Endoluminal vacuum therapy for gastrojejunal anastomotic leaks after Roux-en-Y gastric bypass: a pilot study in a swine model.

BACKGROUND: Roux-en-Y gastric bypass (RYGB) consistently produces the most sustainable weight loss among common interventions for morbid obesity. Anastomotic leaks at the gastrojejunal (GJ) connection result in severe morbidity. We apply endoluminal negative pressure vacuum devices (EVD) to heal anastomotic leaks in a swine model. METHODS: RYGB was performed in 10 pigs (3 control, 7 experimental). GJ anastomoses were fashioned, and a 2-cm defect was made across the staple line. In controls, the defects remained open. In experimental pigs, the EVD was placed across the defect and kept at continuous 50 mmHg suction. All pigs were euthanized on postoperative day seven unless they displayed signs of peritonitis or sepsis. Fluoroscopy and necropsy were performed to assess a persistent leak, and tissue specimens were sent to histology to evaluate for degree of inflammation and ischemia. RESULTS: All three control pigs' GJ anastomoses demonstrated evidence of a persistent leak. All seven experimental pigs with the EVD in place showed evidence that their leak had sealed at time of fluoroscopy (p value 0.008). CONCLUSIONS: Endoluminal vacuum therapy is well tolerated in a swine model. GJ anastomotic leaks were consistently sealed with our device in place compared to controls. This therapy shows promise as a method to address GJ leaks in the bariatric population, and thus, we believe additional evaluation is warranted.

Operating-Room Procedures Do Not Increase Risk of COVID-19 Infection.

BACKGROUND AND OBJECTIVES: Operating-room procedures canceled due to the COVID-19 pandemic depleted hospital revenue and potentially worsened patient outcomes through disease progression. Despite safeguards to resume elective procedures, patients remain apprehensive of contracting COVID-19 during hospitalization and recovery. We investigated symptomatic COVID-19 infection in patients undergoing operating-room procedures during the spring 2020 outbreak in Fairfield County, CT, a heavily affected New York Metropolitan area. METHODS: We retrospectively analyzed 419 operating-room patients in Danbury and Norwalk Hospitals between 3/16/20 and 5/19/20. COVID-19 infection was assessed through test results or documented well-being within 2 weeks postdischarge. Variables studied were procedure classification, length of stay, and discharge disposition. Postprocedural COVID-19 infection was analyzed using binomial tests comparing rates to state-mandated infection data. RESULTS: Six patients developed COVID-19 after 212 urgent-elective and 207 emergent procedures. Overall postprocedural infection risk was equivalent to community infection risk (P > .05). No infections occurred in 1-2 day stays or urgent-elective procedures with discharge home (both P < .05). Discharges home reduced the risk to one-sixth of community spread (P = .03). Risk of infection doubled in hospitalizations > 5 days (P = .05) and quadrupled in discharges to extended care facilities (P = .01). DISCUSSION: Operating-room procedures did not increase the risk of symptomatic COVID-19 infection during an outbreak. Urgent-elective and emergent procedures during further outbreaks appear safe when anticipating short stays with discharges home. When anticipating prolonged hospitalization or discharges to facilities, appropriate delay of urgent-elective procedures may minimize risk of infection.

Unusual anomaly complicating abdominal aortic aneurysm repair: anterior inferior vena cava.

This case illustrates an unusual anomaly of the great veins. To our knowledge, these are the first published photographs of the vena cava traversing anterior to the distal aorta. This anatomic variant caused minor technical problems during open abdominal aortic aneurysm repair.

Endoluminal negative-pressure therapy for preventing rectal anastomotic leaks: a pilot study in a pig model.

BACKGROUND: Anastomotic leak after rectal resection carries substantial morbidity and mortality. A diverting ileostomy is beneficial for high-risk anastomoses, but its creation and reversal carry a surgical risk in addition to that of resection itself. We sought an alternative method for managing complications of rectal anastomosis. METHODS: We developed an endoluminal negative-pressure technology with a diverting proximal sump, and hypothesized that it would close anastomotic disruptions in pigs. We performed rectal resections on pigs, with primary anastomoses and the creation of an anastomotic defect. In animals in the treatment group we inserted an endoluminal negative-pressure device and kept it at a low level of continuous suction for 5 d. No device was inserted in a control group of animals. After the 5-d period of treatment we evaluated the anastomoses in both the treatment and control groups of animals for leakage, using contrast enemas. Specimens of anastomosed rectum were evaluated histologically for mucosal integrity and for the location and density of inflammatory responses. RESULTS: Fourteen pigs were assigned to either the treatment (n=10) or control (n=4) group. Of the pigs in the treatment group, 90% had complete closure of their rectal defect, as compared with 25% of the animals in the control group (χ(2) test, p=0.04). The animals in the treatment group had only minimal mucosal and serosal inflammation, whereas those in the control group had extensive mucosal damage with associated serositis. CONCLUSIONS: Endoluminal negative-pressure therapy was well-tolerated and led to successful closure of 90% of the anastomic rectal defects in the treatment group of animals in the present study. Additional evaluation of this therapy is warranted.

Delayed endoluminal vacuum therapy for rectal anastomotic leaks after rectal resection in a swine model: a new treatment option.

Anastomotic leaks are a dreaded surgical complication following colorectal operations. Creation of a temporary proximal diverting ileostomy is used in high-risk anastomoses, however, additional surgical risk is accumulated with its creation and reversal. Endoluminal vacuum therapy has been shown to seal anastomotic defects in the prophylactic setting in a pig model and we hypothesized it could be utilized in a delayed fashion to rescue subjects with an active anastomotic leak. Yorkshire pigs underwent rectal resection, intentional leak confirmed by fluoroscopy, and endoluminal vacuum therapy device placement to low continuous suction. Following treatment, a contrast enema and necropsy was performed for gross and histopathology. Pigs underwent 2 (or 5) days of free intraperitoneal leak prior to device placement and 5 (or 7) subsequent days of endoluminal vacuum therapy. Six of seven early-treated pigs sealed their anastomotic defect, while two of the four treated pigs in this extended group sealed the defect. Endoluminal vacuum therapy is feasible and well tolerated in a pig model, and it has been shown to seal a significant number of freely leaking anastomoses in the early period (86%). This technology warrants further study as it may provide a noninvasive means to treatment of anastomotic leaks.

Healing of complicated gastric leaks in bariatric patients using endoscopic clips.

INTRODUCTION: Endoscopists have used clipping devices to successfully close acute, iatrogenic perforations throughout the gastrointestinal tract. We applied this technology to our bariatric patients, who tend to present with a more delayed anastomotic leak, to determine whether these leaks and fistulae would also heal with endoclip application. CASE DESCRIPTION: We describe a small series of 2 clinically stable bariatric patients who presented with postoperative anastomotic leaks who met criteria for non-operative therapy. The first underwent a laparoscopic Roux-en-Y gastric bypass and presented postoperatively with a leak at her gastrojejunal anastomosis. The location was not amenable to stent placement; therefore, 2 endoclips were placed. The leak was sealed by fluoroscopic examination 14 d later. The second had a reversal of a previous gastric bypass, creating a new gastrogastric anastomosis. A leak was found at this new connection postoperatively. After failure of a stent to seal the leak, 8 endoclips were used. This patient also had successful closure of her leak on fluoroscopy 14 d postprocedure. DISCUSSION: Anastomotic leaks after bariatric surgery can incur severe morbidity, cost, and detriment to patients' quality of life. Unstable patients require operative intervention. Stable patients are candidates for more-conservative measures. Endoscopic stents have been successful in closing gastric leaks, though some are not anatomically amenable to stent placement, and stents also have the potential to migrate distally. We demonstrate 2 cases of successful closure of leaks in bariatric patients by using endoclips and suggest that this be considered an option in appropriate cases.

Evaluation and management of abdominal lymphoceles after anterior lumbar spine surgery.

STUDY DESIGN: Case report. OBJECTIVE: To examine the management of abdominal lymphoceles after anterior spine surgery and to review the existing literature on lymphoceles after access to the spine. SUMMARY OF BACKGROUND DATA: Abdominal lymphoceles are a rare complication of anterior spinal approaches. METHODS: Case report and review of the literature. RESULTS: In this article, we describe the management of 2 lymphoceles. In the first case, immediate operative drainage was required because of worsening abdominal pain and distention. In the second patient, conservative management was attempted, but the lymphocele ultimately persisted and required surgical intervention. CONCLUSION: Lymphoceles are often difficult to distinguish from ureteral injury, cerebrospinal fluid-leaks and hematomas using conventional imaging techniques. Although surgery remains the gold standard for the treatment of lymphoceles, expectant observation may be reasonable in some situations.