A challenging upper digestive tract continuity restoration after recurrent esophago-colonic anastomosis complications.

BACKGROUND: Acute and chronic complications in esophago-colonic anastomosis have a significant impact in the postoperative course of patients with colonic transposition. Evidence about their management is poor and surgical treatment is mostly based on tailored approaches, so each new experience could be useful to improve knowledge about this peculiar condition. We report a unique case of an esophago-colonic resection and re-anastomosis without sternal approximation after recurrent anastomosis failure and strictures. CASE PRESENTATION: A 69-year-old woman was referred to our hospital for worsening dysphagia. The patient had undergone esophago-gastrectomy with right colon interposition 12 years prior due to caustic ingestion. The esophago-colonic anastomosis was initially complicated by an enterocutaneous fistula, which was treated with anastomosis resection and left colon transposition. This was then further complicated by dehiscence and sternal infection treated with resection of the distal portion of the sternum and a new colo-jejunal anastomosis. Finally, a chronic anastomotic stricture occurred, refractory to endoscopic dilatation and prothesis positioning. We planned a new colonic-esophageal resection and re-anastomosis. The main technical challenges were addressing the adhesions resulting from previous surgery and mobilizing an adequate length of the intestinal tract to allow conduit continuity restoration. Blood supply was assessed through Indocyanine Green Fluorescence. To avoid compression of the digestive conduit sternal margins were not re-approximated, and the transposed tube was covered and protected using both pectoralis major muscles flap. We decided to avoid the use of any prosthetic material to reduce the risk of infection. The patient was able to resume oral food intake on the 12th day postoperatively after a barium swallowing test showed an adequate conduit caliber. CONCLUSION: Esophago-colonic anastomosis complications represent a life-threatening condition. Therefore, reports and sharing of knowledge are important to improve expertise in management of these conditions.

Nonalcoholic Fatty Liver Disease and Fibrosis Associated With Increased Risk of Cardiovascular Events in a Prospective Study.

BACKGROUND & AIMS: Patients with non-alcoholic fatty liver disease (NAFLD) are at increased chance for cardiovascular events (CVEs). Severity of liver fibrosis is used to determine prognoses for patients with NAFLD, but little is known about the relationship between liver fibrosis and CVEs in the real world. METHODS: We analyzed data from the prospective observational progression of liver damage and cardiometabolic disorders in non-alcoholic fatty liver disease study, comprising 898 consecutive outpatients (mean age, 56.4 ± 12.7 years; 37.5% women) screened for liver steatosis by ultrasound according to Hamagughi criteria. Liver fibrosis was defined as FIB-4 score greater than 2.67 and NAFLD fibrosis score greater than 0.676. After enrolment, patients were interviewed by phone every 6 months and examined every 12 months in the outpatient clinic, and CVEs were recorded (fatal or nonfatal ischemic stroke and myocardial infarction, cardiac or peripheral revascularization, new-onset arterial fibrillation and cardiovascular death). The primary outcomes were incidence rate of CVEs in patients with vs without NAFLD and factors associated with CVEs in patients with NAFLD. RESULTS: Over a median follow-up time of 41.4 months (3044.4 patient-years), 58 CVEs (1.9%/year) were registered. The rate of CVEs was higher in patients with (n = 643, 2.1%/year) vs without NAFLD (n = 255, 1.0%/year) (P = .066). In multivariable Cox proportional regression analysis, NAFLD increased risk for CVEs (hazard ratio [HR], 2.41; 95% CI, 1.06-5.47; P = .036), after adjustment for metabolic syndrome. Among patients with NAFLD, male sex, previous CVEs, metabolic syndrome and FIB-4 scores greater than 2.67 (HR, 4.02; 95% CI, 1.21-13.38; P = .023) were independently associated with risk of incident CVEs. NFS scores greater than 0.676 were also independently associated with risk of incident CVEs (HR, 2.35; 95% CI, 1.05-5.27; P = .038). CONCLUSIONS: In an analysis of data from a study of patients screened for NAFLD and followed, individuals with NAFLD had more than a 2-fold increase in risk of CVEs, and those with liver fibrosis had a 4-fold increase in risk. In patients with NAFLD, liver fibrosis indexes were independently associated with risk of incident CVEs. ClinicalTrials.gov no:NCT04036357.

Quality of life and anorectal function after transanal surgery for rectal cancer. A literature review.

AIM: The aim of the study is analyze the results after Transanal Endoscopic Microsurgery (TEM) and Trans-Anal Minimally Invasive Surgery (TAMIS) for rectal cancer in terms of Quality of Life (QoL) and anorectal function. MATERIAL OF STUDY: The authors have conducted a review of the literature through the PubMed database using the following keywords: "quality of life", "rectal cancer", "transanal surgery", "TEM" and "TAMIS". RESULTS: Six and five studies were included on TEM and TAMIS, respectively, for a total of 619 patients with a follow up of up to five years. QoL and anorectal function were evaluated by questionnaires and anorectal manometry in four out of eleven studies. At postoperative evaluation, patients reported temporary changes (from 3 weeks to 36 months) but no long-term effects on anorectal function and QoL. There were no differences in the postoperative functional outcome between surgery with rigid (TEM) or soft (TAMIS) devices. Some of the studies reported postoperative changes at manometry that were not clinically confirmed by the questionnaires. DISCUSSION: During TEM and TAMIS the risk of pelvic autonomic nerves damage, that may compromise urinary and sexual function and the risk of permanent sphincter damage with the need to perform a stoma, are very low. CONCLUSIONS: Quality of life and anorectal function after TEM or TAMIS for the treatment of rectal tumors are good with no postoperative sequelae at mid-term follow up. KEY WORDS: Quality of Life (QoL), Rectal cancer, Transanal surgery, Transanal Endoscopic Microsurgery (TEM), Trans-Anal Minimally Invasive Surgery (TAMIS).

Transanal endoscopic microsurgery for 135 patients with small nonadvanced low rectal cancer (iT1-iT2, iN0): short- and long-term results.

BACKGROUND: Local excision of rectal cancer as an alternative to radical resection for patients with small nonadvanced low rectal cancer (SNALRC) (iT1-iT2, iN0) is debated. This study aimed to analyze the short- and long-term results for a series of 135 patients with SNALRC who underwent local excision by transanal endoscopic microsurgery (TEM). METHODS: According to the study protocol, 135 patients classified by endorectal ultrasound, magnetic resonance imaging (MRI), and computed tomography (CT) imaging as having iT1 iN0 iM0 (n = 51) or iT2 iN0 iM0 (n = 84) low rectal cancer were enrolled in the study. All the patients with iT2 rectal cancer underwent neoadjuvant therapy. The definitive histologic findings showed 24 pT0 patients (17.8%), 66 pT1 patients (48.8%), and 45 pT2 patients (33.4%). RESULTS: Minor complications were observed in 12 patients (8.8%) and major complications in 2 patients (1.5%). During a median follow-up period of 97 months (range, 55-139 months), local recurrences occurred for four patients and distant metastases for two patients. The patients who experienced a recurrence had been preoperatively staged as iT2 and were low or nonresponders to neoadjuvant treatment (ypT2). At the end of the follow-up period, the disease-free survival rates were 100% for the iT1 patients and 93% for the iT2 patients CONCLUSIONS: The long-term results for adequate local excision by TEM with or without neoadjuvant radiochemotherapy in the treatment of SNALRC based on the current study protocol are not inferior to those reported in the literature for radical surgery with total mesorectal excision (TME).

Laparoscopic anterior adrenalectomy for the treatment of adrenal metastases.

Aim of this study was to evaluate the results in 6 patients undergoing laparoscopic adrenalectomy for the treatment of solitary adrenal gland metastases. One hundred forty-five patients underwent laparoscopic adrenalectomy by transperitoneal anterior approach. In 6 patients the indication was the presence of a solitary adrenal gland metastasis. Primary tumors were the following: truncal melanoma, gastric cancer, renal cancer, lung cancer, and breast cancer. Mean age was 57 years (range 44-70 years). Three patients underwent right adrenalectomy and 3 patients a left adrenalectomy. No conversion to open surgery occurred. No mortality or intraoperative complications were observed. Mean operative time was 103 minutes (range 70-150) for right adrenalectomy and 170 minutes (range 90-280) for left adrenalectomy. No postoperative complications occurred. Mean diameter of the tumor was 3.5 cm (range 2-5 cm). Tumor free margins were obtained in every case. Mean hospital stay was 2 days (range 2-3 days). At follow-up, 2 patients have died of systemic dissemination of the disease, one 15 months and one 24 months after the operation. The remaining 4 patients are alive and disease free at a mean follow-up of 7 months (range 4-11 months). So far, no port site metastases or local recurrence have been observed. In our experience adrenal gland metastasis can be treated safely and effectively by the laparoscopic transperitoneal anterior approach.