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Background: Neuroendocrine tumors (NETs), although rare, are considered one of the most common gastrointestinal and bronchopulmonary pediatric neoplasms. We aimed to determine the incidence, tumor characteristics, management, and outcome of NETs and explore the role of genetic predisposition, focusing on low and intermediate grade tumors., Methods: Using the Danish National Pathology Registry, we conducted a nationwide retrospective study including all Danish children aged ≤18 years diagnosed with a pathology-proven NET between 1995 and 2020., Results: We identified 220 patients, with a 1.89:1 female to male ratio. The yearly incidence was 6.84 per 1 million children, with no significant change in incidence throughout the observation period. NETs were located in the appendix (93.2%), the pulmonary system (4.5%), and pancreas (2.3%). One recurrence was noted in the pancreas in a genetically predisposed patient with multiple neuroendocrine neoplasia type 1 (MEN1), resulting in an overall recurrence rate of 0.5% (0% in appendiceal NETs; 0% in bronchopulmonary NETs; 20.0% in pancreatic NETs). No NET-related mortality was registered. Four patients had a known predisposing genetic condition, one appendiceal NET associated with neurofibromatosis type 1, and three pancreatic NETs associated with MEN1. Postsurgical surveillance regimes, choice of tumor markers, and imaging modality varied throughout the study period., Conclusions: We confirmed a stable incidence of pediatric NETs during the study period. The overall recurrence rate was 0.5% and no NET-related mortality was observed. Known genetic predisposition was present in 1.8% of patients. Future guidelines should consider the apparent indolent nature and excellent prognosis of these tumors., (© 2024 The Author(s). Pediatric Blood & Cancer published by Wiley Periodicals LLC.)

Background: Vacuum-assisted abdominal closure (VAC) is being increasingly used as an adjunctive procedure in the surgical treatment of secondary peritonitis. This study compared postoperative mortality and complication rates between VAC and primary abdominal closure (PAC)., Method: This retrospective chart review included all patients diagnosed with secondary peritonitis who underwent laparotomy between 2010 and 2019. Data were collected from six hospitals within Southern Denmark, covering a population of approximately 1,225,000 inhabitants., Results: The study involved 315 patients (139 in the PAC and 176 in the VAC groups). In the VAC group, BMI, ASA, SOFA, MPI, and four quadrant contamination was significantly higher at the index operation. There were no significant differences in nonadjusted and adjusted postoperative mortality at 30 days, 90 days, and 1 year, with cumulative values of 13%, 16%, and 21%, respectively, compared with 16%, 21%, and 31%, in the PAC group (p = 0.519, p = 0.380, and p = 0.051, respectively). Cumulative adjusted surgical postoperative complications at 30 days, 90 days, and 1 year, as assessed by the comprehensive complication index, was significantly higher in the PAC group. Reoperations were significantly more common in the PAC group. The total length of the intensive care unit admission was significantly longer in the VAC group, with a mean of 9.0 ± 12.1 versus 6.7 ± 12.1 days (p < 0.001)., Conclusion: VAC after laparotomy for secondary peritonitis did not significantly reduce mortality but increased ICU stay, whereas primary closure led to higher surgical complication rates and reoperations., (© 2025 The Author(s). World Journal of Surgery published by John Wiley & Sons Ltd on behalf of International Society of Surgery/Société Internationale de Chirurgie (ISS/SIC).)

Purpose: The purpose of this study is to establish more evidence to provide the clinicians with a greater knowledge on the patient reported outcomes and quality of life (QoL) after laparoscopic appendectomy (LA)., Method: 105 patients who had undergone LA for acute appendicitis regardless of severity, were included prospectively at Odense University Hospital, Svendborg. The patient reported consequence of surgery were assessed through the validated electronic survey from European-QoL questionnaire (5Q-5D-5L) including a self-reported VAS-score (0-100). The first survey was sent out the first day after surgery and the subsequent surveys at 7, 30 and 90 days. The replies was converted into an index-score expressing the QoL from 0 (death) to 1 (full health)., Results: All patients experienced pain/discomfort at day 1. At day 7, 30 and 90 it was 95%, 45% and 25%, respectively. The median index-score at day 1, 7, 30 and 90 was 0.778, 0.840, 0.984 and 1.00, respectively., Competing Interests: Declarations. Ethical approval: This study was approved by the Danish Data Protection Agency (22/14542) before initiation. Consent to participate: Oral and written informed consent was obtained from all patients included in the study. Competing interests: The authors declare no competing interests., (© 2024. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany, part of Springer Nature.)

Objective: Anastomotic leakage is a severe complication with multifactorial aetiology, including impaired tissue oxygenation, infection, inflammation, and anastomotic tension. Reinforcement with poly-ε-caprolactone (PCL) scaffold incorporated in a stapled intestinal anastomosis has demonstrated a significant increase in the anastomotic tensile strength. This study aimed to investigate whether incorporation of the scaffold would influence tensile strength with induced ischemia compared to normal blood perfusion., Methods: Eighteen pigs were randomly allocated into an intervention group with a induced relative reduction in blood perfusion to 30% at the anastomotic area and a control group with normal perfusion controlled by quantitative fluorescence angiography. Each pig recieved two stapled small intestinal anastomoses, one with a PCL scaffold incorporated and one without. On postoperative day five, the anastomoses were subjected to a maximal tensile strength test (MATS) and a histopathological analysis. Tensile strength was measured at three events: when a serosal tear became visible (MATS-1), at transmural rupture (MATS-2), and at maximum load before the load-strain curve dropped (MATS-3)., Results: In the intervention group, MATS-1 was significantly higher in scaffold-reinforced anastomoses compared to controls (7.9 ± 4.2N and 4.4 ± 2.5N, p  < 0.02). The same tendency was found for MATS-2 and MATS-3, with statistically significant differences after adjusting for adhesion grade ( p  < 0.05). Histological analysis revealed no significant differences in wound healing between groups., Conclusion: Incorporating a PCL scaffold in a stapled small intestinal anastomosis with induced ischemia improved anastomotic tensile strength.

Background: Repair of large incisional hernias is challenging, and the risks of postoperative complications have been associated with obesity, smoking, and diabetes. The present study was conducted to determine the impact of these risk factors on short and long-term outcomes following the repair with the peritoneal flap hernioplasty (PFH)., Methods: Three hundred twenty-seven patients undergoing PFH for incisional hernia repair were identified. Patient demographics and clinical data were recorded. Patients presenting signs of complications were assessed during a visit to the outpatient clinic. A multivariable regression analysis was performed to evaluate the association between BMI, smoking and diabetes, and postoperative complications., Results: The study included 157 males (48.0%) and 170 females (52.0%). Median BMI was 30.9 kg/m 2 . Diabetes was present in 13.8% of patients. 23.2% were active smokers. The recurrence rate was 2.4%. The odds ratios for postoperative complications were increased by 9% per BMI unit (P < 0.01), due predominantly to a rise in superficial wound infections (P < 0.01) and seroma production (P = 0.07). The adjusted odds ratio increased fourfold in patients with BMI > 40 kg/m 2 (P = 0.06)., Conclusion: Incisional hernia repair with the PFH technique is associated with a low risk of short and long-term complications. The risk is associated with obesity and significantly increased in patients with a BMI exceeding 40 kg/m 2 , where a fourfold increase was observed predominantly due to seroma and superficial wound infections. The recurrence rate was 2.4% and was unaltered across BMI categories. No association was established between smoking, diabetes, and the risk of all-cause complications., (© 2024. The Author(s).)

Background: Minimal invasive inguinal hernia repair is conducted using among others the laparoscopic transabdominal preperitoneal (TAPP) procedure or the extended totally extraperitoneal (eTEP) approach. Robotic-assisted TAPP (R-TAPP) has recently been introduced as an alternative to laparoscopic TAPP and TEP, and a growing number of robotic-assisted procedures are performed worldwide. The present study was conducted to determine the risk of chronic pain and recurrence associated with the two methods., Methods: Three hundred ninety-five patients were retrospectively included in the study and underwent either laparoscopic TAPP (n = 177) or R-TAPP (n = 218). Data on patient demographics, hernia characteristics, and postoperative outcomes were retrieved from medical records. Kaplan-Meier curves and Cox proportional hazards regression were used to assess hernia recurrence. Logistic regression was used to analyze secondary outcomes such as inpatient status, hematoma, and chronic pain., Results: The Kaplan-Meier curves indicated a consistently higher cumulative incidence of recurrence in the TAPP group compared to the R-TAPP. Consistent with this finding, the Cox regression showed a higher risk of recurrence in patients undergoing TAPP, with a hazard ratio (HR) of 3.489 (95% CI: 1.232 to 9.880, p = 0.019). The E-value for this HR was 6.44, suggesting robustness to unmeasured confounding. There was no difference in the rates of chronic pain between the groups (OR: 1.233, 95% CI: 0.430 to 3.533, p = 0.696). A logistic regression analysis for other postoperative complications revealed no significant differences., Conclusion: This study provides evidence that robotic-assisted TAPP is associated with a lower risk of recurrence than laparoscopic TAPP., Competing Interests: Declarations. Ethical approval: This research study was conducted retrospectively from data obtained for clinical purposes. According to MRC regulations, this study does not require ethical approval. Human and animal rights: This article does not contain any studies with human participants or animals performed by any of the authors. Informed consent: Data on patient characteristics and short and long-term outcomes was anonymously retrieved from patient records. The local ethical committee assessed data collection under these circumstances not to require a statement of informed consent. Conflict of interest: Dr. Inan Ihsan has no conflict of interest to declare in direct relation to this article. Outside the context of this article, he has worked as a consultant for Intuitive Surgical Inc. and Medtronic Inc. Otherwise, the authors declare no conflicts of interest as stated by the authors’ ICMJE forms for disclosure of potential conflicts of interest., (© 2024. The Author(s), under exclusive licence to Springer-Verlag France SAS, part of Springer Nature.)

Purpose: This study aimed to investigate the effect of remote ischemic preconditioning (RIPC) on the healing of small intestinal anastomoses, evaluated by tensile strength and histologic wound healing on postoperative day 5., Methods: A total of 22 female pigs were randomized 1:1 into either an intervention or control group. The intervention group received 5 cycles of 3-minute ischemia followed by 3-minute reperfusion on the right forelimb. Two end-to-end anastomoses, a distal and a proximal, were created in the small intestine 30 and 60 min after RIPC, respectively. On postoperative day 5, the anastomoses were harvested and underwent a maximal anastomotic tensile strength (MATS) test (MATS 1-3) followed by histologic analyses., Results: MATS 1, when a tear became visible in the serosa, was significantly increased in the proximal anastomoses of the RIPC group compared with the control group (4.91 N vs 3.83 N; P = .005). No other significant differences were found when comparing these 2 groups., Conclusion: Our study showed no convincing results of RIPC on intestinal anastomotic healing to recommend its use in a general clinical setting. Further animal studies on RIPC's effect after relative or absolute intestinal ischemia may be recommended., Competing Interests: Declaration of competing interest The authors declare no competing interests., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Purpose: We aimed to develop a predictive tool for anastomotic leakage (AL) following colon cancer surgery by combining a clinical early warning score (EWS) with the C-reactive protein (CRP) level., Methods: The records of 1,855 patients who underwent colon cancer surgery at the Oxford University Hospitals NHS Foundation Trust between January 2013 and December 2018, with or without AL, were retrospectively reviewed. EWS and CRP levels were assessed daily from the first postoperative day until discharge. AL was defined as an anastomotic defect observed at reoperation, the presence of feculent fluid in a pelvic drain, or evidence of AL on computed tomography. The tool incorporated postoperative EWS and CRP levels for the accurate early detection of AL., Results: From postoperative days 3 to 7, the mean CRP level exceeded 200 mg/L in patients with AL and was under 200 mg/L in those without AL (P<0.05). From postoperative days 1 to 5, the mean EWS among patients with leakage exceeded 2, while scores were below 2 among those without leakage (P<0.05). Receiver operating characteristic curve analysis identified postoperative day 3 as the most predictive of early leakage, with cutoff values of 2.4 for EWS and 180 mg/L for CRP; this yielded an area under the curve of 0.87 (sensitivity, 90%; specificity, 70%)., Conclusion: We propose using an EWS of 2.4 and a CRP level of 180 mg/L on postoperative day 3 following colon surgery with anastomosis as threshold values to prompt investigation and treatment of AL.

Background: Polymerase chain reaction is a method to detect bacterial DNA and is widely used because it delivers results within a few hours with the potential to guide postoperative antibiotic treatment. This study aims to determine if polymerase chain reaction can accurately detect bacteria in the peritoneal fluid compared with conventional culture from patients operated for acute appendicitis., Methods: This prospective cohort study included patients above the age of 18 years who underwent laparoscopic surgery for acute appendicitis. Peritoneal samples were collected before the appendectomy procedure for conventional culture and polymerase chain reaction using the BioFire Blood Culture Identification 2 Panel for comparison. During surgery, the surgeon assessed the appendicitis as either complicated or noncomplicated., Results: Samples from 102 patients were eligible for analysis. Twelve samples were polymerase chain reaction positive, and 14 samples were culture positive. The concordance of positive results when comparing these 2 methods was 71.4%. The most commonly found bacteria were Escherichia coli and Bacteroides fragilis. Of the 36 patients with complicated appendicitis, no bacteria were detected by either conventional culture or polymerase chain reaction in 21 (58%) of the patients. In patients with uncomplicated appendicitis, bacteria were demonstrated in 1 out of 66 (2%) patients., Conclusion: This study suggests that polymerase chain reaction can be used to detect bacteria in the peritoneal fluid and has the potential to guide postoperative antibiotic treatment., (Copyright © 2024 The Authors. Published by Elsevier Inc. All rights reserved.)

Background: Inguinal hernia repair is a frequently performed surgical procedure, with laparoscopic repair emerging as the preferred approach due to its lower complication rate and faster recovery compared to open repair. Mesh-based tension-free repair is the gold standard for both methods. In recent years, robotic hernia repair has been introduced as an alternative to laparoscopic repair, offering advantages such as decreased postoperative pain and improved ergonomics. This study aims to compare the short- and long-term outcomes, including the surgical stress response, postoperative complications, quality of life, and sexual function, between robotic-assisted transabdominal preperitoneal (rTAPP) and laparoscopic TAPP inguinal hernia repairs., Methods: This randomized controlled trial will involve 150 patients from the Surgical Department of the University Hospital of Southern Denmark, randomized to undergo either rTAPP or laparoscopic TAPP. Surgical stress will be quantified by measuring C-reactive protein (CRP) and cytokine levels. Secondary outcomes include complication rates, quality of life, sexual function, and operative times. Data analysis will adhere to the intention-to-treat principle and will be conducted once all patient data are collected, with outcomes assessed at various postoperative intervals., Discussion: This study holds significance in evaluating the potential advantages of robotic-assisted surgery in the context of inguinal hernia repairs. It is hypothesized that rTAPP will result in a lower surgical stress response and potentially lower the risk of postoperative complications compared to conventional laparoscopic TAPP. The implications of this research could influence future surgical practices and guidelines, with a focus on patient recovery and healthcare costs. The findings of this study will contribute to the ongoing discourse surrounding the utilization of robotic systems in surgery, potentially advocating for their broader implementation if the benefits are substantiated., Trial Registration: ClinicalTrials.gov NCT05839587. Retrospectively registered on 28 February 2023., (© 2024. The Author(s).)

Background: The distinction between complicated and uncomplicated acute appendicitis (AA) is important as it guides postoperative antibiotic treatment. A diagnosis based on intraoperative findings is imprecise and standard cultivation of peritoneal fluid is generally time-consuming with little clinical benefit. The aim of this study was to examine if cultivation of peritoneal fluid in acute appendicitis could reliably detect bacteria within 24 h., Methods: Patients older than 18 years undergoing laparoscopic appendectomy were prospectively enrolled at two surgical departments after informed consent was obtained. Periappendicular fluid was collected prior to appendectomy and sent for cultivation. Sensitivity, specificity and positive and negative predictive values were calculated with 95% confidence intervals (CIs) using 72-hour cultivation results as the gold standard. Patients with complicated AA as determined by the surgeon, received a three-day course of oral antibiotics. Postoperative infectious complications within 30 days after surgery were registered., Results: From July 2020 to January 2021, 101 patients were included. The intraoperative diagnosis was complicated AA in 34 cases. Of these patients, six (17.6%) had bacteria cultured within 24 h after surgery, leading to a sensitivity of 60% and a specificity of 100%. The positive and negative predictive values were 1.00 and 0.96, respectively. Seven patients developed a postoperative infection (five superficial wound infections and two intra-abdominal abscess). In all cases with a positive cultivation result, the intraoperative diagnosis was complicated appendicitis and a postoperative course of antibiotics prescribed., Conclusion: Twenty-four-hour cultivation of the peritoneal fluid in acute appendicitis is a valid indicator for peritoneal bacterial contamination. Randomized studies are necessary to determine if this approach is suitable for targeting postoperative antibiotic treatment as a means to prevent overtreatment without increasing the risk of infectious complications., (© 2024. The Author(s).)

Objectives: We aimed to identify specific anaerobic bacteria causing bacteraemia and a subsequent diagnosis of colorectal cancer., Methods: A nationwide population-based cohort study, which included all episodes of defined specific anaerobic bacteraemia from 2010 (5,534,738 inhabitants) through 2020 (5,822,763 inhabitants) and all cases of colorectal cancer diagnosed from 2010 through 2021 in Denmark. We calculated the incidence and risk of colorectal cancer after bacteraemia with specific anaerobic bacteria using Escherichia coli bacteraemia as reference., Results: Nationwide data on colorectal cancer and specific anaerobic bacteraemia (100% complete, representing 11,124 episodes). The frequencies of colorectal cancer within one year following anaerobic bacteraemia were higher for species, which almost exclusively reside in the colon, such as Phocaeicola vulgatus/dorei (5.5%), Clostridium septicum (24.2%), and Ruminococcus gnavus (4.6%) compared to 0.6% in 50,650 E. coli bacteraemia episodes. Bacteroides spp. had a subhazard ratio for colorectal cancer of 3.9 (95% confidence interval [CI], 3.0 to 5.1) and for Clostridium spp. it was 8.9 (95% CI, 6.7 to 11.8, with C. septicum 50.0 [95% CI, 36.0 to 69.5]) compared to E. coli (reference)., Conclusion: This nationwide study identified specific colorectal cancer-associated anaerobic bacteria, which almost exclusively reside in the colon. Bacteraemia with these bacteria could be an indicator of colorectal cancer., Competing Interests: Declaration of Competing Interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Complete mesocolic excision for right-sided colon cancer yields larger specimens with higher lymph node harvest. This has caused a reduction in recurrence rates and improved survival. However, the technique remains controversial and has been associated with a higher risk of intraoperative complications. More recently published studies do not indicate that CME is associated with increased postoperative morbidity rates as summarised in this review. More detailed consensus regarding the use of the technique is needed, and future studies should aim for prospective confirmation of the current positive long-term results., (Published under Open Access CC-BY-NC-BD 4.0. https://creativecommons.org/licenses/by-nc-nd/4.0/.)

Purpose: Rectal anastomoses have a persisting high incidence of anastomotic leakage. This study aimed to assess whether the use of a poly-ϵ-caprolactone (PCL) scaffold as reinforcement of a circular stapled rectal anastomosis could increase tensile strength and improve healing compared to a control in a piglet model., Method: Twenty weaned female piglets received a stapled rectal anastomosis and were randomised to either reinforcement with PCL scaffold (intervention) or no reinforcement (control). On postoperative day five the anastomosis was subjected to a tensile strength test followed by a histological examination to evaluate the wound healing according to the Verhofstad scoring., Results: The tensile strength test showed no significant difference between the two groups, but histological evaluation revealed significant impaired wound healing in the intervention group., Conclusion: The incorporation of a PCL scaffold into a circular stapled rectal anastomosis did not increase anastomotic tensile strength in piglets and indicated an impaired histologically assessed wound healing., (© 2024. The Author(s).)

Objective: To determine long-term survival in patients undergoing robot-assisted surgery (RAS) or laparoscopic surgery (LAS) for colon cancer., Background: The potential long-term benefits of RAS compared with LAS for colon cancer are not well examined. Using a register-based approach, we aimed to compare these 2 surgical platforms in an analysis of long-term outcomes, including recurrence-free survival and all-cause- and colon cancer-specific mortality., Methods: A nationwide register-based cohort study of patients with Union for International Cancer Control stage I-III colon cancer undergoing planned RAS or LAS from 2010 through 2018. Patient demographic, clinical, and pathological data were retrieved from Danish national registers. Survival and recurrence rates were estimated by Cox proportional hazard multivariate regression analysis adjusting for baseline covariates., Results: A total of 7565 patients [LAS=6905 (91%) and RAS=660 (9%)] were included in the complete case survival analysis. Patients undergoing LAS had a significantly increased risk of cancer recurrence [LAS=1178 (17.1%), RAS=82 (12.4%), P =0.002] with a mean follow-up time of 4.93 years (standard deviation 2.47). The survival analysis of recurrence-free survival favored RAS [hazard ratio adjusted =0.80, 95% CI (0.64-1.00), P =0.049]. No associations between the 2 surgical platforms were evident regarding all-cause [hazard ratio adjusted =0.98, 95% CI (0.82-1.17), P =0.783] or colon cancer-specific mortality [hazard ratio adjusted =0.89, 95% CI (0.67-1.18), P =0.405]., Conclusions: Adopting RAS for colon cancer was associated with improved recurrence-free survival. However, it did not cause a lower all-cause- or colon cancer-specific mortality., Competing Interests: The authors report no conflicts of interest., (Copyright © 2023 Wolters Kluwer Health, Inc. All rights reserved.)

Background: Hirschsprung's disease (HD) may result in an impaired quality of life (QoL) due to bowel problems, postoperative complications and other health-related issues. The Hirschsprung and Anorectal Malformation Quality of Life (HAQL) questionnaire is a disease-specific instrument developed in the Netherlands to measure the QoL in patients with HD and anorectal malformations. The aim of this study was to translate, culturally adapt and validate HAQL in a Danish Hirschsprung population., Material and Methods: Translation and cultural adaptation were performed according to international guidelines. Invitations to participate in the validation were sent to 401 patients operated for HD during the period from 1985 to 2012. A total of 156 patients completed the translated and culturally adapted Danish versions of HAQL and 35 parents of children and adolescents completed the corresponding parent questionnaire. Reliability was evaluated in terms of internal consistency using Cronbach's α and test-retest reliability using Intraclass Correlation Coefficient for the retest step. Known groups comparison was performed with comparison of mild HD (defined as recto-sigmoidal HD) and serious HD (defined as more proximal disease)., Results: The internal consistency of the dimensions was overall satisfactory for adults and adolescents but more problematic for children, where Cronbach's α was less than 0.7 in 60% of the dimensions. For both children and adolescents, the α-value was unsatisfactory for social functioning, emotional functioning, and body image. The test-retest reliability was overall good. The known groups comparison was only able to demonstrate a significant difference between mild and severe HD within one dimension., Conclusions: The translated version of the HAQL questionnaires provides an overall reliable instrument for evaluating disease-specific QoL in a Danish HD population, but it is important to acknowledge the limitations of the questionnaire, especially in children and adolescents., (© 2024. The Author(s).)

Introduction:  Infants born with abdominal wall defects and esophageal atresia (EA) are at risk of impaired growth. Little is known about the optimal nutritional strategy and its impact on growth for these infants. This study aims to explore nutrition, focusing on breastfeeding, and the presumed impact on infant growth during the first year of life., Materials and Methods:  We performed a registry study. The participants comprised infants born with gastroschisis, omphalocele, or EA from 2009 to 2020. Breastfed healthy infants from the Odense Child Cohort served as the control group. Descriptive statistics were applied when presenting data on nutrition. Growth data were converted to weight z -scores at birth and at discharge, and estimated weight z -scores at 6 and 12 months were calculated. Univariate regression analysis was applied., Results:  The study included 168 infants in the study group and 403 infants in the control group. Exclusive breastfeeding rates at discharge were as follows: 55.7% (gastroschisis), 58.3% (omphalocele), 50.9% (EA), and 7.7% (long-gap EA). For the study group our data demonstrate no difference in growth at 1 year of age when comparing mother's milk to formula feeding. During the first year of life, infants in the study group showed slower growth compared with the control group. At 12 months of age, all infants had a mean weight z -score above -2., Conclusion:  Breastfeeding in infants with abdominal wall defects and EA can be established without compromising growth. Mother's milk can be recommended for infants with abdominal wall defects and EA., Competing Interests: None declared., (Thieme. All rights reserved.)

The diagnosis of Hirschsprung's disease relies on histologically proven aganglionosis and nerve trunk hypertrophy in rectal biopsies. Although the frequency of inconclusive biopsies is relatively low, it is a relevant clinical problem. The aim of the present study was to investigate whether a re-evaluation of archived full-thickness biopsies (FTBs) stained with hematoxylin and eosin (HE), together with immune histochemical (IHC) staining, would be diagnostic in biopsies otherwise deemed inconclusive at initial examination with HE only. A total of 34 inconclusive biopsies in 31 patients were identified. From each tissue block, three slices were cut and stained with HE, S100 and calretinin. A blinded pathologist examined the tissue samples. At re-evaluation, one patient was found positive for HD and 11 negative for HD with both HE and IHC staining, respectively. In all 12 cases, the result was confirmed by the final diagnosis at a 5-year follow-up. The rest of the cases were deemed inconclusive. A re-evaluation of the remaining tissue from the biobank might have saved one third of the children from a re-biopsy. The value of adding IHC to conventional HE staining is dubious.

Background: Intestinal resection and a proximal stoma is the preferred surgical approach in patients with severe secondary peritonitis due to perforation of the small intestine. However, proximal stomas may result in significant nutritional problems and long-term parenteral nutrition. This study aimed to assess whether primary anastomosis or suturing of small intestine perforation is feasible and safe using the open abdomen principle with vacuum-assisted abdominal closure (VAC)., Methods: Between January 2005 and June 2018, we performed a retrospective chart review of 20 patients (> 18 years) with diffuse faecal peritonitis caused by small intestinal perforation and treated with primary anastomosis/suturing and subsequent open abdomen with VAC., Results: The median age was 65 years (range: 23-90 years). Twelve patients were female (60%). Simple suturing of the small intestinal perforation was performed in three cases and intestinal resection with primary anastomosis in 17 cases. Four patients (20%) died within 90-days postoperatively. Leakage occurred in five cases (25%), and three patients developed an enteroatmospheric fistula (15%). Thirteen of 16 patients (83%) who survived were discharged without a stoma. The rest had a permanent stoma., Conclusions: Primary suturing or resection with anastomosis and open abdomen with VAC in small intestinal perforation with severe faecal peritonitis is associated with a high rate of leakage and enteroatmospheric fistula formation., Trial Registration: The study was approved by the Danish Patient Safety Authority (case number 3-3013-1555/1) and the Danish Data Protection Agency (file number 18/28,404). No funding was received., (© 2023. BioMed Central Ltd., part of Springer Nature.)

Background: There is a potential benefit on long-term outcomes following complete mesocolic excision (CME) for right-sided colon cancer when compared to conventional colectomy. This study aims to analyze the learning curve and short-term outcomes of laparoscopic CME with intracorporeal anastomosis (ICA) for right-sided colon cancer in the hands of experienced colorectal surgeons., Methods: A two-center cohort study of consecutive patients undergoing right-sided colectomy from September 2021 to May 2022 at two tertiary colorectal centers in Denmark. Learning curves of surgical time were estimated using a cumulative sum analysis (CUSUM)., Results: A total of 61 patients were included. According to the CUSUM analysis, 32 cases were needed to obtain a peak in operative time, resulting in a decrease in time consumption (group 1/learning phase: 217.2 min [SD 53.6] and group 2/plateau phase 191.6 min [SD 45.1], p = 0.05). There was a nonsignificant reduction in the rates of severe surgical complications (Clavien-Dindo > 3) (13% vs. 7%, p = 0.67) between the two groups, while the length of hospital stay remained constant (median 3.0 days, interquartile range, IQR [2.0; 4.0])., Conclusion: The learning curve of laparoscopic CME with ICA for right-sided colon cancer demonstrated that 32 cases were needed to obtain a plateau phase expressed by operative time., (© 2023 The Authors. Journal of Surgical Oncology published by Wiley Periodicals LLC.)

Purpose: The intracorporeal anastomosis (IA) technique possibly results in enhanced recovery and reduced morbidity rates compared to the extracorporeal anastomosis (EA) technique. This study compared the short-term morbidity rates of IA versus EA in segmental resections for colon cancer., Method: We performed a retrospective cohort study of consecutive patients from 2015 to 2020 using the IA or EA technique at a single Danish colorectal center. Comparative outcomes of interest were surgical efficacy and short-term morbidity rates. An inverse probability of treatment weighting (IPTW) analysis of clinically relevant outcomes was conducted to explore potential baseline confounding., Results: We included 328 patients, 129 in the EA and 199 in the IA groups. There was no significant difference in preoperative baseline characteristics between the two groups. The rate of overall surgical (16% in both groups, p = 1.000) and medical complications (EA: 25 (19%) vs. IA: 27 (14%), p = 0.167) was comparable for both groups. The IA technique did not cause a reduction in operative time (EA: 127.0 min [103.0-171.0] vs. IA: 134.0 min [110.0-164.0], p = 0.547). The IPTW analysis indicated that having an IA caused a reduction in the rate of major surgical complications (RRR adjusted  = 0.45, 95%CI [0.29-0.69], p = 0.000)., Conclusion: Adopting IA for colon cancer resulted in similar overall morbidity rates without increasing the duration of the surgical procedure compared to EA. The IA technique had a probable protective effect against developing severe surgical complications. However, this must be interpreted cautiously, limited by the retrospective study design., (© 2023. The Author(s).)

Background: Securing sufficient blood perfusion to the anastomotic area after low-anterior resection is a crucial factor in preventing anastomotic leakage (AL). Intra-operative indocyanine green fluorescent imaging (ICG-FI) has been suggested as a tool to assess perfusion. However, knowledge of inter-observer variation among surgeons in the interpretation of ICG-FI is sparse. Our primary objective was to evaluate inter-observer variation among surgeons in the interpretation of bowel blood-perfusion assessed visually by ICG-FI. Our secondary objective was to compare the results both from the visual assessment of ICG and from computer-based quantitative analyses of ICG-FI between patients with and without the development of AL., Method: A multicenter study, including patients undergoing robot-assisted low anterior resection with stapled anastomosis. ICG-FI was evaluated visually by the surgeon intra-operatively. Postoperatively, recorded videos were anonymized and exchanged between centers for inter-observer evaluation. Time to visibility (TTV), time to maximum visibility (TMV), and time to wash-out (TWO) were visually assessed. In addition, the ICG-FI video-recordings were analyzed using validated pixel analysis software to quantify blood perfusion., Results: Fifty-five patients were included, and five developed clinical AL. Bland-Altman plots (BA plots) demonstrated wide inter-observer variation for visually assessed fluorescence on all parameters (TTV, TMV, and TWO). Comparing leak-group with no-leak group, we found no significant differences for TTV: Hazard Ratio; HR = 0.82 (CI 0.32; 2.08), TMV: HR = 0.62 (CI 0.24; 1.59), or TWO: HR = 1.11 (CI 0.40; 3.11). In the quantitative pixel analysis, a lower slope of the fluorescence time-curve was found in patients with a subsequent leak: median 0.08 (0.07;0.10) compared with non-leak patients: median 0.13 (0.10;0.17) (p = 0.04)., Conclusion: The surgeon's visual assessment of the ICG-FI demonstrated wide inter-observer variation, there were no differences between patients with and without AL. However, quantitative pixel analysis showed a significant difference between groups., Trial Registration: ClinicalTrials.gov Identifier: NCT04766060., (© 2023. The Author(s).)

Diverting loop ileostomy has become routine in low anterior resection (LAR) for rectal cancer. The optimal time for stoma reversal is controversial. The aim of the present study was to compare the results after planned early (within 8-12 days) versus late (> 3 months) stoma reversal. The primary outcomes were morbidity and mortality, as measured by the Comprehensive Complication Index (CCI) within 30 days after stoma reversal, and the secondary outcomes were morbidity and mortality within 90 days after LAR. This was a multicentre trial including all patients scheduled for anterior low resection for rectal cancer with curative intent. Inclusion period was from April 2011 to December 2018. All patients were randomized 1:1 prior to surgery. Among 257 consecutive and eligible patients, a total of 214 patients were randomized: 107 patients to early stoma reversal and 107 to late reversal. A total of 68 patients were excluded for various reasons, and 146 patients completed the study, with 77 in the early reversal group and 69 in the late reversal group. The patients were asked to complete the Gastrointestinal Quality of Life Index before surgery (baseline) and at 6 and 12 months after LAR. Ostomy-related complications were evaluated by dedicated ostomy staff using the validated DET score. ClinicalTrials Identifier: NCT01865071. Fifty-three patients (69%) in the early reversal group and 60 patients (87%) in the late reversal group received the intended treatment. There were no significant differences in CCI within 90 days after index surgery with the LAR and within 30 days after stoma reversal between the two groups. There were no differences in patient-reported quality of life but significantly more stoma-related complications in the late reversal group. A total of 5 patients experienced anastomotic leakage (AL) after stoma reversal, 4 in the early reversal group and one in the late reversal group. Early and late stoma reversal showed similar outcomes in terms of overall complications and quality of life. The risk of developing anastomotic leakage after early ostomy reversal is a concern., (© 2023. The Author(s).)

Background: Complete mesocolic excision (CME) surgery is increasingly implemented for the resection of right-sided colonic cancer, possibly resulting in improved 5-year overall and disease-free survival compared to non-CME surgery. However, it is not clear what surgical platform should be used. The aim of this study was to compare the following outcomes between robot-assisted and laparoscopic CME-surgery for right-sided colonic cancer: (i) short-term clinical outcomes, (ii) pathological specimen quality, and (iii) long-term oncological outcomes., Methods: Medline, Embase, and Cochrane Database of Systematic Reviews were searched from inception until August 2021. Pooled proportions were calculated by applying the inverse variance method. Heterogeneity was explored by I-square and supplemented by sensitivity- and meta-regression analyses. The risk of bias was evaluated by either MINORS or Cochrane's risk-of-bias tool (RoB 2)., Results: Fifty-five studies with 5.357 patients (740 robot-assisted and 4617 laparoscopic) were included in the meta-analysis. Overall postoperative morbidity was 17% [95% CI (14-20%)] in the robot-assisted group and 13% [95%CI (12-13%)] in the laparoscopic group. Robot-assisted CME was associated with a shorter hospital stay, lower intraoperative blood loss, a higher amount of harvested lymph nodes, and better 3-year oerall and disease-free survival. MINORS and RoB2 indicated a serious risk of bias across studies included., Conclusions: This review which includes predominantly non-randomized studies suggests a possible advantage of the robot-assisted CME compared with a laparoscopic technique for several short-term outcomes., (© 2022. Springer Nature Switzerland AG.)

Aim: To compare the accuracy and interobserver variation of routine computed tomography (CT) on postoperative day 6-8 to detect anastomotic leakage (AL) verified by re-operation and/or endoscopy. A secondary objective was to identify the predictive values of different CT findings as an indicator for AL., Material and Methods: The material for this study originates from two previous prospective multicentre studies including 277 patients who were scheduled for routine abdominal CT postoperative day 6-8. Inclusion criteria for the present study were routine CT without contrast medium followed by CT with rectal contrast medium. Two independent senior radiologists blinded to the clinical outcome reviewed the CT examinations for specific findings according to a predefined scheme., Results: A total of 52 patients fulfilled the inclusion criteria. AL occurred in 14 patients of which nine were clinical and five subclinical. The two radiologists diagnosed AL at unenhanced CT with sensitivities of 71.4% and 50%, respectively, and of 57.1% and 35.7% with rectal contrast medium. The corresponding specificities were 55.3% and 81.6%, and 94.7% and 92.1%. Peri-anastomotic free air and contrast medium leakage had the highest odds ratios for AL., Conclusion: The diagnostic sensitivity and specificity of routine postoperative CT to detect AL after low anterior resection for rectal cancer is low and with considerable interobserver variation., (Copyright © 2022 The Author(s). Published by Elsevier Ltd.. All rights reserved.)

Introduction:  Treatment for long-gap esophageal atresia (LGEA) aims at achieving primary anastomosis with minimal tension. Previous studies have shown that intramural injections with botulinum toxin type-A (BTX-A) from the adventitial side can increase the elongation of the piglet and rat esophagus before bursting, and that this effect is dose and time dependent. Our aim was to determine if endoscopic injections would be feasible, safe, and with an effect on the mechanical properties of the esophagus., Methods:  Twenty-two male piglets (5.15 kg) were randomized into two groups, one receiving 2 units/kg BTX-A, the other equal volume 0.9% NaCl. On day 3, the esophagus was harvested and tested in a stretch-tension machine to evaluate elongation and maximum load, followed by histological examination., Results:  No adverse effects to the procedure were observed. No statistically significant difference in elongation or maximum load before bursting between the treatment and placebo group was found. In histopathological analysis, inflammation and abscess formation were observed with no statistically significant difference between the two groups., Conclusion:  Endoscopic placement of BTX-A injections in the piglet esophagus was safe and feasible but did not result in any difference in the mechanical properties or histology of the esophagus., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: To investigate the effects of a reversed segment of the distal small intestine to improve weight gain in an experimental short bowel syndrome (SBS) model in piglets., Methods: Twenty-four piglets underwent resection of 70% of the distal small intestine. In half of the animals a conventional anastomosis was performed, and in the other half, the distal 25 cm of the remnant jejunum was reversed before the intestinal continuity was recreated. Weight was measured daily until day 28, where the animals were euthanized. Glucagon-Like Peptide-2 (GLP-2) and Glucose-dependent Insulinotropic Peptide (GIP) was measured pre- and postoperatively at day 28., Results: The group with reversal of small intestine had a significant lower weight gain at 5.26 ± 3.39 kg (mean ± SD) compared to the control group with 11.14 ± 3.83 kg (p < 0.05). In the control group greater villus height and crypt depth was found distally, and greater muscular thickness was found proximally in the intervention group. GLP-2 and GIP levels increased significantly in the control group., Conclusions: Treatment of short bowel syndrome with a reversed jejunal segment of 25 cm had a detrimental effect on the weight gain., (© 2022. The Author(s).)

Background: The effect of remote pre- and postconditioning on anastomotic healing has been sparsely studied. The aim of our study was to investigate whether remote ischemic conditioning (RIC) applied before and after the creation of a small bowel anastomosis had an effect on anastomotic healing on postoperative day five evaluated by a tensile strength test and histological analysis., Materials and Methods: Twenty-two female piglets were randomized into two groups. The intervention group ( n  = 12) received RIC on the forelimbs consisting of 15 min of ischemia followed by 30 min of reperfusion before the first end-to-end ileal anastomosis was created. The RIC procedure was repeated and the second and more distal anastomosis was performed. The control group ( n  = 10) had two similar anastomoses with similar time intervals but without RIC. On postoperative day five, the anastomoses were subjected to macroscopic evaluation, tensile strength test and histological examination., Results: Mean tensile strength when the first transmural rupture appeared (MATS-2) was significantly lower in the first anastomosis in the intervention group compared to the control group (11.4 N vs 14.7 N, p  < .05). Similar result was found by the maximal strength (MATS-3) as defined by a drop in the load curve (12.3 N vs 15.9 N, p  < .05). Histologically, a significantly higher necrosis score was found in the anastomosis in the intervention group (1.4 vs 0.8, p  < .05). No other significant differences were found., Conclusions: In conclusion, post-anastomotic remote ischemic conditioning had a detrimental effect and pre-anastomotic conditioning seems to have no effect on small intestinal anastomotic strength.

Introduction: In patients with familial adenomatous polyposis, the Spigelman classification is recommended for staging and risk stratification of duodenal adenomatosis. Although the classification has been used for decades, it has never been formally validated., Methods: We included consecutive FAP patients undergoing upper gastrointestinal endoscopic surveillance and evaluated the inter- and intrarater reliability of the Spigelman classification., Results: The interrater reliability of the endoscopic parameters and the Spigelman classification was good and excellent, respectively. The intrarater reliability of the endoscopic parameters and the Spigelman classification was moderate and good, respectively., Discussion: The results support continued use of the Spigelman classification as the primary end point for future studies and as key endoscopic performance measure., (Copyright © 2021 The Author(s). Published by Wolters Kluwer Health, Inc. on behalf of The American College of Gastroenterology.)

Background: The aim of this review was to identify relevant randomized controlled trials (RCTs) and non-RCTs to evaluate the existing knowledge on the effect of antibiotic treatment for infants with necrotizing enterocolitis (NEC)., Objective: Identifying 1) the best antibiotic regimen to avoid disease progression as assessed by surgery or death, 2) the best antibiotic regimen for infants operated for NEC as assessed by re-operation or death., Methods: Embase, MEDLINE and Cochrane were searched systematically for human studies using antibiotics for patients with NEC, Bell's stage II and III., Results: Five studies were included, with a total of 375 infants. There were 2 RCT and 3 cohort studies. Four main antibiotic regimens appeared. Three with a combination of ampicillin + gentamycin (or similar) with an addition of 1) clindamycin 2) metronidazole or 3) enteral administration of gentamycin. One studied investigated cefotaxime + vancomycin. None of the included studies had a specific regimen for infants undergoing surgery., Conclusions: No sufficient evidence was found for any recommendation on the choice of antibiotics, the route of administration or the duration in infants treated for NEC with Bell's stage II and III., (© 2022. The Author(s).)

Background: Robot-assisted surgery is increasingly adopted in colorectal surgery. However, evidence for the implementation of robot-assisted surgery for colon cancer is sparse. This study aims to evaluate the short-term outcomes of robot-assisted colon surgery (RCS) for cancer compared to laparoscopic colon surgery (LCS)., Methods: Embase, MEDLINE, and Cochrane Library were searched between January 1, 2005 and October 2, 2020. Randomized clinical trials and observational studies were included. Non-original literature was excluded. Primary endpoints were anastomotic leakage rate, conversion to open surgery, operative time, and length of hospital stay. Secondary endpoints were surgical efficacy and postoperative morbidity. We evaluated risk of bias using RoB2 and ROBINS-I quality assessment tools. We performed a pooled analysis of primary and secondary endpoints. Heterogeneity was assessed by I 2 , and possible causes were explored by sensitivity- and meta-regression analyses. Publication bias was evaluated by Funnel plots and Eggers linear regression test. The level of evidence was assessed by GRADE., Results: Twenty studies enrolling 13,799 patients (RCS 1740 (12.6%) and LCS 12,059 (87.4%) were included in the meta-analysis that demonstrated RCS was superior regarding: anastomotic leakage (odds ratio (OR) = 0.54, 95% CI [0.32, 0.94]), conversion (OR = 0.31, 95% CI [0.23, 0.41]), overall complication rate (OR = 0.85, 95% CI [0.73, 1.00]) and time to regular diet (MD =  - 0.29, 95% CI [- 0.56, 0.02]). LCS proved to have a shortened operative time compared to RCS (MD = 42.99, 95% CI [28.37, 57.60]). Level of evidence was very low according to GRADE., Conclusion: RCS showed advantages in colonic cancer surgery regarding surgical efficacy and morbidity compared to LCS despite a predominant inclusion of non-RCT with serious risk of bias assessment and a very low level of evidence., (© 2021. The Author(s).)

Background . Incorporation of a poly-ε-caprolactone (PCL) scaffold in circular stapled anastomoses has been shown to increase the anastomotic tensile strength on postoperative day (POD) 5 in a pig model. The aim of this study was to investigate the effects of incorporation of a PCL scaffold in a circular stapled end-to-end small intestine anastomosis, with stricture formation and anastomotic histology as primary outcomes in a 30-day observation period. Methods . A total of 15 piglets were included. In each piglet, three circular stapled end-to-end anastomoses were made in the small intestines. Two were interventional and one was a control. On POD 10, 20, or 30, the anastomoses were subjected to in vivo intraluminal contrast study, and the index for anastomotic lumen was calculated. The anastomotic segment was resected and subjected to a tensile strength test and histological examination. Results . At POD 10, the mean ± SD value for anastomotic index was .749 ± .065 in control anastomoses and .637 ± .051 in interventional anastomosis ( P = .0046), at POD 20, .541 ± .150 and .724 ± .07 ( P = .051), and at POD 30, .645 ± .103 and .686 ± .057 ( P = .341), respectively. No significant difference was observed in maximum tensile strength and histology at POD 30. Conclusions . The incorporation of a PCL scaffold in a circular stapled end-to-end small intestine anastomosis does not increase the risk of stricture or impair wound healing after 30 days.

Background: Robot-assisted surgery is being increasingly adopted in treating colorectal cancer, and the transition from laparoscopic surgery to robot-assisted surgery is a trend. The evidence of the benefits of robot-assisted surgery is sparse. However, findings are associated with improved patient-related outcomes and overall morbidity rates compared to laparoscopic surgery. This induction is unclear, considering both surgical modalities are characterized as minimally invasive. This study aims to evaluate the systemic and peritoneal inflammatory stress response induced by robot-assisted surgery compared with laparoscopic surgery for elective colon cancer resections in a prospective, randomized controlled clinical trial., Methods: This study is a single-centre randomized controlled superiority trial with 50 colon cancer participants. The primary endpoint is the level of systemic inflammatory response expressed as serum C-reactive protein (CRP) and interleukin 6 (IL-6) levels between postoperative days one and three. Secondary endpoints include (i) levels of systemic inflammation in serum expressed by a panel of inflammatory and pro-inflammatory cytokines measured during the first three postoperative days, (ii) postoperative surgical and medical complications (30 days) according to Clavien-Dindo classification and Comprehensive Complication Index, (iii) intraoperative blood loss, (iv) conversion rate to open surgery, (v) length of surgery, (vi) operative time, (vii) the number of harvested lymph nodes, and (viii) length of hospital stay. The exploratory endpoints are (i) levels of peritoneal inflammatory response in peritoneal fluid expressed by inflammatory and pro-inflammatory cytokines between postoperative day one and three, (ii) patient-reported health-related quality of recovery-15 (QoR-15), (iii) 30 days mortality rate, (iv) heart rate variability and (v) gene transcript (mRNA) analysis., Discussion: To our knowledge, this is the first clinical randomized controlled trial to clarify the inflammatory stress response induced by robot-assisted or laparoscopic surgery for colon cancer resections. Trial registration This trial is registered at Clinicaltrials.gov (Identifier: NCT04687384) on December, 29, 2020, Regional committee on health research ethics, Region of Southern Denmark (N75709) and Data Protection Agency, Hospital Sønderjylland, University Hospital of Southern Denmark (N20/46179)., (© 2021. The Author(s).)

Introduction:  An antegrade colonic enema (ACE) via an appendicostomy has been shown to be effective in the management of functional bowel problems. In cases with a missing appendix, a neoappendicostomy may be considered., Materials and Methods:  A retrospective review of clinical outcomes in children who underwent ileal neoappendicostomy for ACE. Medical records were reviewed for data on demography, intra- and postoperative complications. A follow-up questionnaire on stoma problems, ACE-related problems, bowel function, patient satisfaction, well-being, and effect on daily activities was performed., Results:  Ten patients were included at an average age of 10.6 years at surgery. In half of the patients, minor postoperative complications (Clavien-Dindo grade 2 or less) were found. Nine patients answered the questionnaire with a mean follow-up of 57 months. Despite complaints of stomal leakage, difficulties with catheterization, and pain during irrigation, they reported a high grade of satisfaction, improvements in well-being, and bowel function and the achievement of continence., Conclusion:  Ileal neoappendicostomy may be an alternative to ACE in children with severe and medically intractable constipation and or/and fecal incontinence where the appendix is missing or not available., Competing Interests: None declared., (Thieme. All rights reserved.)

Aim: The objective of this systematic review was to investigate the outcomes of ileorectal anastomosis (IRA) in Crohn's disease and to clarify whether there are any time-related trends in outcome measures. The primary outcomes are risk of anastomotic leakage, death, clinical recurrence and subsequent diverting or permanent stoma and/or proctectomy. Secondary end-points are quality of life and functional outcome., Methods: Systematic searches were conducted using the Cochrane Library, Embase and MEDLINE. The complete search strategy is uploaded online at http://www.crd.york.ac.uk/prospero/. Human studies in English with over five subjects were included and no limit was set regarding the date of publication. All relevant studies were screened by two reviewers. The web-based software platform www.covidence.org was used for primary screening of the title, abstract, full-text review and data extraction., Results: The search identified 2231 unique articles. After the screening process, 37 remained. Key results were an overall anastomotic leak rate of 6.4%; cumulative rates of clinical recurrence of 43% and 67% at 5 and 10 years, respectively; an overall rate of proctectomy of 18.9%; and subsequent ileostomy required in 18.8%. Only one study presented useful data on quality of life. Recurrence rates remained stable over time. A small decline in the anastomotic leak rate was found., Conclusions: Only minor improvements in the outcomes of IRA in patients with Crohn´s disease have occurred during the past 50 years regarding anastomotic leakage and recurrence, except for a slight increase in the rate of a functioning IRA. These results call for implementation guidelines in patient selection for IRA and postoperative medical treatment and follow-up., (© 2021 Association of Coloproctology of Great Britain and Ireland.)

Background: Indocyanine green fluorescence imaging (ICG-FI) can be used to evaluate intestinal perfusion prior to anastomosis. Several software for the quantification of fluorescence have emerged, but these have not previously been compared. The aim of this study was to compare the results from quantitative ICG-FI analysis of relative perfusion in an experimental setting using two different software-based quantification algorithms (FLER and Q-ICG)., Methods: Twenty pigs received a laparotomy, and ischemic areas were created in three segments of the small intestine of each pig. For each ischemic area, fluorescence imaging was performed and the fluorescence recordings were quantitatively analyzed using FLER and Q-ICG. The quantitative analysis resulted in a set of perfusion lines for each software for either 30%, 60% or 100% relative perfusion. The perfusion lines were compared by registering the normalized slope for each set of perfusion lines, calculating the relative perfusion percentage in the FLER perfusion line according to Q-ICG, and measuring the length of the ischemic area for each analysis., Results: Fifty-four fluorescence recordings from 18 pigs were included. The ischemic segment for FLER was significantly longer in the 30% perfusion group and significantly shorter in the 100% perfusion group as compared to Q-ICG. The normalized slope for the FLER perfusion lines was significantly higher in the 30% perfusion group and significantly lower in the 100% perfusion group as compared to the Q-ICG perfusion lines. For the perfusion lines defined by FLER as 30%, 60%, and 100%, Q-ICG found 35.2% (p = 0.07), 63.7% (p = 0.31), and 84.1% perfusion (p = 0.003) respectively., Conclusion: The two software demonstrated significant differences in quantitative fluorescence analysis when perfusion was either very high or very low. The clinical relevance of these differences is unclear., (© 2020. Springer Science+Business Media, LLC, part of Springer Nature.)

Background: Esophageal atresia (EA) is a congenital malformation affecting 1:3000-4500 newborns. Approximately 15% have a long-gap EA (LGEA), in which case a primary anastomosis is often impossible to achieve. To create continuity of the esophagus patients instead have to undergo lengthening procedures or organ interpositions; methods associated with high morbidity and poor functional outcomes. Esophageal injections of Botulinum Toxin Type A (BTX-A) could enable primary anastomosis and mitigate stricture formation through decreased tissue tension., Methods and Analysis: In this randomized controlled blinded animal trial, 24 pigs are divided into a long- or short-gap EA group (LGEA and SGEA, respectively) and randomized to receive BTX-A or isotonic saline injections. In the LGEA group, injections are given endoscopically in the esophageal musculature. After seven days, a 3 cm esophageal resection and primary anastomosis is performed. In the SGEA group, a 1 cm esophageal resection and primary anastomosis is performed, followed by intraoperative injections of BTX-A or isotonic saline. After 14 days, stricture formation, presence of leakage, and esophageal compliance is assessed using endoscopic and manometric techniques, and in vivo and ex vivo contrast radiography. Tissue elongation is evaluated in a stretch-tension test, and the esophagus is assessed histologically to evaluate anastomotic healing., Ethics and Dissemination: The study complies with the ARRIVE guidelines for animal studies and has been approved by the Danish Animal Experimentation Council. Results will be published in peer-reviewed journals and presented at national and international conferences., Highlights: The optimal management of long-gap esophageal atresia remains controversialPrimary anastomosis could improve functional outcomes and reduce complicationsBotulinum Toxin Type A decreases tissue tension and could facilitate anastomosisReduced tension could further abate the risk for anastomotic stricture and leakageWe present a model to evaluate the method in long- and short-gap esophageal atresia., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2021 The Author(s).)

Background: Antegrade colonic enema (ACE) via an appendicostomy is a recognised method of treatment for medically intractable fecal incontinence and/or constipation. In case of a missing appendix, ileal neoappendicostomy (INA) is considered a suitable alternative. The aim of this study was to review the postoperative complications, functional outcome, stoma-related complications and quality of life of patients treated with this method., Methods: A systematic literature search was performed in Embase, MEDLINE, PubMed (NCBI) and Cochrane Library from inception to September 2020 using the search terms "antegrade enema" OR "continence enema". Studies on children and adults with fecal incontinence, constipation or a combination of both, who underwent ileal neoappendicostomy for ACE due to the failure of medical treatment and/or anal irrigation were included in the studies, which reported one or more of the following primary outcomes: postoperative complications, functional results, and stoma-related complications., Results: A total of 780 studies were identified, 8 of which, comprising 6 studies in adults and 2 in children, were eligible for review. Overall, 139 patients were included. All studies were retrospective and the methods for reporting outcomes were highly heterogeneous. Improvements in incontinence and constipation were reported in all studies, together with an improved quality of life when reported (5 studies). Stomal stenosis and leakage rates were 0-29% and 14-60%, respectively. Postoperative complications were relatively common and included potentially life-threatening complications., Conclusions: Taking into consideration that studies of INA were few and of poorly quality; ACE via an INA had a positive impact on bowel function and quality of life. Stoma-related complications and postoperative complications remain a concern., (© 2021. Springer Nature Switzerland AG.)

Background: Robot-assisted surgery is increasingly implemented for the resection of colorectal cancer, although the scientific evidence for adopting this technique is still limited. This study's main objective was to compare short-term complication rates, oncological outcomes, and the inflammatory stress response after colorectal resection for cancer performed laparoscopic or robot-assisted., Methods: We conducted a retrospective cohort study comparing the robot-assisted approach to laparoscopic surgery for elective malignant colorectal neoplasm. Certified colorectal and da Vinci ® robotic surgeons performed resections at a Danish tertiary colorectal high volume center from May 2017 to March 2019. We analyzed the two surgical groups using uni- and multivariate regression analyses to detect differences in intra- and postoperative clinical outcomes and the inflammatory stress response., Results: Two hundred and ninety-eight patients were enrolled in the study. Significant differences favoring robot-assisted surgery was demonstrated for; length of hospital stay (4 days, interquartile range (4, 5) versus 5 days, interquartile range (4-7), p < 0.001), and intraoperative blood loss (50 mL, interquartile range (20-100) versus 100 mL, interquartile range (50-150), p < 0.001) compared to laparoscopic surgery. The inflammatory stress response was significantly higher after laparoscopic compared to robot-assisted surgery reflected by an increase in C-reactive protein concentration (exponentiated coefficient = 1.23, 95% confidence interval (1.06-1.46), p = 0.008). No differences between the two groups were found concerning mortality, microradical resection rate, conversion to open surgery, and surgical or medical short-term complication rates., Conclusion: Robot-assisted surgery is feasible and can be safely implemented for colorectal resections. The robot-assisted approach, when compared to laparoscopic surgery, was associated with improved intra- and postoperative outcomes. Extensive prospective studies are needed to determine the short- and long-term outcomes of robotic surgery for colorectal cancer.

Introduction: In some cases, surgical treatment is necessary to manage intussusception despite advances in enema reduction. The purpose of this study was to analyse treatment in two tertiary referral university centres for paediatric surgery to identify time-related factors influencing treatment of intussusception., Methods: This was a retrospective two-centre chart review, performed for all patients under the age of 16 years who underwent treatment for intussusception during the period from 2005 to 2015. Demographic data and data on different time intervals from symptom debut to end of treatment and compliacations were retrieved from the medical record., Results: A total of 158 children were included. Non-surgical reduction was used as the primary treatment modality in 48% and intussusception was successfully reduced in 32% of these cases. The non-surgical success rate was found to be significantly higher when the diagnosis was confirmed within four hours of hospitalisation (p = 0.003). A lower rate of bowel resection was observed when the diagnosis was confirmed within four hours of hospitalisation (p = 0.026) and treatment was initiated within six hours of hospitalisation (p = 0.033)., Conclusions: This study found a relatively low utilisation rate for enema reduction and an overall low enema success rate. The success rate of enema was significantly higher and the intestinal resection rate lower when the diagnosis was confirmed within four hours of hospitalisation, which underpins the importance of a quick and timely diagnosis., Funding: none., Trial Registration: not relevant., (Articles published in the DMJ are “open access”. This means that the articles are distributed under the terms of the Creative Commons Attribution Non-commercial License, which permits any non-commercial use, distribution, and reproduction in any medium, provided the original author(s) and source are credited.)

Aim: The aim was to investigate the overall postoperative complication rate within 90 days following ileal pouch-anal anastomosis (IPAA), with or without a diverting stoma, together with complications 30 days after stoma closure and overall pouch failure rate., Method: This was a retrospective chart review including IPAA patients with or without a diverting loop-ileostomy for ulcerative colitis (1 January 1983 to 31 December 2015). Demographic data and postoperative complications were retrieved and recorded., Results: A total of 434 patients were included. A diverting loop-ileostomy was performed in 348 patients (80%). Baseline data were similar in the two groups except for body mass index (BMI) and the ratio of women, which were significantly higher in the group without a protective ileostomy. Overall 90-day complication rate after IPAA [Clavien-Dindo (CD) > 2] was similar in the two groups. Clinical anastomotic leaks (CD > 2) were higher in patients without a diverting stoma (9.3% vs 1.7%) (P = 0.002). The odds ratio for leakage after adjustments (age, gender, immune-modulating medicine and BMI) was 5.0 for omitting a diverting stoma (P = 0.004). Complications (CD > 2) after loop-ileostomy closure were seen in 61 cases (14.1%). Omitting a diverting stoma at IPAA demonstrated a non-significant odds ratio of 1.04 (0.46, 2.38) (P = 0.924) for pouch failure after adjustments (age, gender, immune-modulating medicine, BMI, time from pouch formation and clinical leakage)., Conclusion: The overall postoperative surgical and medical complication rate within 90 days after IPAA was similar in the group with and without diverting stoma. Postoperative complication rate after reversal was 14%. Omitting a diverting stoma at IPAA demonstrated an increased risk of leaks but no significant risk of long-term pouch failure., (© 2020 The Association of Coloproctology of Great Britain and Ireland.)

Introduction:  Anastomosis with minimal tension is desirable in long-gap esophageal atresia. Prior studies in piglets showed that intraesophageal injection of botulinum toxin type A (BTX-A) results in significant esophageal elongation. Our aim was to determine the BTX-A dose, number of injections, and time necessary to elicit maximal response., Materials and Methods:  Adult male Wistar rats ( n  = 48) were randomly assorted into five groups. Four treatment groups received 2 or 4 U/kg of BTX-A, delivered using two or four injections, and a control group received 0.9% NaCl. Esophagus was removed 6 or 24-hours postinjection and tested ex vivo using a stretch tension device. Subsequently, an optimal dose and time following injection was used to study the effects of BTX-A on anastomotic healing in vivo. Rats ( n  = 12) received an intraesophageal injection of BTX-A or 0.9% NaCl, followed by resection of 0.5 cm of esophagus and end-to-end anastomosis. Rats were observed for 9 days, and esophagus was removed for gross and histological evaluation., Results:  The largest effect on elongation was recorded in the BTX-A (2 U/kg) 24 hour, four injection group. In the anastomosis study, stricture formation was observed in all animals in the control group. Absence of esophageal stricture was found in three out of four animals in the treatment group macroscopically and histologically., Conclusion:  We found that BTX-A exerts a positive effect on stretch characteristics of esophageal tissue in rats at 2 U/kg via four-injection delivery and 24-hour waiting period. This study suggests that BTX-A might improve anastomotic healing., Competing Interests: None declared., (Thieme. All rights reserved.)

Background: Indocyanine green fluorescence imaging (ICG-FI) may be used to visualize intestinal perfusion prior to anastomosis. Methods for quantification of the fluorescence signal are required to ensure an objective evaluation. The aim of this study was to evaluate a method for quantification of relative perfusion and to investigate the correlation between the perfusion level and the anastomotic strength., Method: This blinded, randomized, experimental trial included twenty pigs. Each pig received three small intestinal anastomoses with 30%, 60%, or 100% perfusion, respectively. The perfusion levels were determined relative to healthy intestine using ICG-FI. Ischemia was induced by mesenteric ligation and the perfusion level of each anastomosis was determined using a software-based analysis of the fluorescence signal. On postoperative day 5, the anastomoses were subjected to tensile strength test and histopathological assessment., Results: No anastomotic leakage occurred. The tensile strength of the 30% perfusion group was 9.09 N, which was significantly lower than the 60% perfusion group (11.5 N) and the 100% perfusion group (12.9 N). The difference between the 60% perfusion group and the 100% perfusion group was not significant. The histopathological assessment showed no significant differences between perfusion groups., Conclusions: A reduction in blood supply to 30%, as determined by ICG-FI, in small intestinal anastomoses was necessary to demonstrate a decrease in tensile strength.

Background: Anastomotic leakage is a severe complication in gastrointestinal surgery. Different methods have been evaluated for anastomotic reinforcement to prevent anastomotic leakage. The aim of this study was to investigate the effect of a poly-ε-caprolactone (PCL) scaffold incorporated in the staple-line, on the anastomotic strength and histological wound healing, of small intestinal anastomoses in piglets., Method: This randomized experimental trial included 17 piglets. In each piglet, three end-to-end anastomoses were performed in the small intestine with a circular stapler, i.e. one control and two interventional anastomoses. On postoperative day 5, the anastomoses were resected and subjected to tension stretch test and histological examination., Results: No anastomotic leakage occurred. In the interventional anastomoses, the mean value for maximal tensile strength was 15.7 N, which was significantly higher than control anastomoses 12.7 N (p = 0.01). No statistically significant differences were found between the two groups in the histopathological parameters., Conclusion: To conclude, this study has shown that the incorporation of a PCL scaffold in the staple-line was feasible and significantly increased the maximal tensile strength of small intestine anastomoses in piglets on postoperative day 5. The difference in histological parameters was not significantly distinct.

Aim: Anastomotic leakage (AL) is a common and serious complication following sphincter-preserving surgery for rectal cancer. Early detection and intervention can improve clinical outcomes. The aim of this prospective cohort study was to compare intraperitoneal microdialysis with a clinical scoring system for early detection of AL., Method: A microdialysis catheter was anchored near the anastomosis at low anterior resection (LAR) for rectal cancer. Peritoneal fluid samples were analysed (lactate, pyruvate, glucose and glycerol concentration) 4-hourly and compared with a daily clinical leak score (DULK = Dutch leakage). At day 7 a pelvic CT with rectal contrast enema was performed to establish if there had been a radiological leak., Results: In this two-centre study, 129 patients [median age 65 (26-82) years; 60.5% male] underwent LAR. The leak rate was 27% (grade A, n = 11; grade B, n = 12; grade C, n = 12). Receiver operator characteristic analysis demonstrated a lactate cut-off value of 9.8 mm and had 77% sensitivity, 82% specificity, 78% accuracy, a positive predictive value (PPV) of 58, a negative predictive value (NPV) of 88 (CI 79-94) and an area under the curve (AUC) of 0.9 for AL. This compared with a clinical score ≥ 4, which had 57% sensitivity, 79% specificity, 71% accuracy, a PPV of 46, a NPV of 82 and an AUC of 0.7 for AL. The mean day for a positive test when using delta lactate ≥ 6.3 mm was 1.6 days and for leak score ≥ 4 it was 3.3 days (NS)., Conclusion: When AL occurs, intraperitoneal lactate concentration increases over time, and at a certain cut-off has a higher sensitivity, specificity, accuracy, PPV and NPV than a clinical scoring system., (Colorectal Disease © 2019 The Association of Coloproctology of Great Britain and Ireland.)

In the original article, most of the reference numbers in the first column in Table 1 are off by one reference. Following is the corrected table.

Background: The aim was to investigate the incidence of postoperative complications to surgery for necrotizing enterocolitis (NEC) with primary focus on enterostomy related complications., Methods: A retrospective chart review of surgically treated NEC during the period from 2008 to 2014 was performed. Enterostomy with secondary anastomosis was our standard treatment. Postoperative complications were classified according to the Clavien-Dindo Classification (CDC)., Results: Forty-two cases were included in the study. NEC was most frequently located in the small bowel and the length of resected intestine was median 15 cm (2-50). Thirty-nine (93%) patients received an ileostomy and the rest a colostomy. Twenty-two (52%) patients underwent a total of 35 reoperations, and 25 (71%) of these were stoma related with stenosis was the most frequent cause, other causes of reoperation were re-NEC, high-output ileostomy, Ileus and second look., Conclusions: The rate of reoperation due to complications was high and most often caused by stoma related complications.

Background: Microdialysis is a technique for continuous measurement of extracellular substances. It may be used to monitor tissue viability. The clinical implications of using microdialysis as a tool in gastrointestinal surgery have yet to be defined. The aim of the present study was to evaluate the clinical significance of microdialysis with special attention to different markers measured to predict the clinical outcome of surgical patients., Methods: Embase, MEDLINE, and the Cochrane Library were searched systematically for human studies written in English. Study selection, data extraction, and quality assessment were performed independently by two authors. We included studies in which the microdialysis technique was used for postoperative monitoring of patients undergoing gastrointestinal surgery. To be eligible, studies had to compare patients with and without postoperative complications., Results: Twenty-six studies were included in this review. MINORS score ranged from 3 to 12 (median 10.5). Most studies showed that levels of biomarkers obtained by microdialysis correlated with the postoperative clinical course. Lactate, pyruvate, glucose, and glycerol were the most frequently measured biomarkers. Several studies found that changes in biomarkers in complicated patients preceded symptoms of complications and/or changes in conventional paraclinical methods of postoperative monitoring., Conclusions: Studies show that microdialysis may have the potential to become a tool in postoperative surveillance of surgical patients. Larger randomized studies are needed to define the clinical implications of microdialysis.