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A pedicled jejunal graft was successfully used to treat a colorectal anastomotic dehiscence, which eliminated the tension on the anastomotic site.

Objective: To assess the association of systemic inflammation and outcome after major abdominal surgery. Background: Major abdominal surgery carries a high postoperative morbidity and mortality rate. Studies suggest that inflammation is associated with unfavorable outcome. Methods: Levels of C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-a and the systemic inflammatory response syndrome (SIRS) were assessed in 137 patients undergoing major abdominal surgery. Blood samples were drawn on days 0, 1, 3, and 7, and SIRS was scored during 48 hours after surgery. Primary outcome was a composite of mortality, pneumonia, sepsis, anastomotic dehiscence, wound infection, noncardiac respiratory failure, atrial fibrillation, congestive heart failure, myocardial infarction, and reoperation within 30 days of surgery. Results: An IL-6 level more than 432 pg/mL on day 1 was associated with an increased risk of complications (adjusted odds ratio: 3.3; 95% confidence interval [CI]: 1.3-8.5) and a longer median length of hospital stay (7 vs 12 days, P

Uvod: Dehiscencija kolo-rektalne anastomoze (DKRA) je najteža komplikacija u hirurgiji karcinoma rektuma (KR) i direktno utiče na rane postoperativne ishode, prognozu i stopu preživljavanja. Cilj: ispitati povezanost godišnjeg volumena procedure hirurga i ranih postoperativnih ishoda i analizirati odnos uticajnih faktora rizika za nastanak DKRA u kontekstu iskustva hirurga. Materijal i metode: Retrospektivna,klinička studija jednog centra sa kohortom od 546 bolesnika oba pola sa KR. Kod svih je učinjena klasična (otvorena) prednja resekcija rektuma sa kreiranjem kolo-rektalne anastomoze (KRA) šavnom ili stepler tehnikom, u 10-godišnjem periodu. Bolesnici su podeljeni u tri grupe, shodno godišnjem volumenu procedura 18. ordinirajućih hirurga u kolorektalnoj hirurgiji. Analizirano je sedam ranih postoperativnih ishoda, kao i druga 22 faktora rizika (nezavisne, zavisne i „zbunjujuće“ varijable) od značaja za ishode operativnog lečenja i objašnjenje razlika između grupa hirurških volumena i njihovog uticaja na rane ishode lečenja. Sve operacije su izvedene u Klinici za opštu i abdominalnu hirurgiju KC Banja Luka (RS). Rezultati: Većina hirurga (77,7%) pripadala je grupi sa niskim i srednjim volumenom procedura. DKRA je nastala kod 53 (9,7%) bolesnika sa statistički značajnom razlikom između grupa hirurških volumena. Intrahospitalna smrtnost iznosila je 4,8% (26/546), bez statistički značajne razlike između grupa. Dužina hospitalizacije (> 8 dana, 65,4%) bila je u signifikantnoj korelaciji sa učestalošću DKRA. Grupa hirurga sa visokim volumenom imala je signifikantno bolje rezultate u četiri ranih ishoda. Zaključak: Signifikantni faktori rizika za nastanak DKRA su: T3 N1-2 M0 stadijum KR, nivo anastomoze do 12sm od analnog ruba, Charlson-ov indeks komorbiditeta ≥3, znatan fekalni sadržaj u kolonu (82,5%), preoperativna radioterapija, intraoperativni gubitak krvi >200ml., intraoperativna fekalna kontaminacija (30,8%), protektivna stoma (62,5%) i niski godišnji volumen procedura hirurga. Ovi faktori rizika obeležavaju posebnu „high-risk“grupu bolesnika sa KR, predisponiranu za nastanak DKRA. Visoki godišnji volumen hirurga je najvažniji prediktor uspešnih ranih ishoda u lečenju bolesnikasa KR. Introduction: Dehiscence of the colorectal anastomosis (AD) is the most severe complication of rectum cancer surgery which directly influences early postoperative outcome, prognosis and survival rate. Aim. To examine the connection between the annualvolume of the surgeon and early postoperative outcomes, as well as to analyze risk factors for the development of AD in the context of the surgeon individual experience. Method: Retrospective study performed in a single center, with a cohort of 546 patients of both sexeswith rectal cancer (RC), over a 10-year period.In all patients a classical (open) anterior resection of the rectum with a colorectal anastomosis (CRA), created viasuture or stapler,was performed. Patients were divided into three groups, according to the annual volume of their attending surgeon. Seven early postoperative outcomes were analyzed, as well as 22 other risk factors (independent, dependent, and “confusing” variables) of significance for surgical outcome. The risk factors were analyzed to explain the difference between the groups of surgeons and their influence on the outcomes. All surgeries were performed in the Clinic for general and abdominal surgery, Banja Luka (Republic of Srpska). Results: The majority of surgeons (77.7%) belonged to the low and medium annual volume groups. AD developed in 53 (9.7%) patients, with significant difference between the annual volume groups. The in-hospital death rate was4.8% (26/546), without significant difference between the groups. The length of stay in the hospital (> 8 days in 65.4%) was in significant correlation with the incidence of AD. The high annual volume surgeon group was associated with significantly better results in four of the outcomes. Conclusion: Risk factors for the development of AD were: T3N1-2M0 stadium of RC, anastomosis level up to 12 cm from the anal edge, Charlson comorbidity index of ≥3, significant fecal load of colon (82.5%), preoperative radiotherapy, intraoperative blood loss of more than 200 ml, intraoperative fecal contamination (30.8%), protective stoma (62.5%) and low annual volume of surgeons. These factors mark the particular high risk group of patients with RC predisposed to develop AD. The high annual volume surgeon was the most important predictor of success of the RC surgery.

Summary Background Anterior resection is nowadays the preferred option of surgical treatment for rectal cancer without sphincter involvement. However, this operation is associated with the risk of anastomosis dehiscence (AD). Aim The aim of this study was to estimate the influence of neoadjuvant radiotherapy and other factors on the risk of anastomosis dehiscence after total mesorectal excision for stage II and III rectal cancer. Materials/Methods One hundred and thirty consecutive patients operated on due to histologically confirmed rectal carcinoma were studied with prospective data collection. Elective surgery with curative intent was administered. All patients underwent sphincter-sparing anterior resection with total mesorectal excision. End-to-end anastomosis with double stapled technique was performed. Impact of patient-, tumour- and treatment-related variables on anastomosis dehiscence rate was evaluated in univariate and multivariate analysis. Results Incidence of AD was 10.6%. There was no leakage-related mortality. Univariate analysis showed that patient's age and gender, presence of lymph node metastases and irradiation setting (pre- vs post-operative) did not significantly influence dehiscence rate (P>0.05). Tumour level at or below 7cm from the anal verge was related to increased AD risk with statistical importance (P=0.0438). Neither pelvic drainage nor omentoplasty effectively protected the anastomosis. Proximal diversion with protective stoma resulted in significantly decreasing AD risk (P=0.0012). In multivariate analysis the presence of transversostomy was found as the most important factor independently associated with significantly lower incidence of AD. Conclusions Neoadjuvant radiotherapy does not seem to be a significant risk factor for anastomosis dehiscence, even after resection of low-sited tumours, but proximal diversion with temporary stoma needs to be considered.

A deiscência de anastomose é uma complicação importante nas cirurgias do aparelho digestivo. Vários fatores podem prejudicar o processo de cicatrização, entre eles, a presença de drenos na cavidade. O objetivo deste estudo foi avaliar a interferência da drenagem abdominal na cicatrização de anastomoses colônicas, em ratos. Quarenta ratos que foram distribuídos em 4 grupos, sendo submetidos à ressecção de segmento do colón, com anastomose local. Um grupo foi controle e nos demais foram colocados drenos de Látex, PVC e Silicone, respectivamente. O sacrifício ocorreu após 1 semana, quando foram avaliados os aspectos da cavidade abdominal (peritonite, aderências, deiscências e abscessos), a histologia e bioquímica (hidroxiprolina). No total, foram analisados, individualmente, 18 critérios: 4 macroscópicos, 13 microscópicos e 1 bioquímico. O grupo látex apresentou uma discrepância negativa em relação aos outros grupos. O grupo Controle (sem dreno) apresentou cicatrização positiva em relação aos outros grupos. Com base nos resultados, concluímos que a utilização de drenos (independente do material) seria um fator negativo para a cicatrização da anastomose. Entre os drenos, os de Látex interferiram negativamente na cicatrização quando comparado com os drenos de outros materiais.Anastomosis dehiscence is a main complication of the gastrointestinal surgical procedures. Different factors might influence the healing process, including the presence of an abdominal drain. The aim of the present study was to evaluate the role of different abdominal drains, on the colonic anastomosis healing, in rats. Forty rats, all submitted to a colonic resection followed by a local anastomosis, were divided into 4 groups. Group I was the control. Groups II, III and IV received and abdominal drain constituted of latex, PVC or silicone, respectively. One week after, animals were killed and had their abdominal cavity inspected macroscopically (peritonitis, adhesions, dehiscence, and abscesses). The anastomotic regions were submitted to histological and biochemical evaluations. In total, 4 macroscopic, 13 histological and 1 biochemical criteria were evaluated and some of them did not show statistical differences between groups. Group II showed a negative outcome in comparison to the others. Control groups had a positive healing condition in comparison to the others. In conclusion, the abdominal drain, independently of the constituting material, is a negative factor which interferes with anastomosis healing, compared to controls. The latex drain showed the worse effect on healing, when compared to other drains.

A deiscência de anastomose é uma complicação importante nas cirurgias do aparelho digestivo. Vários fatores podem prejudicar o processo de cicatrização, entre eles, a presença de drenos na cavidade. O objetivo deste estudo foi avaliar a interferência da drenagem abdominal na cicatrização de anastomoses colônicas, em ratos. Quarenta ratos que foram distribuídos em 4 grupos, sendo submetidos à ressecção de segmento do colón, com anastomose local. Um grupo foi controle e nos demais foram colocados drenos de Látex, PVC e Silicone, respectivamente. O sacrifício ocorreu após 1 semana, quando foram avaliados os aspectos da cavidade abdominal (peritonite, aderências, deiscências e abscessos), a histologia e bioquímica (hidroxiprolina). No total, foram analisados, individualmente, 18 critérios: 4 macroscópicos, 13 microscópicos e 1 bioquímico. O grupo látex apresentou uma discrepância negativa em relação aos outros grupos. O grupo Controle (sem dreno) apresentou cicatrização positiva em relação aos outros grupos. Com base nos resultados, concluímos que a utilização de drenos (independente do material) seria um fator negativo para a cicatrização da anastomose. Entre os drenos, os de Látex interferiram negativamente na cicatrização quando comparado com os drenos de outros materiais. Anastomosis dehiscence is a main complication of the gastrointestinal surgical procedures. Different factors might influence the healing process, including the presence of an abdominal drain. The aim of the present study was to evaluate the role of different abdominal drains, on the colonic anastomosis healing, in rats. Forty rats, all submitted to a colonic resection followed by a local anastomosis, were divided into 4 groups. Group I was the control. Groups II, III and IV received and abdominal drain constituted of latex, PVC or silicone, respectively. One week after, animals were killed and had their abdominal cavity inspected macroscopically (peritonitis, adhesions, dehiscence, and abscesses). The anastomotic regions were submitted to histological and biochemical evaluations. In total, 4 macroscopic, 13 histological and 1 biochemical criteria were evaluated and some of them did not show statistical differences between groups. Group II showed a negative outcome in comparison to the others. Control groups had a positive healing condition in comparison to the others. In conclusion, the abdominal drain, independently of the constituting material, is a negative factor which interferes with anastomosis healing, compared to controls. The latex drain showed the worse effect on healing, when compared to other drains.

INTRODUCCIÓN: La dehiscencia de la anastomosis pancreatoyeyunal es la complicación más temida de la pancreatoduodenectomía proximal (PDP) y puede ocacionar la muerte del paciente. Objetivo Presentamos nuestra experiencia acumulada en 198 PDPs reconstruídos utilizando la técnica simplificada de la anastomosis pancreatoyeyunal. TÉCNICA OPERATORIA: Consiste en realizar una sutura en bolsa de tabaco alrededor del borde libre del yeyuno para introducir 4 cm de muñón pancreático guiado por dos suturas transfixiantes entre el páncreas y el intestino, cerrar el yeyuno sobre el páncreas ajustando la sutura en bolsa de tabaco y colocar 4 puntos separados para "anclar" la anastomosis. Se descomprime las anastomosis pancreática y biliar mediante yeyunostomía. MATERIAL Y MÉTODO: Estudio prospectivo de 198 pacientes consecutivos que tuvieron PDP en el Instituto de Enfermedades Neoplásicas en el periodo 1995-2005. RESULTADOS: La morbilidad post operatoria global fue 38.4% (76 de 198 pacientes). Trece pacientes (6.6%) presentaron dehiscencia de anastomosis pancreatoyeyunal. La mortalidad post operatoria a 30 días y la mortalidad hospitalaria fue 2 % y 3.5 %, respectivamente. CONCLUSIÓN: Nuestra técnica modificada de anastomosis pancreatoyeyunal es simple, aplicable a todo tipo de páncreas y sobretodo segura, logrando reducir de manera importante la incidencia de dehiscencia de la anastomosis pancreatoyeyunal, la morbilidad y la mortalidad post operatorias. INTRODUCTION: Pancreatojejunal anastomosis dehiscence is the most feared complication of proximal pancreatoduodenectomies and it is the cause of other complications, including death. OBJECTIVE: We present our cumulative experience gathered with 198 proximal pancreatoduodenectomies reconstructed by using the simplified pancreatojejunal anastomosis technique. OPERATION TECHNIQUE: It consists of performing a tobacco-pouch suture around the free edge of the jejunum in order to introduce 4 cm of the pancreatic stump guided by two transfixing sutures between the pancreas and the intestine, closing the jejunum over the pancreas tightening the tobacco-pouch suture and making four separate stitches to ìanchorî the anastomosis. The pancreatic and bile anastomoses are decompressed by jejunostomy. MATERIAL AND METHOD: Prospective study in 198 consecutive patients who had proximal pancreatoduodenectomies at the Institute for Neoplastic Diseases during the 1995 - 2005 period. RESULTS: Overall post-operative morbidity was 38.4% (76 out of 198 patients). Thirteen patients (6.6%) showed pancreatojejunal anastomosis dehiscence. Post-operative mortality after 30 days and hospital mortality were 2% and 3.5%, respectively. CONCLUSIONS: Our modified pancreatojejunal anastomosis technique is simple, applicable to all types of pancreata and, most importantly, safe. It greatly reduces incidences of pancreatojejunal anastomosis dehiscence as well as post-operative morbidity and mortality.

Alagille syndrome (AS) is a dominantly inherited, multisystem disorder involving the liver, heart, eyes, face, and skeleton. From October 1997 through July 2004, 260 pediatric orthotopic liver transplantations (OLTx) were performed in 231 patients. This report describes 21 patients of median age 1.95 years (range, 0.7-16.7) who had alagille syndrome. We present the technical features of the OLTx, incidence and type of complications, medical conditions related to the syndrome, need for retransplantation, as well as patient and graft survival rates. A split liver technique was used in 16 patients (76%) who received a left lateral segment (LLS) graft whereas 7 patients (33%) received a whole liver. Only cadaveric donors were used. The major surgical complications requiring reintervention in 11 patients (52%) included biliary problems (19%) and vascular complications (17%). One case of hepatic artery thrombosis required retransplantation. Three recipients (14%) died. All other patients are alive with an actuarial survival rate of 90% at 1 year and 80% at 5 years. The actuarial graft survival rate is 85% at 1 year and 75% at 5 years. Patients with AS, despite the associated cardiovascular anomalies, can be treated successfully by a combined approach between cardiologist, radiologist, cardiothoracic, and liver transplant surgeons. With careful planning and operative management, the results are comparable with those obtained with other more common cholestatic diseases.

Background and Study Aims: Benign anastomotic stenosis (BAS) represents a frequent complication following esophagectomy and cervical esophagogastrostomy for cancer. This study was undertaken to evaluate through early postoperative esophagoscopy the morphologic change of the anastomosis which could be related to BAS development. Patients and Methods: Thirty-nine patients who underwent subtotal esophagectomy and cervical esophagogastrostomy were prospectively evaluated. The analyzed factors were: age; sex; the anastomotic size; the presence and number of endoscopically visible stitches; the presence and percentage of mucosal ulcerations involving the anastomotic suture line; the presence of anastomotic leak or dehiscence; the vascularization of the gastric tube; the patency of pylorus. Results: No complications related to the early esophagoscopy were observed. Twelve patients (30.7%) developed a stenosis postoperatively. The univariate analysis demonstrated anastomotic leak (p

The success of every intestinal surgical procedure primarily depends on correct technical execution of the intestinal sutures. Despite the continuing improvements in intestinal synthesis techniques and the introduction of mechanical staplers, the risk of anastomotic dehiscence remains a major concern. For high-risk anastomoses, defined as those performed under critical conditions, n-butyl-2-cyanoacrylate tissue adhesive allows for quick sealing of the two stumps and supports the physiological wound-healing process. Furthermore, no experimental or clinical studies have shown that this glue has any carcinogenic or mutagenic properties. Thus, we believe that n-butyl-2-cyanoacrylate will be extremely useful for intestinal anastomoses with a high risk of dehiscence.