but showed greater precision.

It is important to quantify the amount of crossover innervation from the anterior interosseous nerve (AIN) through Martin-Gruber anastomosis (MGA) particularly in patients with high ulnar nerve injury who undergo nerve transfer surgery. The objective of this study is to describe a novel electrophysiological method for quantifying innervation from the AIN that can be done using conventional nerve conduction study setup and commonly available software for analysis.Seven subjects with MGA and nine patients who had undergone AIN to ulnar nerve transfer underwent conventional motor nerve conduction studies. Recording was done over the hypothenar and first dorsal interosseous muscles while stimulating the median and ulnar nerves at the wrist and elbow. Datapoint-by-datapoint subtraction of the compound muscle action potentials evoked at the elbow and wrist was performed after they had been onset-aligned. The results were compared to the collision technique and innervation ratio method.Results from the digital subtraction method were highly correlated with the collision technique (r = 0.96, p 0.05). In contrast, its correlation with the innervation ratio method is substantially lower.In comparison to previously described techniques, the digital subtraction method has a number of practical advantages. It uses conventional nerve conduction study setup, and the added step of digital alignment and subtraction can be done through commonly available software. With the increasing use of nerve transfer surgery in severe high ulnar nerve injury, this could be a useful method to identify the presence of MGA prior to surgery and for evaluating nerve recovery following surgery.

Management of neonates with long gap esophageal atresia (LGEA) is one of the most challenging situations facing pediatric surgeons. Delayed anastomosis after internal traction for esophageal lengthening was reported as a useful technique for long gap cases. Additionally, the use of near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) has gained popularity in pediatric surgery, especially for blood perfusion validation. We report a novel technique for safe and secure anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence.A pregnant woman with polyhydramnios was admitted to the department of obstetrics in our hospital. At 29 weeks of gestation, ultrasound showed mild polyhydramnios and absence of the fetal stomach. A male neonate was born at 38 weeks of gestation with 21 trisomy. EA (Gross type A) was diagnosed based on an X-ray study that showed the absence of gastric bubble with a nasogastric tube showing the "coil-up" sign. Thoracoscopic internal traction and laparoscopic gastrostomy were performed on day 4 after birth. We confirmed the distance between the upper pouch and lower pouch on X-ray. On day 16 after birth, thoracoscopic anastomosis was performed. We successfully performed esophageal anastomosis without tearing the esophageal wall. Blood perfusion of the upper and lower pouch was validated after anastomosis using ICG-guided NIR fluorescence.Delayed anastomosis for LGEA in the neonatal period using internal traction and ICG-guided NIR fluorescence is safe and feasible.

Background Postoperative recurrence [POR] of Crohn’s disease following ileocolonic resection is common. The impact of immediate postoperative intra-abdominal septic complications [IASC] on endoscopic and surgical recurrence has not been elucidated. Aims To evaluate if IASC is associated with an increased risk for endoscopic and surgical POR. Methods This was a retrospective study of adult Crohn’s disease patients undergoing ileocolonic resection with primary anastomosis between 2009 and 2020. IASC was defined as anastomotic leak or intra-abdominal abscess within 90 days of the date of surgery. Multivariable logistic and Cox proportional hazard modelling were performed to assess the impact of IASC on endoscopic POR [modified Rutgeerts’ score ≥ i2b] at index postoperative ileocolonoscopy and long-term surgical recurrence. Results In 535 Crohn’s disease patients [median age 35 years, 22.1% active smokers, 35.7% one or more prior resection] had an ileocolonic resection with primary anastomosis. A minority of patients [N = 47; 8.8%] developed postoperative IASC. In total, 422 [78.9%] patients had one or more postoperative ileocolonoscopies, of whom 163 [38.6%] developed endoscopic POR. After adjusting for other risk factors for postoperative recurrence, postoperative IASC was associated with significantly greater odds (adjusted odds ratio [aOR]: 2.45 [1.23–4.97]; p = 0.01) and decreased time (adjusted hazards ratio [aHR]: 1.60 [1.04–2.45]; p = 0.03] to endoscopic POR. Furthermore, IASC was associated with increased risk (aOR: 2.3 [1.04–4.87] p = 0.03) and decreased survival-free time [aHR: 2.53 [1.31–4.87]; p = 0.006] for surgical recurrence. Conclusion IASC is associated with an increased risk for endoscopic and surgical POR of Crohn’s disease. Preoperative optimization to prevent IASC, in addition to postoperative biological prophylaxis, may help reduce the risk for endoscopic and surgical POR.

Background Leakage of rectal anastomoses is one of the most important and feared complications in colorectal surgery. Apart from patient-specific risk factors, technical aspects may influence the occurrence of anastomotic complications. This study investigated whether using single-stapling techniques (SST) instead of the double-stapling technique (DST) for minimal-invasive rectal anastomosis is associated with a lower rate of anastomotic complications. Methods A retrospective review of 272 patients who received a minimally invasive stapled rectal anastomosis (3–16 cm from the anal verge) at our institution from 2015 to 2020 was performed. In 131 patients, rectal anastomosis was created by SST (SST group), while 141 patients received a rectal anastomosis with crossing stapler lines (DST group). The impact of the anastomotic technique on patient outcomes was determined by uni- and multivariate analyses. Results Overall anastomotic leakage rate was 6%. Patients with SST anastomoses had a lower leakage rate than patients with DST anastomoses (3% vs. 9% in the DST group, p = 0.045). The rate of anastomotic stenosis was lower in the SST group than in the DST group (1% vs. 6%, p = 0.037). Overall morbidity and mortality did not differ between the two groups. Multivariate analysis showed that single-stapling techniques significantly reduce the risk of anastomotic leakage (OR 3.5 [1.0–11.5], p = 0.043). Conclusion The use of SST for rectal anastomosis may help to reduce anastomotic complications. This finding should be confirmed by a randomized controlled trial.

Objective. This study introduces a technique for esophagojejunostomy with half transected and self-pulling (HTSP) and evaluates the safety, feasibility, and clinical results of this technique in totally laparoscopic total gastrectomy (TLTG). Materials and Methods. From May 2019 to March 2021, 42 patients (HTSP group) who underwent HTSP-TLTG surgery in the Department of Abdominal Tumor Surgery of Jiangxi Cancer Hospital were included in this study. The control group consisted of 50 patients undergoing conventional TLTG surgery (conventional anastomosis group) performed by the same surgical team from March 2018 to March 2020. The clinical data of the two groups were retrospectively analyzed and compared. Results. The mean operation time of the HTSP-TLTG surgery was 166.7 ± 13.1 minutes and the anastomosis time was 20.8 ± 2.0 minutes, which were significantly shorter than those of traditional TLTG ( P < 0.05 ). There were no significant differences between the two groups in blood loss, time to first exhaust, postoperative hospital stay, and incidence of surgery-related complications. Conclusion. HTSP is a safe and feasible way of endoscopic esophagojejunal anastomosis, which requires a relatively low suture technique under endoscopy, and is suitable for promotion.

This review aims to evaluate the surgical outcomes of hand-sewn esophageal anastomosis compared to mechanical anastomosis to reconstruct total gastrectomy. A systematic review and meta-analysis of comparative studies evaluating hand-sewn and stapled anastomosis were performed. A total of 12 studies were selected, comprising 1761 individuals. The results indicate that the hand-sewn and stapled esophageal anastomosis have similar surgical outcomes. Stapled anastomosis has a shorter operation time.

In laparoscopic total gastrectomy, esophago-jejunal anastomosis is still considered a complicated procedure, even though laparoscopic surgery has become widespread. Esophagojejunostomy leakage can be fatal and adversely affect postoperative cancer treatment. The leakage rate has been reported to be 2.4-5.5%, and a safer and more reliable technique needs to be established. In this multi-media article, we describe the technique of laparoscopic esophagojejunostomy using a simple and safe T-shaped esophagojejunostomy.We performed laparoscopic total gastrectomy with ante-colic Roux-en-Y reconstruction using a T-shaped anastomosis. First, insertion holes are made on the right side of the esophageal stump and the opposite side of the mesentery of the lift-up jejunal stump. Second, a linear stapler is inserted into each insertion hole, and a 40-45-mm V-shaped esophageal jejunal anastomosis is performed. Third, three temporary sutures are added for closing the common edge. Finally, a second stapling is used to close the entry hole and resect the esophageal stump.We performed this procedure in 35 patients between May 2016 and December 2018. The median duration of surgery was 338 min (range, 248-542 min) and median bleeding was 20 mL (range, 0-240 mL). There were no esophagojejunostomy-related complications higher than Clavien-Dindo grade II. Additionally, no postoperative stenosis occurred during the follow-up period (median: 48 months, range: 4-68 months).Considering the present results, T-shaped esophago-jejunal anastomosis is a simple and safe procedure and a promising laparoscopic total gastrectomy option.

Patients with familial adenomatous polyposis are sometimes treated with prophylactic or therapeutic proctocolectomy to either prevent or treat the almost inevitable colorectal cancer that develops in the numerous, early onset tubular adenomas to which they are prone. These patients are potential candidates for a restorative IPAA.This study aimed to highlight the particular nuances of ileal pouch-anal surgery faced by patients with familial adenomatous polyposis and point out the implications of the syndrome for patients who are candidates for an IPAA and the surgeons operating on them.A literature search was performed on PubMed and MEDLINE using the terms "ulcerative colitis," "familial adenomatous polyposis," "surgery," and "ileal pouch-anal anastomosis."As a result of a fundamental difference in pathophysiology, there are significant differences in demographics, presentation, surgical strategy, and sequelae of proctocolectomy and IPAA between familial adenomatous polyposis and ulcerative colitis. Proctocolectomy with IPAA in selected familial adenomatous polyposis patients can be performed in 1 stage, but their lack of symptoms means that any complications assume a greater significance. In polyposis patients, postoperative endoscopic surveillance of residual large intestine begins immediately, whereas surveillance of the pouch itself becomes increasingly important. Symptoms leading to a diagnosis of pouchitis are instead often due to structural and functional issues.

The aims of this study were to investigate if recipient artery choice in right lobe living donor liver transplant affects postoperative complications and discuss solutions accordingly.Three hundred fourteen right lobe living donor liver transplantation patients were divided into 2 groups: 163 patients using right hepatic artery as the recipient vessel and 151 patients using left hepatic artery as the recipient vessel. Cases involving 2 recipient blood vessels or the use of other blood vessels as recipient vessels were excluded.Overall vascular embolism rate in both groups was 1.3%, and our complication rate was lower than those in previous studies. There was no significant difference in complication rate between the groups, but a significant difference in recipient/donor artery size ratio was noted.Although left hepatic artery's anatomical position makes it less affected by bile duct anastomosis and thus fewer postoperative complications, we believe that the ratio of the donor-recipient blood vessel size and the length of the anastomosis vessel stumps are the key factors that affect the outcome of the vascular anastomosis.

Anastomotic stricture is the most common complication after esophageal atresia (EA) repair. We sought to determine if postoperative acid suppression is associated with reduced stricture formation.A prospective, multi-institutional cohort study of infants undergoing primary EA repair from 2016 to 2020 was performed. Landmark analysis and multivariate Cox regression were used to explore if initial duration of acid suppression was associated with stricture formation at hospital discharge (DC), 3-, 6-, and 9-months postoperatively.Of 156 patients, 79 (51%) developed strictures and 60 (76%) strictures occurred within three months following repair. Acid suppression was used in 141 patients (90%). Landmark analysis showed acid suppression was not associated with reduction in initial stricture formation at DC, 3-, 6- and 9-months, respectively (p = 0.19-0.95). Multivariate regression demonstrated use of a transanastomotic tube was significantly associated with stricture formation at DC (Hazard Ratio (HR) = 2.21 (95% CI 1.24-3.95, p0.01) and 3-months (HR 5.31, 95% CI 1.65-17.16, p0.01). There was no association between acid suppression duration and stricture formation.No association between the duration of postoperative acid suppression and anastomotic stricture was observed. Transanastomotic tube use increased the risk of anastomotic strictures at hospital discharge and 3 months after repair.

Summary Background Delayed colo-anal anastomosis (DCA) is an underused technique rarely performed after resection of primary low rectal adenocarcinoma. The objective of this study was to compare the short-term outcomes of DCA and classical colo-anal anastomosis (CAA). Methods This is a retrospective comparative study carried out at two tertiary centres in Morocco and France. It included all patients who underwent colo-anal anastomosis after complete mesorectal excision for primary rectal adenocarcinoma between January 2018 and December 2019. The main outcomes were 90-day morbidity and rates completing the surgical steps of DCA and CAA. Results Among 215 rectal resections, 45 patients received colo-anal anastomosis, including 19 DCA and 26 CAA. Seventeen patients in the DCA group completed the two steps compared to 16 in the CAA group (89.5% vs. 61.5%, P = 0.04). The rates of severe complications (26.9% vs. 26.3%, P = 0.96) and anastomotic leakage (42.3% vs. 31.6%, P = 0.46) were not different between the two groups. Conclusion This study showed that DCA was associated with a higher rate of completing the two surgical steps, with no difference in overall and severe morbidity. DCA may be a strong alternative to classical colo-anal anastomosis.

Purpose The aim of this experimental study was to test the method of prevention of postoperative complications, especially infectious, in partial dehiscence following stapler anastomosis in rectal surgeries. Methods The method includes the application of a hyaluronic acid-based gel in combination with triclosan, which has antibacterial properties. The gel was applied to the space around the rectum with an artificial, precisely defined dehiscence so that the dehiscence was separated from the rest of pelvis and the peritoneal cavity to avoid the spread of infection. The study included 30 female pigs. The rectosigmoid colon was mobilized and transected completely. Anastomosis was constructed with circular staplers. A perforator was then used to create precisely defined artificial dehiscence. Subsequently the lesser pelvis was filled with hyaluronic gel such that the site of artificial dehiscence was covered completely. Results All animals survived for 14 days until the second-look revision with no signs of failure in the anastomosis healing, local inflammation, and sepsis or postoperative complications, such as chills, refusal of liquid or feed, abdominal distension, and bowel obstruction. Conclusion Hyaluronic acid applied as a precursor solution around the rectal anastomosis fills the lesser pelvis perfectly. It prevents the leakage of intestinal contents in the lesser pelvis. Triclosan as an antibacterial substance prevents the spread of inflammation in the pelvis or even in the abdominal cavity.

Objective. The aim of this study is to evaluate the feasibility of the 3D exoscope in a mi-crovascular anastomosis training setting and compare it with the gold-standard technique using the operating microscope (OM). Methods. Participants were recruited among otorhinolaryngology head and neck surgery (OHNS) residents of two tertiary care hospitals. Trainees were asked to complete 4 micro-vascular end-to-end anastomoses on chicken thighs with the OM and VITOM 3D exoscope. The performances were scored by experienced microvascular surgeons; an objective evaluation of the anastomosis and a subjective assessment of the workload were conducted. Results. 8 OHNS residents were recruited. Considering the amount of time needed to complete (TTC) the anastomosis, an improvement was shown by all the participants throughout the training program. The objective evaluation of the anastomosis did not show a significant difference. No significant differences were found by analyzing the subjective workload with the different tools. Conclusions. This article represents the first attempt to compare the use of the OM and the 3D exoscope during training for microsurgery. The results of our study demonstrate the noninferiori-ty of microsurgical training obtained using the 3D exoscope compared to that offered by the OM.

BACKGROUND: To decrease morbidity caused by anastomotic leakages after a low anterior resection (LAR) with primary anastomosis, a diverting ostomy is often created. Reversal of a diverting ostomy is associated with morbidity, which may result in non-reversal, particularly in the elderly. This study aimed to describe the diverting ostomy-related outcomes in elderly patients with more advanced rectal cancer after LAR.MATERIALS AND METHODS: All rectosigmoid and rectal cancer patients ≥70 years who underwent LAR with primary anastomosis between 2006 and 2019 in the Catharina Hospital (Eindhoven, The Netherlands) were included for analyses. Reversal rates, ostomy-related complications, morbidity and mortality after ostomy reversal, and definitive ostomy rates were evaluated.RESULTS: In total 164 patients were included, of which 150 (91.5%) underwent primary or secondary ostomy creation. Ostomy-related complications were reported in 34.7% (95%-CI 27.1-42.9%). In total, 72.5% (95%-CI 64.2-79.7%) reversed their diverting ostomy. Non-reversal was mostly due to relapsing disease (52.6%). Median time to ostomy reversal was 3.2 months (IQR 2.3-5.0). No or minor complications after ostomy reversal were observed in 84.0% (95%-CI 75.3-90.6%). Over time, ostomy recreation was performed in 15.0% (95%-CI 8.6-23.5%), and ultimately 65.8% (95%-CI 57.8-73.2%) were ostomy-free after the median follow-up of 3.8 years.CONCLUSION: Although most elderly successfully reversed their diverting ostomy after LAR with limited morbidity, attention should be paid for the risk of non-reversal and ostomy recreation over time. Preoperative patient counselling is important in every individual to be able to decide if LAR with primary anastomosis or a permanent end colostomy is preferred.

The aim was to define the risk factors for acute urinary retention (AUR) and urinary tract infections (UTIs) in colon or high rectum anastomosis patients based on the absence of a urinary catheter (UC) or the early removal of the UC (24 h).This is a multicentre, international retrospective analysis of a prospective database including all patients undergoing colon or high rectum anastomoses. Patients were part of the enhanced recovery programme audit, developed by the Francophone Group for Enhanced Recovery after Surgery, and were included if no UC was inserted or if a UC was inserted for24 h.In all, 9389 patients had colon or high rectum anastomoses using laparoscopy, open surgery or robotic surgery. Among these patients, 4048 were excluded because the UC was left in place24 h (43.1%) and 97 were excluded because the management of UC was unknown (1%). Among the 5244 colon or high rectum anastomoses patients included, AUR occurred in 5.2% and UTI occurred in 0.7%. UCs were in place for24 h in 2765 patients (52.7%) and 2479 did not have UCs in place (47.3%). Multivariate analysis showed that management of the UC was not significantly associated with the occurrence of AUR and that risk factors for AUR were male gender, ≥65 years old, having an American Society of Anesthesiologists score ≥3 and receiving epidural analgesia. Conversely, being of male gender was a protective factor of UTI, while being ≥65 years old, having open surgery and receiving epidural analgesia were risk factors for UTIs. The management of the UC was not significantly associated with the occurrence of UTIs but the occurrence of AUR was a more significant risk factor for UTIs.UCs in place for24 h did not reduce the occurrence of AUR or UTI compared to the absence of UCs.

Background Endoscopic vacuum therapy (EVT) with or without early surgical closure (ESC) is considered an effective option in the management of pelvic anastomotic leakage. This meta-analysis evaluated the effectiveness of EVT in terms of stoma reversal rate and the added value of ESC. Methods A systematic search of PubMed, MEDLINE, and the Cochrane Library was conducted in November 2021 to identify articles on EVT in adult patients with pelvic anastomotic leakage. The primary outcome was restored continuity rate. Following PRISMA guidelines, a meta-analysis was undertaken using a random-effects model. Results Twenty-nine studies were included, accounting for 827 patients with leakage who underwent EVT. There was large heterogeneity between studies in design and reported outcomes, and a high risk of bias. The overall weighted mean restored continuity rate was 66.8 (95 per cent c.i. 58.8 to 73.9) per cent. In patients undergoing EVT with ESC, the calculated restored continuity rate was 82 per cent (95 per cent c.i. 50.1 to 95.4) as compared to 64.7 per cent (95 per cent c.i. 55.7 to 72.7) after EVT without ESC. The mean number of sponge exchanges was 4 (95 per cent c.i. 2.7 to 4.6) and 9.8 (95 per cent c.i. 7.3 to 12.3), respectively. Sensitivity analysis showed a restored continuity rate of 81 per cent (95 per cent c.i. 55.8 to 99.5) for benign disease, 69.0 per cent (95 per cent c.i. 57.3 to 78.7) for colorectal cancer, and 65 per cent (95 per cent c.i. 48.8 to 79.1) if neoadjuvant radiotherapy was given. Conclusion EVT is associated with satisfactory stoma reversal rates that may be improved if it is combined with ESC.

Blood supply is especially weak near the gastric fundus. Making the anastomosis in this area would increase the risk of anastomotic leakage (AL). In cervical anastomosis, the gastric conduit needs to travel through the thorax. Therefore, the relative length between the stomach and the thorax is an essential factor in deciding if the poorly supplied area could be removed. This study was to explore if a small relative gastric length was a risk of cervical AL. If all other conditions are equal, could intrathoracic anastomosis be a better choice?Patients who underwent esophagectomy with a preoperative barium swallow in West China Hospital between 2014 and 2017 were included. The length of the greater curvature and the thorax were obtained from the barium esophagogram. The ratio between the length of the greater curvature and the thorax was the relative gastric length calculated from the greater curvature (RGL-G).A total of 782 patients were enrolled in the final analysis. The cervical AL group had a significantly higher ratio of patients with an RGL-G less than 1.3 (26.7% vs. 8.9%, p = 0.003). The multivariate logistic regression proved that RGL-G less than 1.3 was a risk factor for cervical anastomotic leakage (p = 0.012). Correspondingly, RGL-G less than 1.3 was not a risk factor (6.3% vs. 14.3%, p = 0.289) in the intrathoracic anastomosis group.RGL-G less than 1.3 was a new risk factor for cervical AL, but it would not be a problem for intrathoracic anastomosis.

Background Reported incidence of anastomotic leakage (AL) of rectal anastomoses is up to 29% with an overall mortality up to 12%. Nevertheless, there is no uniform evidence-based diagnostic procedure for early detection of AL. The objective of this prospective clinical trial was to demonstrate the diagnostic value of early postoperative flexible endoscopy for rectal anastomosis evaluation. Methods Flexible endoscopy between 5 and 8th postoperative day was performed consecutively in 90 asymptomatic patients. Sample size calculation was made using the two-stage Simon design. Diagnostic value was measured by management change after endoscopic evaluation. Anastomoses were categorized according to a new classification. Study is registered in German Clinical Trials Register (DRKS00019217). Results Of the 90 anastomoses, 59 (65.6%) were unsuspicious. 20 (22.2%) were suspicious with partial fibrin plaques (n = 15), intramural hematoma and/or local blood coagulum (n = 4) and ischemic area in one. 17 of these anastomoses were treated conservatively under monitoring. In three a further endoscopic re-evaluation was performed and as consequence one patient underwent endoscopic vacuum therapy. 11 (12.2%) AL were detected. Here, two could be treated conservatively under monitoring, four with endoscopic vacuum therapy and five needed revision surgery. No intervention-related adverse events occurred. A change in postoperative management was made in 31 (34.4%) patients what caused a significant improvement of diagnosis of AL (p Conclusions Early postoperative endoscopic evaluation of rectal anastomoses is a safe procedure thus allows early detection of AL. Early treatment for suspicious anastomoses or AL could be adapted to avoid severe morbidity and mortality. Graphical abstract

Anastomotic leakage (AL) is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate an innovative and convenient technique of laparoscopic demucositized suture the overlapping point of the "dog ear" area after the double stapling anastomosis (lds-DSA), as an improved alternative for conventional DSA, and whether it could reduce the AL rate in laparoscopic anterior resection (Lapa-AR). Between January 2018 and December 2020, a total of 245 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectal cancer were divided into the lsd-DSA group (n = 99) and the DSA group (n = 146). Data were analyzed retrospectively. Morbidity, AL rate and other perioperative outcomes were compared between the two groups. Patient demographics, preoperative comorbidity, preoperative chemoradiotherapy, tumor size, stage, and other operative details were comparable between the two groups. There was no difference in surgical time between the two groups (196.41 ± 76.71 vs. 182.39 ± 49.10 min, p = 0.088). The overall complication rate was also without a difference (11/99, 11.11% vs. 21/146, 14.38%, p = 0.456), but AL rate significantly lower in the lsd-DSA group than in the DSA group (2/99, 2.02% vs. 12/146, 8.22%, p = 0.040). For other perioperative outcomes, the lsd-DSA group shortened the total and postoperative hospital stay, and the time to pull out drainage tube than in the DSA group. Our comparative study demonstrates lds-DSA to have a better short-term outcome in reducing AL compared with DSA. This technique could be an alternative approach to maximize the patients' benefit in Lapa-AR.

Purpose: The aim of this study was to evaluate the anastomotic leakage (AL) rate and predictors for AL following minimally invasive restorative rectal resection (RRR) among rectal cancer patients managed according to up-to-date standardized treatment. Furthermore, we explored the impact of symptomatic AL on long-term survival. Methods: The study cohort was rectal cancer patients undergoing minimally invasive RRR in Central Denmark Region between 2013 and 2017. Data was retrieved from a prospective clinical quality database and supplemented with data from medical records. The AL rate was calculated as the proportion of patients who developed symptomatic AL within 30 days. Predictors for AL were identified through logistic regression. The impact of AL on long-term survival was analyzed using Kaplan–Meier methods and Cox regression. Results: AL occurred in 15.1% of 604 patients. The AL rate for males was 20.1% (95% CI 16.3–24.3) and 5.0% (95% CI 2.4–9.0) for females. Odds ratio (OR) of AL in females vs. males was 0.25 (95% CI 0.12–0.51). The use of at least three firings when transecting the rectum was associated with OR of 2.71 (95% CI 1.17–6.26) for AL. The 5-year survival for patients with vs. those without AL was 76.1% (95%CI 65.1–84.0) and 83.6% (95%CI 79.8–86.7), corresponding to adjusted hazard ratio of 1.43 (95%CI 0.84–2.41). Conclusion: Symptomatic AL is still a challenge in a standardized setting using minimally invasive surgery in rectal cancer patients undergoing RRR, especially in men. Multiple firings should be avoided in transection of the rectum with an endoscopic stapler. AL had a statistical non-significant negative impact on survival.

Background Pancreaticojejunostomy, an independent risk factor for pancreatic fistula, is the cause of several postoperative complications of pancreaticoduodenectomy. As suturing in minimally invasive surgery is difficult to perform, more simplified methods are needed to guarantee a safe pancreatic anastomosis. The concept of “biological healing” proposed in recent years has changed the conventional understanding of the anastomosis, which recommends rich blood supply, low tension, and loose sutures in the reconstruction of the pancreatic outflow tract. Methods A literature search was conducted in PubMed for articles on pancreaticojejunostomy published between January 2014 and December 2021. After following a due selection process, several techniques developed in accordance with the concept of biological healing that were found suitable for minimally invasive surgery and their related clinical outcomes were described in this review. Results The incidence of clinically relevant pancreatic fistula associated with the presented techniques did not exceed 15.9%, indicating superior results compared to Cattell–Warren double-layer duct-to-mucosa anastomosis (incidence: approximately 20%). The features and drawbacks of these approaches have been enumerated from the viewpoint of biological healing. Conclusions This review described several modified pancreaticojejunostomy techniques with the advantages of a simplified procedure and a lower incidence of pancreatic fistula. Surgeons can choose to apply them in clinical practice to improve patient prognosis.

Esophagojejunal anastomosis (EJA) complications after total gastrectomy are related to significant morbidity and mortality. The aim of this study was to evaluate the association between arterial calcifications and EJA complications such as leak and stricture for gastric cancer. Between January 2014 and October 2019, 30 patients with EJA complications after total gastrectomy were enrolled and matched to 30 patients without complications through retrospective data review. Arterial calcification grade on preoperative computed tomography (CT) was reported in the abdominal aorta and superior mesenteric artery (SMA) as “absent”, “minor”, or “major”, and in the jejunal vascular arcade (JVA) and left inferior phrenic artery (LIPA) as “absent” or “present”. A Chi-square test was used to compare the variables between the two groups. p-Value < 0.050 was considered statistically significant. Among 30 patients, the numbers of patients with leak and stricture were 23 and seven, respectively. Aortic calcifications were not associated with EJA complications regardless of their grade (p = 0.440). Only major SMA calcifications were associated with EJA complications, as they were present in five patients (16.7%) in the complication group and absent in the non-complication group (p = 0.020). Major SMA calcifications were more related to anastomotic stricture than leak. Three (13.0%) out of 23 patients with leak and two (28.6%) out of seven with stricture had major SMA calcifications (p = 0.028). No calcifications were detected in the JVA or LIPA in any of the 60 patients. Major SMA calcifications were found to be associated with EJA complications, especially in stricture.

Lower limb lymphorrhea is a condition with a considerable impact on the quality of life. It is usually associated with inguinal lymph node dissection and vascular procedures with femoral exposure. In this case report, we describe a patient who underwent a below-knee amputation and two years later developed lymphorrhea from the stump, preventing adaptation to the prosthesis. Lymphoscintigraphy showed a delayed lymphatic progression. After failure of conservative treatment, she underwent lymphaticovenular anastomosis with a successful outcome. Drainage cessation suggests that lymphaticovenular anastomosis may be an effective treatment for patients with lymphorrhea from and amputation stump, although further studies are required to determine long-term efficacy.A linforreia do membro inferior é uma patologia com grande impacto na qualidade de vida. Está geralmente associada a esvaziamentos ganglionares inguinais e a procedimentos vasculares com exposição dos vasos femorais. Apresentamos o caso de uma doente que sofreu uma amputação abaixo do joelho e dois anos depois desenvolveu linforreia a partir do coto de amputação, impedindo a adaptação à prótese. A linfocintigrafia revelou um atraso na progressão linfática. Após falência do tratamento conservador, foi submetida a anastomoses linfático-venosas, com resolução da linforreia. A cessação da drenagem sugere que a realização de anastomoses linfático-venosas poderá ser um tratamento eficaz em doentes com inforreia a partir de um coto de amputação, embora sejam necessários mais estudos para determinar a sua eficácia a longo prazo.

To determine the influence of the staple line configuration on the leakage of small intestinal functional end-to-end stapled anastomosis (FEESA).Experimental, ex vivo, randomized study.Jejunal segments (N = 72) from 10 mature, canine cadavers.Jejunal segments (10 cm) were randomly assigned to a control group (8 segments) and 4 FEESA groups (16 segments/group (8 constructs/group)), according to the number of rows of staples used in the vertical (V) and transverse lines (T), respectively: Control, 2-row V/2-row T (2V/2T), 2-row V/3-row T (2V/3T), 3-row V/2-row T (3V/2T), 3-row V/3-row T (3V/3T). Initial leak pressure (ILP), maximum intraluminal pressure (MIP), and initial leakage location (ILL) were compared.The ILP (mean ± SD) for control segments, 2V/2T, 2V/3T, 3V/2T and 3V/3T were 321.38 ± 34.59, 32.88 ± 7.36, 50.13 ± 10.46, 34.38 ± 11.78, 69.88 ± 21.23 mmHg, respectively. All FEESAs initially leaked at lower pressures than intact segments. The only other differences detected between groups consisted of ILPs that were higher when FEESAs were closed with 3V/3T (69.88 ± 21.23 mmHg) than 2V/2T (32.88 ± 7.36, P .001). Initial leakage occurred predominantly from the transverse staple line rather than the anastomotic crotch (P .001).Placing 3 rows of staples in the transverse line (with or without a third row in the vertical staple line) improved resistance to leakage of FEESAs in normal cadaveric specimens.The addition of a third row of staples in the transverse line (with or without a third row in the vertical staple line) in FEESAs should be further investigated as a strategy to reduce intestinal leakage clinically.

Being one of the core techniques of magnetic surgery, magnetic compression technique (MCT) has been used for digestive tract anastomosis reconstruction in experimental studies. This study verified the feasibility of gastroenteric anastomosis through natural orifice using MCT in rats.The parent and daughter magnets were designed and manufactured for oral and anal insertion in 20 Sprague-Dawley rats. After anesthesia, the parent magnet was inserted into the colon spleen area through the anus, and the daughter magnet was inserted into the stomach through the mouth. Then the two magnets were positioned to attract each other and bind together. The position of the two magnets was monitored using X-ray. The time required for the formation of the anastomosis and expulsion of the magnets were recorded. 2 weeks later, the animal was sacrificed and the anastomotic specimen was obtained which was observed under naked eye and microscope.The gastroenteric anastomosis was successfully performed via natural orifices in 18 out of 20 rats. The mean time to construct the anastomosis was 3.78 ± 0.88 min. X-ray examination showed that the magnets were in the appropriate position in 17 rats. The magnets were excreted in 9.47 ± 1.62 days after surgery. The gross and microscopic examination of the specimen showed that the anastomoses were patent and the mucosa at the anastomotic was smooth. The mean bursting pressure of the anastomosis was 136.94 ± 6.79 mmHg.It is feasible to perform gastroenteric anastomosis through natural orifices by MCT.

Background: The use of magnetic devices in digestive surgery has been a matter of debate in recent years. The aim of this review was to describe the physical bases, indications, and results of the ...

A radiocephalic arteriovenous fistula (RCAVF) is associated with better long-term patency and fewer complications. However, RCAVF have lower maturation rate for hemodialysis compared with upper AVF or arteriovenous graft. We performed this study to determine the effect of the radiocephalic (RC) anastomotic length on the AVF maturation.We reviewed the patients who underwent RCAVF creation with a side-to-end manner from March 2015 to December 2018. AVF maturation was defined as successful hemodialysis (HD) in at least two consecutive sessions. We compared the possible factors including the RC anastomotic length between the initial HD success group and initial HD failure group.A total of 114 patients underwent RCAVF creation: 72 males and 42 females (63.2% and 36.8%, respectively). The mean preoperative arteriotomy length of the AVF was 14.1 mm (range 11.0-16.0 mm). Out of 114 patients, initial HD was executed successfully in 83 patients (72.8%). Among the 31 patients with initial HD failure (27.2%) balloon angioplasty was successfully performed in 17 patients, failed in 4 patients, and not performed in 10 patients. The secondary success rate after balloon angioplasty was 87.7%. After factor analysis, pre-emptive AVF (P = 0.01), vein diameter (P0.001), and flow rate (P0.001) were revealed significant factors for initial HD success, but not RC anastomotic length of AVF (P = 0.55).The length of the radiocephalic anastomosis does not affect the RCAVF maturation rate statistically. However, lengthening of arteriotomy on the radial artery may increase the initial success rate of HD.

Introduction Diverticular disease is one of the most common gastrointestinal diseases that require hospital admission. This study aims to identify trends in prior hospital admissions for patients that ultimately require a Hartmann’s procedure for complicated diverticulitis. Methods The Nationwide Readmissions Database for 2010–2014 was queried for all patients aged 18 years or older admitted with an ICD-9 code for colonic diverticulitis and end colostomy creation. Patients with prior hospital admissions were identified. The primary outcome was mortality after Hartmann’s procedure. Secondary outcomes were prior hospital admission and previous percutaneous drain placement. Multivariable logistic regression was performed to control for confounding factors for each outcome and results were weighted for national estimates. Results There were 90,162 patients admitted with complicated diverticulitis requiring end colostomy creation. Prior hospital admissions were found in 28.1% (n = 25,307) and 14.4% (n = 12,947) had a previous percutaneous drain placed during a prior admission. The overall mortality rate was 5.9% (n = 5314) after Hartman’s procedure. The mortality rate for patients with prior hospital admissions was 8.7% ( P < .001), and the mortality rate for patients with previous percutaneous drain placement was 4.3% ( P < .001). After controlling for confounding factors including comorbidities, patients with prior admission had an increased risk of mortality (OR 1.48 [1.40–1.58], P < .001) and patients with previous percutaneous drain placement had a decreased risk of mortality (OR .66 [.60-.72], P < .001). Conclusions Hospitalizations for complications of diverticulitis are a costly burden to our healthcare system. By identifying those patients at high risk for readmission and emergency surgery, perioperative outcomes may be improved.