Short-term Outcomes of Different Techniques for Gastric Ischemic Preconditioning Before Esophagectomy: A Network Meta-analysis.

BACKGROUND: Ischemia at the anastomotic site plays a critical role determinant in the development of anastomosis-related complications after esophagectomy. Gastric ischemic conditioning (GIC) before esophagectomy has been described to improve the vascular perfusion at the tip of the gastric conduit with a potential effect on anastomotic leak (AL) and stenosis (AS) risk minimization. Laparoscopic (LapGIC) and angioembolization (AngioGIC) techniques have been reported. PURPOSE: Compare short-term outcomes among different GIC techniques. MATERIALS AND METHODS: Systematic review and network meta-analysis. One-step esophagectomy (noGIC), LapGIC, and AngioGIC were compared. Primary outcomes were AL, AS, and gastric conduit necrosis (GCN). Risk ratio (RR) and weighted mean difference (WMD) were used as pooled effect size measures, whereas 95% credible intervals (CrIs) were used to assess relative inference. RESULTS: Overall, 1760 patients (14 studies) were included. Of those, 1028 patients (58.4%) underwent noGIC, 593 (33.6%) LapGIC, and 139 (8%) AngioGIC. AL was reduced for LapGIC versus noGIC (RR=0.68; 95% CrI 0.47-0.98) and AngioGIC versus noGIC (RR=0.52; 95% CrI 0.31-0.93). Similarly, AS was reduced for LapGIC versus noGIC (RR=0.32; 95% CrI 0.12-0.68) and AngioGIC versus noGIC (RR=1.30; 95% CrI 0.65-2.46). The indirect comparison, assessed with the network methodology, did not show any differences for LapGIC versus AngioGIC in terms of postoperative AL and AS risk. No differences were found for GCN, pulmonary complications, overall complications, hospital length of stay, and 30-day mortality among different treatments. CONCLUSIONS: Compared to noGIC, both LapGIC and AngioGIC before esophagectomy seem equivalent and associated with a reduced risk for postoperative AL and AS.

Early Interventional Treatment of High Output Chyle Leak After Esophagectomy is Associated With Improved Survival.

OBJECTIVE: To investigate overall survival and length of stay (LOS) associated with differing management for high output (>1 L over 24 hours) leaks (HOCL) after cancer-related esophagectomy. BACKGROUND: Although infrequent, chyle leak after esophagectomy is an event that can lead to significant perioperative sequelae. Low-volume leaks appear to respond to nonoperative measures, whereas HOCLs often require invasive therapeutic interventions. METHODS: From a prospective single-institution database, we retrospectively reviewed patients treated from 2001 to 2021 who underwent esophagectomy for esophageal cancer. Within that cohort, we focused on a subgroup of patients who manifested a HOCL postoperatively. Clinicopathologic and operative characteristics were collected, including hospital LOS and survival data. RESULTS: A total of 53/2299 patients manifested a HOCL. These were mostly males (77%), with a mean age of 62 years. Of this group, 15 patients received nonoperative management, 15 patients received prompt (<72 hours from diagnosis) interventional management, and 23 received late interventional management. Patients in the late intervention group had longer LOSs compared with early intervention (slope = 9.849, 95% CI: 3.431-16.267). Late intervention (hazard ratio: 4.772, CI: 1.384-16.460) and nonoperative management (hazard ratio: 4.731, CI: 1.294-17.305) were associated with increased mortality compared with early intervention. Patients with early intervention for HOCL had an overall survival similar to patients without chyle leaks in survival analysis. CONCLUSIONS: Patients with HOCL should receive early intervention to possibly reverse the prognostic implications of this potentially detrimental complication.

Risk factors for anastomotic leak and postoperative morbidity after right hemicolectomy for colon cancer: results from a prospective, multi-centre, snapshot study in China.

BACKGROUND: Right hemicolectomy is the standard treatment for right-sided colon cancer. There is variation in the technical aspects of performing right hemicolectomy as well as in short-term outcomes. It is therefore necessary to explore best clinical practice following right hemicolectomy in expert centres. METHODS: This snapshot study of right hemicolectomy for colon cancer in China was a prospective, multicentre cohort study in which 52 tertiary hospitals participated. Eligible patients with stage I-III right-sided colon cancer who underwent elective right hemicolectomy were consecutively enrolled in all centres over 10 months. The primary endpoint was the incidence of postoperative 30-day anastomotic leak. RESULTS: Of the 1854 patients, 89.9 per cent underwent laparoscopic surgery and 52.3 per cent underwent D3 lymph node dissection. The overall 30-day morbidity and mortality were 11.7 and 0.2 per cent, respectively. The 30-day anastomotic leak rate was 1.4 per cent. In multivariate analysis, ASA grade > II (P < 0.001), intraoperative blood loss > 50 ml (P = 0.044) and D3 lymph node dissection (P = 0.008) were identified as independent risk factors for postoperative morbidity. Extracorporeal side-to-side anastomosis (P = 0.031), intraoperative blood loss > 50 ml (P = 0.004) and neoadjuvant chemotherapy (P = 0.004) were identified as independent risk factors for anastomotic leak. CONCLUSION: In high-volume expert centres in China, laparoscopic resection with D3 lymph node dissection was performed in most patients with right-sided colon cancer, and overall postoperative morbidity and mortality was low. Further studies are needed to explore the optimal technique for right hemicolectomy in order to improve outcomes further.

Anastomotic Leakage in Relation to Type of Mesorectal Excision and Defunctioning Stoma Use in Anterior Resection for Rectal Cancer.

BACKGROUND: Anastomotic leakage after anterior resection for rectal cancer is more common after total mesorectal excision compared to partial mesorectal excision but might be mitigated by a defunctioning stoma. OBJECTIVE: The aim is to assess how anastomotic leakage is affected by type of mesorectal excision and defunctioning stoma use. DESIGN: This is a retrospective multicenter cohort study evaluating anastomotic leakage after anterior resection. Multivariable Cox regression with HRs and 95% CIs was used to contrast mesorectal excision types and defunctioning stoma use with respect to anastomotic leakage, with adjustment for confounding. SETTINGS: This multicenter study included patients from 11 Swedish hospitals between 2014 and 2018. PATIENTS: Patients who underwent anterior resection for rectal cancer were included. MAIN OUTCOMES MEASURES: Anastomotic leakage rates within and after 30 days of surgery are described up to 1 year after surgery. RESULTS: Anastomotic leakage occurred in 24.2% and 9.0% of 1126 patients operated with total and partial mesorectal excision, respectively. Partial compared to total mesorectal excision was associated with a reduction in leakage, with an adjusted HR of 0.46 (95% CI, 0.29-0.74). Early leak rates within 30 days were 14.9% with and 12.5% without a stoma, whereas late leak rates after 30 days were 7.5% with and 1.9% without a stoma. After adjustment, defunctioning stoma was associated with a lower early leak rate (HR 0.47; 95% CI, 0.28-0.77). However, the late leak rate was nonsignificantly higher in patients with defunctioning stomas (HR 1.69; 95% CI, 0.59-4.85). LIMITATIONS: This study was limited by its retrospective observational study design. CONCLUSIONS: Anastomotic leakage is common up to 1 year after anterior resection for rectal cancer, where partial mesorectal excision is associated with a lower leak rate. Defunctioning stomas seem to decrease the occurrence of leakage, although partially by only delaying the diagnosis. See Video Abstract . FUGA ANASTOMTICA SEGN EL TIPO DE EXCISIN MESORRECTAL Y LA CONFECCIN DE OSTOMA DE PROTECCIN EN LA RESECCIN ANTERIOR POR CNCER DE RECTO: ANTECEDENTES:La fuga anastomótica después de una resección anterior por cáncer de recto es más frecuente después de la excisión total del mesorrecto comparada con la excisión parcial del mismo, pero podría mitigarse con la confección de ostomías de protección.OBJETIVO:El objetivo es evaluar cómo la fuga anastomótica se ve afectada según el tipo de excisión mesorrectal y la confección de una ostomía de protección.DISEÑO:Estudio de cohortes multicéntrico y retrospectivo que evalúa la fuga anastomótica después de la resección anterior. Se aplicó la regresión multivariada de Cox con los índices de riesgo (HR) y los intervalos de confianza (IC) al 95% para contrastar los tipos de excisión mesorrectal y el uso de otomías de protección con respecto a la fuga anastomótica, realizando ajustes respecto a las variables de confusión.AJUSTES:El presente estudio multicéntrico incluyó pacientes de 11 hospitales suecos entre 2014 y 2018.PACIENTES:Se incluyeron todos aquellos sometidos a resección anterior por cáncer de recto.PRINCIPALES MEDIDAS DE RESULTADOS:Las tasas de fuga anastomótica dentro y después de los 30 días de la cirugía fueron descritos hasta un año mas tarde al acto quirúrgico.RESULTADOS:La fuga anastomótica ocurrió en el 24,2% y el 9,0% de 1126 pacientes operados por excisión total y parcial del mesorrecto respectivamente.La excisión parcial del mesorrecto en comparación con la total se asoció con una reducción de la fuga, HR ajustado de 0,46 (IC del 95 %: 0,29 a 0,74). Las tasas de fuga temprana dentro de los 30 días fueron del 14,9 % con y el 12,5 % sin estoma, mientras que las tasas de fuga tardía después de 30 días fueron del 7,5 % con y el 1,9 % sin estoma.Después del ajuste de variables de confusión, las ostomías de protección se asociaron con una tasa de fuga temprana más baja (HR 0,47; IC 95 %: 0,28-0,77). Sin embargo, la tasa de fuga tardía no fue significativamente mayor en pacientes ostomizados (HR 1,69; IC 95%: 0,59-4,85).LIMITACIONES:Las limitaciones del presente estudio estuvieron vinculadas con el diseño de tipo observacional y retrospectivo.CONCLUSIONES:La fuga anastomótica es común hasta un año después de la resección anterior por cáncer de recto, donde la excisión parcial del mesorrecto se asocia con una menor tasa de fuga. La confección de ostomías de protección parece disminuir la aparición de fuga anastomótica, aunque en parte sólo retrasen el diagnóstico. (Traducción-Dr. Xavier Delgadillo ).

Risk Factors for Rectal Stump Leakage After Discontinuity Resection: Stump Length Matters Most.

BACKGROUND: Discontinuity resection is commonly conducted to avoid anastomotic leakage in high-risk patients but potentially results in rectal stump leakage. Although risk factors for anastomotic leakage have been widely studied, data on rectal stump leakage rates and underlying risk factors are scarce. OBJECTIVE: To determine rectal stump leakage rates following Hartmann's procedure and to identify patient-and surgery-associated risk factors. DESIGN: A retrospective study with univariate and multivariate analyses was performed to identify risk factors of rectal stump leakage. A subgroup analysis of scheduled operations was performed. SETTINGS: The study was conducted at Heidelberg University Hospital, Germany. PATIENTS: Patients were included who underwent discontinuity resection with rectal stump formation between 2010 and 2020. MAIN OUTCOME MEASURES: The main outcome measures included rectal stump leakage rates, 30-day mortality, length of hospitalization, and necessity for further invasive treatment. RESULTS: Rectal stump leakage occurred in 11.78% of patients. Rectal stump leakage rates varied considerably depending on the surgical procedure performed and were highest following subtotal pelvic exenteration (34%). Diagnosis of rectal stump leakage peaked on postoperative day 7. A short rectal stump ( p = 0.001), previous pelvic radiotherapy ( p = 0.04), chemotherapy ( p = 0.004), and previous laparotomy ( p = 0.03) were independent risk factors for rectal stump leakage in the entire patient collective. In patients undergoing scheduled surgery, a short rectal stump was the only independent risk factor ( p = 0.003). Rectal stump leakage was not associated with increased 30-day mortality but prolonged length of hospitalization and frequently necessitated further invasive treatment. LIMITATIONS: Study results are limited by the retrospective design, a high number of emergency operations, and the mere inclusion of symptomatic leakages. CONCLUSIONS: Rectal stump leakage is a relevant complication after discontinuity resection. Risk factors should be considered during surgical decision-making when both discontinuity resection and abdominoperineal resection are feasible. See Video Abstract. FACTORES DE RIESGO PARA LA FUGA DEL MUN RECTAL DESPUS DE UNA RESECCIN POR DISCONTINUIDAD LA LONGITUD DEL MUN ES LO MS IMPORTANTE: ANTECEDENTES:La resección de discontinuidad se realiza comúnmente para evitar la fuga anastomótica en pacientes de alto riesgo, pero potencialmente da como resultado una fuga del muñón rectal. Si bien los factores de riesgo de fuga anastomótica se han estudiado ampliamente, los datos sobre las tasas de fuga del muñón rectal y los factores de riesgo subyacentes son escasos.OBJETIVO:Determinar las tasas de fuga del muñón rectal después del procedimiento de Hartmann e identificar los factores de riesgo asociados con el paciente y la cirugía.DISEÑO:Se realizó un estudio retrospectivo con análisis univariado y multivariado para identificar los factores de riesgo de fuga del muñón rectal. Se llevó a cabo un análisis de subgrupos de las operaciones programadas.AJUSTES:El estudio se realizó en el Hospital Universitario de Heidelberg, Alemania.PACIENTES:Se incluyeron pacientes que se sometieron a resección de discontinuidad con formación de muñón rectal entre 2010 y 2020.MEDIDAS DE RESULTADO PRINCIPALES:Las principales medidas de resultado incluyeron las tasas de fuga del muñón rectal, la mortalidad a los 30 días, la duración de la hospitalización y la necesidad de un tratamiento invasivo adicional.RESULTADOS:La fuga del muñón rectal ocurrió en el 11,78% de los pacientes. Las tasas de fuga del muñón rectal variaron considerablemente según el procedimiento quirúrgico realizado y fueron más altas después de la exenteración pélvica subtotal (34%). El diagnóstico de fuga del muñón rectal alcanzó su punto máximo en el día 7 del postoperatorio. Un muñón rectal corto (p = 0,001), radioterapia pélvica previa (p = 0,04), quimioterapia (p = 0,004) y laparotomía previa (p = 0,03) fueron factores de riesgo independientes de fuga rectal. Fuga del muñón en todo el colectivo de pacientes. En los pacientes sometidos a cirugía programada, el muñón rectal corto fue el único factor de riesgo independiente (p = 0,003). La fuga del muñón rectal no se asoció con un aumento de la mortalidad a los 30 días, pero con una duración prolongada de la hospitalización y con frecuencia requirió un tratamiento invasivo adicional.LIMITACIONES:Los resultados del estudio están limitados por el diseño retrospectivo, un alto número de operaciones de emergencia y la mera inclusión de fugas sintomáticas.CONCLUSIONES:La fuga del muñón rectal es una complicación relevante tras la resección por discontinuidad. Se deben considerar los factores de riesgo durante la toma de decisiones quirúrgicas cuando son factibles tanto la resección por discontinuidad como la resección abdominoperineal. (Traducción-Yesenia Rojas-Khalil ).

Redefining Esophagectomy: The Manual Layered Insertion Method That May Reduce Anastomotic Leakage.

INTRODUCTION: Anastomotic leakage post-esophagectomy remains a significant challenge. Despite the use of both mechanical and manual anastomosis, leakage rates remain high. This study evaluated the effectiveness of the manual layered insertion anastomosis technique in addressing this issue. METHODS: A retrospective analysis was conducted on patients who underwent this technique from September 2020 to December 2021. The process involved thoracoscopic release of the esophagus, mediastinal lymph node dissection, laparoscopic stomach release, and its transformation into a tube. The latter was then guided to the neck for anastomosis. The posterior anastomotic wall was reshaped in the neck first for optimal insertion, followed by layered suturing with the gastric conduit. The anterior wall was subsequently sutured and repositioned into the chest. RESULTS: The study included 56 patients (51 men, five women, mean age 65.4 y), with nine having undergone neoadjuvant therapy. All received minimally invasive esophagectomy. Average intraoperative blood loss was 79.8 mL, operation time averaged 331 min, and feeding resumed after an average of 6.3 d. No anastomotic leakages were reported, with reduced incidences of anastomotic stenosis and gastric acid reflux compared to previous studies. CONCLUSIONS: The manual layered insertion anastomosis technique may reduce anastomotic leakage and associated complications, improving the efficacy of esophagectomy, which may improve postoperative results and patient quality of life, suggesting the method's potential suitability for wider clinical application.

Association of omental pedicled flap with anastomotic leak following low anterior resection for rectal cancer.

BACKGROUND AND OBJECTIVES: Anastomotic leak following colorectal anastomosis adversely impacts short-term, oncologic, and quality-of-life outcomes. This study aimed to assess the impact of omental pedicled flap (OPF) on anastomotic leak among patients undergoing low anastomotic resection (LAR) for rectal cancer using a multi-institutional database. METHODS: Adult rectal cancer patients in the US Rectal Cancer Consortium, who underwent a LAR for stage I-III rectal cancer with or without an OPF were included. Patients with missing data for surgery type and OPF use were excluded from the analysis. The primary outcome was the development of anastomotic leaks. Multivariable logistic regression was used to determine the association. RESULTS: A total of 853 patients met the inclusion criteria and OPF was used in 106 (12.4%) patients. There was no difference in age, sex, or tumor stage of patients who underwent OPF versus those who did not. OPF use was not associated with an anastomotic leak (p = 0.82), or operative blood loss (p = 0.54) but was associated with an increase in the operative duration [ß = 21.42 (95% confidence interval = 1.16, 41.67) p = 0.04]. CONCLUSIONS: Among patients undergoing LAR for rectal cancer, OPF use was associated with an increase in operative duration without any impact on the rate of anastomotic leak.

Minor impact of anastomotic leakage in anterior resection for rectal cancer on long-term male urinary and sexual function.

PURPOSE: Anastomotic leakage after anterior resection for rectal cancer induces bowel dysfunction, but the influence on urinary and sexual function is largely unknown. This cross-sectional cohort study evaluated long-term effect of anastomotic leakage on urinary and sexual function in male patients. METHODS: Patients operated with anterior resection for rectal cancer in 15 Swedish hospitals 2007-2013 were identified. Anastomotic leakage and other clinical variables were retrieved from the Swedish Colorectal Cancer Registry and medical records. Urinary and sexual dysfunction were evaluated at 4 to 11 years after surgery using the International Prostate Symptom Score, International Index of Erectile Function, and European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire CR29. The effect of anastomotic leakage on average scores of urinary and sexual dysfunction was evaluated as a primary outcome, and the single items permanent urinary catheter and sexual inactivity as secondary outcomes. The association of anastomotic leakage and functional outcomes was analyzed using regression models with adjustment for confounders. RESULTS: After a median follow-up of 84 months (interquartile range: 67-110), 379 out of 864 eligible men were included. Fifty-nine (16%) patients had anastomotic leakage. Urinary incontinence was more common in the leakage group, with an adjusted mean score difference measured by EORTC QLQ ColoRectal-29 of 8.69 (95% confidence interval: 0.72-16.67). The higher risks of urinary frequency, permanent urinary catheter, and sexual inactivity did not reach significance. CONCLUSION: Anastomotic leakage after anterior resection had a minor negative impact on urinary and sexual function in men.

Fact or fiction? Does the position of the end-to-end (EEA) stapler spike matter for colorectal anastomoses using a double-stapled technique?

AIM: Surgeons often have strong opinions about how to perform colorectal anastomoses with little data to support variations in technique. The aim of this study was to determine if location of the end-to-end (EEA) stapler spike relative to the rectal transection line is associated with anastomotic integrity. METHOD: This study was a retrospective analysis of a quality collaborative database at a quaternary centre and regional hospitals. Patients with any left-sided colon resection with double-stapled anastomosis were included (December 2019 to August 2022). Our primary endpoint was a composite outcome including positive air insufflation test, incomplete anastomotic donut, or thin/eccentric donut. Our secondary endpoint was clinical leak. RESULTS: Overall, 633 patients were included and stratified by location of the stapler spike relative to the rectal transection line. Of note, 86 patients had an end-colon to anterior rectum ("reverse Baker") anastomosis with no crossing staple lines. The rates of the composite endpoint based on position of the stapler spike were 12.4% (anterior), 8.1% (through), 12.8% (posterior), 5.1% (corner), and 2.3% for the "reverse Baker" (p = 0.03). The overall rate of clinical leak was 3.8% and there were no differences between methods. In a multivariate analysis, the "reverse Baker" anastomosis was associated with decreased odds of poor anastomotic integrity when compared to anastomoses with crossing staple lines (OR 0.20, 95% CI: 0.05-0.87, p = 0.03). CONCLUSIONS: For anastomoses with crossing staple lines, the position of the stapler spike relative to the rectal staple line is not associated with differences in anastomotic integrity. In contrast, anastomoses with no crossing staple lines resulted in significantly lower rates of poor anastomotic integrity, but no difference in clinical leaks.

Is proctoscopy sufficient for the evaluation of colorectal anastomosis prior to ileostomy reversal? A nationwide retrospective analysis of the Italian Society of Surgical Oncology Colorectal Cancer Network Collaborative group (SICO-CCN).

AIM: Several methods for assessing anastomotic integrity have been proposed, but the best is yet to be defined. The aim of this study was to compare the different methods to assess the integrity of colorectal anastomosis prior to ileostomy reversal. METHOD: A retrospective cohort analysis on patients between 1 January 2010 and 31 December 2020 with a defunctioning stoma for middle and low rectal anterior resection was performed. A propensity score matching comparison between patients who underwent proctoscopy alone and patients who underwent proctoscopy plus any other preoperative method to assess the integrity of colorectal anastomosis prior to ileostomy reversal (transanal water-soluble contrast enema via conventional radiology, transanal water-soluble contrast enema via CT, and magnetic resonance) was performed. RESULTS: The analysis involved 1045 patients from 26 Italian referral colorectal centres. The comparison between proctoscopy alone versus proctoscopy plus any other preoperative tool showed no significant differences in terms of stenoses (p = 0.217) or leakages (p = 0.103) prior to ileostomy reversal, as well as no differences in terms of misdiagnosed stenoses (p = 0.302) or leakages (p = 0.509). Interestingly, in the group that underwent proctoscopy and transanal water-soluble contrast enema the comparison between the two procedures demonstrated no significant differences in detecting stenoses (2 vs. 0, p = 0.98), while there was a significant difference in detecting leakages in favour of transanal water-soluble contrast enema via CT (3 vs. 12, p = 0.03). CONCLUSIONS: We can confirm that proctoscopy alone should be considered sufficient prior to ileostomy reversal. However, in cases in which the results of proctoscopy are not completely clear or the surgeon remains suspicious of an anastomotic leakage, transanal water-soluble contrast enema via CT could guarantee its detection.

Effects of endoluminal vacuum sponge therapy on the perfusion of gastric conduit in a porcine model for esophagectomy.

BACKGROUND: After esophagectomy, the postoperative rate of anastomotic leakage is up to 30% and is the main driver of postoperative morbidity. Contemporary management includes endoluminal vacuum sponge therapy (EndoVAC) with good success rates. Vacuum therapy improves tissue perfusion in superficial wounds, but this has not been shown for gastric conduits. This study aimed to assess gastric conduit perfusion with EndoVAC in a porcine model for esophagectomy. MATERIAL AND METHODS: A porcine model (n = 18) was used with gastric conduit formation and induction of ischemia at the cranial end of the gastric conduit with measurement of tissue perfusion over time. In three experimental groups EndoVAC therapy was then used in the gastric conduit (- 40, - 125, and - 200 mmHg). Changes in tissue perfusion and tissue edema were assessed using hyperspectral imaging. The study was approved by local authorities (Project License G-333/19, G-67/22). RESULTS: Induction of ischemia led to significant reduction of tissue oxygenation from 65.1 ± 2.5% to 44.7 ± 5.5% (p < 0.01). After EndoVAC therapy with - 125 mmHg a significant increase in tissue oxygenation to 61.9 ± 5.5% was seen after 60 min and stayed stable after 120 min (62.9 ± 9.4%, p < 0.01 vs tissue ischemia). A similar improvement was seen with EndoVAC therapy at - 200 mmHg. A nonsignificant increase in oxygenation levels was also seen after therapy with - 40 mmHg, from 46.3 ± 3.4% to 52.5 ± 4.3% and 53.9 ± 8.1% after 60 and 120 min respectively (p > 0.05). An increase in tissue edema was observed after 60 and 120 min of EndoVAC therapy with - 200 mmHg but not with - 40 and - 125 mmHg. CONCLUSIONS: EndoVAC therapy with a pressure of - 125 mmHg significantly increased tissue perfusion of ischemic gastric conduit. With better understanding of underlying physiology the optimal use of EndoVAC therapy can be determined including a possible preemptive use for gastric conduits with impaired arterial perfusion or venous congestion.

One anastomosis gastric bypass as a primary bariatric surgery: MBSAQIP database analysis of short-term safety and outcomes.

BACKGROUND: One anastomosis gastric bypass (OAGB) is described as a simpler, potentially safe, and effective bariatric-metabolic procedure that has been recently endorsed by the American Society of Metabolic and Bariatric Surgery. OBJECTIVES: First, we aim to compare the 30-day outcomes between OAGB and other bypass procedures: Roux-en-Y gastric bypass (RYGB) and single anastomosis duodenoileal bypass with sleeve gastrectomy (SADI-S). Second, identify the odds between postoperative complications and each surgical procedure. METHODS: Patients who underwent primary OAGB, RYGB, and SADI-S were identified using the MBSAQIP database of 2020 and 2021. An analysis of patient demographics and 30-day outcomes were compared between these three bypass procedures. In addition, a multilogistic regression for overall complications, blood transfusions, unplanned ICU admissions, readmission, reoperation, and anastomotic leak stratified by surgical procedure was performed. RESULTS: 1607 primary OAGBs were reported between 2020 and 2021. In terms of patient demographics, patients who underwent RYGB and SADI-S showed a higher incidence of comorbidities. On the other hand, OAGB had shorter length of stay (1.39 ± 1.10 days vs 1.62 ± 1.42 days and 1.90 ± 2.04 days) and operative times (98.79 ± 52.76 min vs 125.91 ± 57.76 min and 139.85 ± 59.20 min) than RYGB and SADI-S. Similarly, OAGB showed lower rates of overall complications (1.9% vs 4.5% and 6.4%), blood transfusions (0.4% vs 1.1% and 1.8%), unplanned ICU admission (0.3% vs 0.8% and 1.4%), readmission (2.4% vs 4.9% and 5.0%), and reoperation (1.2% vs 1.9% and 3.1%). A multilogistic regression analysis was performed, RYGB and SADI-S demonstrated higher odds of 30-day complications. CONCLUSION: The incidence of primary OAGB has increased since its approval by ASMBS, from 0.05% reported between 2015 and 2019 to 0.78% between 2020 and 2021. OAGB had better 30-day outcomes and shorter operative times than RYGB and SADI-S and therefore, could be considered a viable alternative.

Placing vacuum sponges in esophageal anastomotic leaks - how we do it.

PURPOSE: Endoluminal vacuum sponge therapy has dramatically improved the treatment of anastomotic leaks in esophageal surgery. However, the blind insertion of vacuum sponge kits like Eso-Sponge® via an overtube and a pusher can be technically difficult. METHODS: We therefore insert our sponges under direct visual control by a nonstandard "piggyback" technique that was initially developed for the self-made sponge systems preceding these commercially available kits. RESULTS: Using this technique, we inserted or changed 56 Eso-Sponges® in seven patients between 2018 and 2023. Apart from one secondary sponge dislocation, no intraprocedural complications were encountered. One patient died due to unrelated reasons. In all others, the defects healed and they were dismissed from the hospital. Long-term follow-up showed three strictures that were successfully treated by dilatation. CONCLUSION: We conclude that sponge placement via piggyback technique is a fast, safe, and successful alternative to the standard method of insertion.

Fashioning esophagogastric anastomosis in robotic Ivor-Lewis esophagectomy: a multicenter experience.

BACKGROUND: The aim of the present study is to compare outcomes of the robotic hand-sewn, linear- and circular-stapled techniques performed to create an intrathoracic esophagogastric anastomosis in patients who underwent Ivor-Lewis esophagectomy. METHODS: Patients who underwent a planned Ivor-Lewis esophagectomy were retrospectively analysed from prospectively maintained databases. Only patients who underwent a robotic thoracic approach with the creation of an intrathoracic esophagogastric anastomosis were included in the study. Patients were divided into three groups: hand-sewn-, circular stapled-, and linear-stapled anastomosis group. Demographic information and surgery-related data were extracted. The primary outcome was the rate of anastomotic leakages (AL) in the three groups. Moreover, the rate of grade A, B and C anastomotic leakage were evaluated. In addition, patients of each group were divided in subgroups according to the characteristics of anastomotic fashioning technique. RESULTS: Two hundred and thirty patients were enrolled in the study. No significant differences were found between the three groups about AL rate (p = 0.137). Considering the management of the AL for each of the three groups, no significant differences were found. Evaluating the correlation between AL rate and the characteristics of anastomotic fashioning technique, no significant differences were found. CONCLUSIONS: No standardized anastomotic fashioning technique has yet been generally accepted. This study could be considered a call to perform ad hoc high-quality studies involving high-volume centers for upper gastrointestinal surgery to evaluate what is the most advantageous anastomotic technique.

Blood flow evaluation of reconstructed gastric tube in esophageal surgery using near-infrared imaging and retrospective time-intensity curve analysis.

PURPOSE: Near-infrared fluorescence imaging using indocyanine green (ICG-NIFI) can visualize a blood flow in reconstructed gastric tube; however, it depends on surgeon's visual assessment. The aim of this study was to re-analyze the ICG-NIFI data by an evaluator independent from the surgeon and feasibility of creating the time-intensity curve (TIC). METHODS: We retrospectively reviewed 97 patients who underwent esophageal surgery with gastric tube reconstruction between January 2017 and November 2022. From the stored ICG videos, fluorescence intensity was examined in the four regions of interest (ROIs), which was set around the planned anastomosis site on the elevated gastric tube. After creation the TICs using the OpenCV library, we measured the intensity starting point and time constant and assessed the correlation between the anastomotic leakage. RESULTS: Postoperative leakage occurred for 12 patients. The leakage group had significantly lack of blood flow continuity between the right and left gastroepiploic arteries (75.0% vs. 22.4%; P < 0.001) and tended to have slower ICG visualization time assessed by the surgeon's eyes (40 vs. 32 s; P = 0.066). TIC could create in 65 cases. Intensity starting point at all ROIs was faster than the surgeon's assessment. The leakage group tended to have slower intensity starting point at ROI 3 compared to those in the non-leakage group (22.5 vs. 19.0 s; P = 0.087). CONCLUSION: A TIC analysis of ICG-NIFI by an independent evaluator was able to quantify the fluorescence intensity changes that the surgeon had visually determined.

Impact of intraoperative fluid management on postoperative complications in patients undergoing minimally invasive esophagectomy for esophageal cancer: a retrospective single-center study.

BACKGROUND: Esophagectomy is a high-risk procedure that can involve serious postoperative complications. There has been an increase in the number of minimally invasive esophagectomies (MIEs) being performed. However, the relationship between intraoperative management and postoperative complications in MIE remains unclear. METHODS: After the institutional review board approval, we enrolled 300 patients who underwent MIE at Tohoku University Hospital between April 2016 and March 2021. The relationships among patient characteristics, intraoperative and perioperative factors, and postoperative complications were retrospectively analyzed. The primary outcome was the relationship between intraoperative fluid volume and anastomotic leakage, and the secondary outcomes included the associations between other perioperative factors and postoperative complications. RESULTS: Among 300 patients, 28 were excluded because of missing data; accordingly, 272 patients were included in the final analysis. The median [interquartile range] operative duration was 599 [545-682] minutes; total intraoperative infusion volume was 3,747 [3,038-4,399] mL; total infusion volume per body weight per hour was 5.48 [4.42-6.73] mL/kg/h; and fluid balance was + 2,648 [2,015-3,263] mL. The postoperative complications included anastomotic leakage in 68 (25%) patients, recurrent nerve palsy in 91 (33%) patients, pneumonia in 62 (23%) patients, cardiac arrhythmia in 13 (5%) patients, acute kidney injury in 5 (2%) patients, and heart failure in 5 (2%) patients. The Cochrane-Armitage trend test indicated significantly increased anastomotic leakage among patients with a relatively high total infusion volume (P = 0.0085). Moreover, anastomotic leakage was associated with male sex but not with peak serum lactate levels. Patients with a longer anesthesia duration or recurrent nerve palsy had a significantly higher incidence of postoperative pneumonia than those without. Further, the incidence of postoperative pneumonia was not associated with the operative duration, total infusion volume, or fluid balance. The operative duration and blood loss were related to the total infusion volume. Acute kidney injury was not associated with the total infusion volume or serum lactate levels. CONCLUSIONS: Among patients who underwent MIE, the total infusion volume was positively correlated with the incidence of anastomotic leakage. Further, postoperative pneumonia was associated with recurrent nerve palsy but not total infusion volume or fluid balance.

Surgical treatment of esophago-tracheobronchial fistulas after esophagectomy.

The aim of this study was to evaluate the surgical treatment of esophago-tracheobronchial fistulas (ETBFs) that occurred after esophagectomy with gastric conduit reconstruction in a tertiary referral center for esophageal surgery. All patients who underwent surgical repair for an ETBF after esophagectomy with gastric conduit reconstruction were included in a tertiary referral center. The primary outcome was successful recovery after surgical treatment for ETBF, defined as a patent airway at 90 days after the surgical fistula repair. Secondary outcomes were details on the clinical presentation, diagnostics, and postoperative course after fistula repair. Between 2007 and 2022, 14 patients who underwent surgical repair for an ETBF were included. Out of 14 patients, 9 had undergone esophagectomy with cervical anastomosis and 5 esophagectomy with intrathoracic anastomosis after which 13 patients had developed anastomotic leakage. Surgical treatment consisted of thoracotomy to cover the defect with a pericardial patch and intercostal flap in 11 patients, a patch without interposition of healthy tissue in 1 patient, and fistula repair via cervical incision with only a pectoral muscle flap in 2 patients. After surgical treatment, 12 patients recovered (86%). Mortality occurred in two patients (14%) due to multiple organ failure. This study evaluated the techniques and outcomes of surgical repair of ETBFs following esophagectomy with gastric conduit reconstruction in 14 patients. Treatment was successful in 12 patients (86%) and generally consisted of thoracotomy and coverage of the defect with a bovine pericardial patch followed by interposition with an intercostal muscle.

Management of esophageal anastomotic leaks, a systematic review and network meta-analysis.

There is currently no consensus as to how to manage esophageal anastomotic leaks. Intervention with endoscopic vacuum-assisted closure (EVAC), stenting, reoperation, and conservative management have all been mooted as potential options. To conduct a systematic review and network meta-analysis (NMA) to evaluate the optimal management strategy for esophageal anastomotic leaks. A systematic review was performed as per the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) guidelines with extension for NMA. NMA was performed using R packages and Shiny. In total, 12 retrospective studies were included, which included 511 patients. Of the 449 patients for whom data regarding sex was available, 371 (82.6%) were male, 78 (17.4%) were female. The average age of patients was 62.6 years (standard deviation 10.2). The stenting cohort included 245 (47.9%) patients. The EVAC cohort included 123 (24.1%) patients. The conservative cohort included 87 (17.0%) patients. The reoperation cohort included 56 (10.9%) patients. EVAC had a significantly decreased complication rate compared to stenting (odds ratio 0.23 95%, confidence interval [CI] 0.09;0.58). EVAC had a significantly lower mortality rate than stenting (odds ratio 0.43, 95% CI 0.21; 0.87). Reoperation was used in significantly larger leaks than stenting (mean difference 14.66, 95% CI 4.61;24.70). The growing use of EVAC as a first-line intervention in esophageal anastomotic leaks should continue given its proven effectiveness and significant reduction in both complication and mortality rates. Surgical management is often necessary for significantly larger leaks and will likely remain an effective option in uncontained leaks with systemic features.

The Therapeutic Effect of Laparoscopic Combined with Plasma Electric Cutting Knife on Patients with Rectal Cancer and its Impact on Serum Inflammatory Factors: A Retrospective Study.

Objective: This study investigated the therapeutic effect of laparoscopic surgery combined with the plasma electric cutting knife on patients diagnosed with rectal cancer and its impact on serum inflammatory factors in the bloodstream. Methods: The researchers examined the clinical data of 85 patients who underwent laparoscopic low anterior resection for rectal cancer in our hospital from April 2020 to December 2021. The patients comprised two groups: an observation group of 40 cases and a control group of 45 cases. The CD3+, CD4+, CD8+, and CD4+/CD8+ levels in both groups were detected using flow cytometry. The levels of relevant inflammatory factors in serum were measured using an automatic biochemical analyzer. The researchers then compared the perioperative outcomes between the two groups. Results: The observation group demonstrated significantly shorter duration for the first time passing gas after surgery (P = .029) and hospital stays (P = .002) than the control group. Both groups experienced decreased levels of CD8+ cells following treatment, with the observation group exhibiting lower levels than the control group (P < .05). After three months of treatment, both groups showed reduced levels of relevant serum inflammatory factors, TNF-α, IL-1, IL-6, and IL-8; however, the observation group was significantly lower than the control group with statistical significance (P < .05). Similarly, after three months of treatment, both groups exhibited lower levels of relevant serum electrolytes K+, Na+, and Cl-, with the observation group having lower levels than the control group (P < .05). Throughout the 12-month follow-up period, the two groups had no significant differences (P > .05) in complications such as urinary tract infection, anastomotic leakage, or anastomotic bleeding. Conclusion: Using a combination of laparoscopic techniques and a plasma electric cutting knife proved a highly effective surgical approach in treating rectal cancer. The method has numerous advantages, such as enhanced safety and few complications. When considering perioperative complications, it was evident that laparoscopic combined with the plasma electric cutting knife surpassed other surgical methods in treating rectal cancer.

Technical outcomes of robotic-assisted surgery versus laparoscopic surgery for rectal tumors: a single-center safety and feasibility study.

PURPOSE: Robot-assisted surgery has a multi-joint function, which improves manipulation of the deep pelvic region and contributes significantly to perioperative safety. However, the superiority of robot-assisted surgery to laparoscopic surgery remains controversial. This study compared the short-term outcomes of laparoscopic and robot-assisted surgery for rectal tumors. METHODS: This single-center, retrospective study included 273 patients with rectal tumors who underwent surgery with anastomosis between 2017 and 2021. In total, 169 patients underwent laparoscopic surgery (Lap group), and 104 underwent robot-assisted surgery (Robot group). Postoperative complications were compared via propensity score matching based on inverse probability of treatment weighting (IPTW). RESULTS: The postoperative complication rates based on the Clavien-Dindo classification (Lap vs. Robot group) were as follows: grade ≥ II, 29.0% vs. 19.2%; grade ≥ III, 10.7% vs. 5.8%; anastomotic leakage (AL), 6.5% vs. 4.8%; and urinary dysfunction (UD), 12.1% vs. 3.8%. After adjusting for the IPTW method, although AL rates did not differ significantly between groups, postoperative complications of both grade ≥ II (odds ratio [OR] 0.66, 95% confidence interval [CI] 0.50-0.87, p < 0.01) and grade ≥ III (OR 0.29, 95% CI 0.16-0.53, p < 0.01) were significantly less frequent in the Robot group than in the Lap group. Furthermore, urinary dysfunction also tended to be less frequent in the Robot group than in the Lap group (OR 0.62, 95% CI 0.38-1.00; p = 0.05). CONCLUSION: Robot-assisted surgery for rectal tumors provides better short-term outcomes than laparoscopic surgery, supporting its use as a safer approach.