Effect of anastomotic configuration on Crohn's disease recurrence after primary ileocolic resection: a comparative monocentric study of end-to-end versus side-to-side anastomosis.

There is ongoing debate whether the type of anastomosis following intestinal resection for Crohn's disease (CD) can impact on complications and postoperative recurrence. The aim of the present study is to describe the outcomes of side-to-side (S-S) vs end-to-end (E-E) anastomosis after ileocecal resection for CD. A retrospective comparative study was conducted in consecutive CD patients who underwent primary ileocecal resection between 2005 and 2013. All patients underwent colonoscopy 6 months postoperatively to assess endoscopic recurrence, defined as Rutgeerts' score (RS) ≥ i2. Surgical recurrence implied reoperation due to CD activity at the anastomotic site. Modified surgical recurrence was defined as the need for reoperation or balloon-dilation. Perioperative factors related to recurrence were evaluated. Of the 127 patients included, 51 (40.2%) received an E-E anastomosis. Median follow-up was longer in the E-E group (8.62 vs 13.68 years). Apart from the microscopic resection margins, patient, disease and surgical characteristics were similar between both groups. Anastomotic complications were comparable (S-S 5.3% vs E-E 5.8%, p = 1.00)0. Postoperatively, biologicals were used in 55.3% and 62.7% (p = 0.47) in S-S and E-E patients, respectively. Endoscopic recurrence did not differ between S-S and E-E patients (78.9 vs 72.9%, p = 0.37), with no significant difference in RS values between both groups (p = 0.87). Throughout follow-up, a higher surgical (p = 0.04) and modified surgical recurrence (p = 0.002) rate was observed in the E-E anastomosis group. Type of anastomosis was an independent risk factor for modified surgical recurrence. The type of anastomosis did not influence endoscopic recurrence and immediate postoperative disease complications. However, the wide diameter and the morphologic characteristic of the stapled S-S anastomosis resulted in a significant reduced risk for surgical and endoscopic reintervention on the long term.

Hybrid Repair of an Aneurysm of the Innominate Artery.

INTRODUCTION: Innominate artery aneurysms (IAAs) are rare. They are notorious for causing thromboembolic events. Modern imaging modalities make early detection in an asymptomatic phase possible. In Kieffer group B aneurysms the origin of the innominate artery is affected. Thanks to the combination of open and endovascular techniques, off pump repair is feasible in patients with a fragile aortic arch. During this hybrid procedure the aortic arch is debranched and reinforced with a stent graft. REPORT: A 73 year old white man with a history of extensive thoraco-abdominal aortic reconstructions for aneurysmal disease presented with a progressive Kieffer B IAA of 35 mm. He underwent an off pump hybrid repair. A bifurcated Dacron prosthesis was used for the debranching. The main body originated from the ascending aorta. The right limb was anastomosed to the common ostium of the right carotid and subclavian arteries. The left limb was anastomosed to the left subclavian and carotid artery. The aortic arch was reinforced with a 40 × 162 mm Zenith TX2 endoprosthesis. The endoprosthesis was inserted through a temporary conduit on the main body and deployed during rapid ventricular pacing. The endoprosthesis lined the ascending aorta distal to the debranching up to Ishimaru zone 3. The antegrade insertion prevented excessive manipulation of the aortic arch and the tortuous aorta, which was lined with mural thrombus. Post-operative computed tomography showed a patent debranching with excellent alignment of the endoprosthesis without endoleak. DISCUSSION: Hybrid repair of the aortic arch is well described in literature. This technique was adapted in the treatment of a Kieffer group B IAA. The tortuous aorta and mural thrombus led to the antegrade placement of the endoprosthesis through the main body of the debranched aorta. This approach seems safe and feasible.

Moderating the Enthusiasm of Sleeve Gastrectomy: Up to Fifty Percent of Reflux Symptoms After Ten Years in a Consecutive Series of One Hundred Laparoscopic Sleeve Gastrectomies.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become a popular one-stage bariatric procedure with a proven efficacy on weight loss. However, the relationship between LSG and gastroesophageal reflux disease (GERD) remains a subject of debate. The objective is to determine the long-term effect of LSG on weight loss and reflux disease. METHODS: A retrospective analysis of 100 consecutive patients who underwent an LSG between January 2005 and March 2009 was performed. The effect of LSG on weight evolution and the relationship between preoperative and postoperative GERD symptoms and PPI dependency was analyzed. RESULTS: A mean follow-up of 8.48 years (range 6.1-10.3) was achieved. We observed a long-term % excess weight loss (%EWL) of 60%. A significant increase in reflux symptoms and use of PPIs was seen. Seventeen percent suffered from reflux disease preoperatively versus 50% at the end of the postoperative follow-up (RR = 2.5882, 95% CI [1.6161-4.1452], p value = 0.0001). The chance of developing de novo reflux after LSG was 47.8% (32/67). Reflux disease was present in 7 of the 26 patients who underwent a secondary Roux-en-Y gastric bypass (RYGB). In four of these seven patients, reflux disease disappeared completely after the secondary RYGB (57.1%). CONCLUSIONS: A satisfactory long-term effect on weight loss was achieved. However, a significant increase in GERD and PPI dependency after LSG was noted. New onset GERD was seen in more than 40% of the study population. Conversion to RYGB is a good option in patients with refractory reflux disease after LSG.