New clinical insights into the treatment of benign uretero-ileal anastomotic stricture following radical cystectomy and urinary diversion.

BACKGROUND: Benign uretero-ileal anastomotic stricture (UIAS) is a potentially serious complication that can arise after radical cystectomy (RC) and subsequent urinary diversion. To preserve residual renal function and improve prognosis, it is crucial to derive insights from experience and tailor individualized treatment strategies for different patients. PATIENTS AND METHODS: From October 2014 to June 2021, a total of 47 patients with benign UIAS underwent endoscopic management (n = 19) or reimplantation surgery (n = 28). The basic data, perioperative conditions, and postoperative outcomes of the two groups were compared and analyzed to evaluate efficacy. RESULTS: Comparing preoperative and postoperative clinical efficacy within the same group, the endoscopic group showed no significant differences in creatinine and blood urea nitrogen (BUN) levels before surgery or after extubation (p > 0.05). However, significant differences were observed in glomerular filtration rate (GFR) levels on the affected side before surgery and after extubation (p < 0.05). In contrast, the laparoscopic reimplantation group did not exhibit significant differences in creatinine, BUN, or GFR levels of affected side before surgery and after extubation (p > 0.05). Postoperative clinical efficacy showed no significant difference in creatinine and BUN levels between the two groups (p > 0.05). However, GFR values of affected side in the endoscopic treatment group decreased more than those in the laparoscopic reimplantation group (p < 0.05). Additionally, the laparoscopic reimplantation group was able to remove the single-J tube earlier than the endoscopic treatment group (p < 0.05), had a lower recurrence rate of hydronephrosis after extubation (p < 0.05), and experienced a later onset of hydronephrosis compared to the endoscopic treatment group (p < 0.05). CONCLUSIONS: Based on our experience in treating UIAS following RC combined with urinary diversion, laparoscopic reimplantation effectively addresses the issue of UIAS, allowing for the removal of the ureteral stent relatively soon after surgery. This approach maintains long-term ureteral patency, preserves residual renal function, reduces the risk of ureteral restenosis and hydronephrosis, and has demonstrated superior therapeutic outcomes in this study.

Artery Grafting for Arterial Anastomoses in Head and Neck Free Tissue Transfer Reconstruction.

BACKGROUND: Vessel grafting is an important technique in head and neck free tissue transfer (FTT) reconstruction when a tension-free anastomosis is not otherwise feasible. To our knowledge, there are limited data regarding interposition artery grafts for arterial anastomoses in head and neck reconstruction. Here, we present a multi-institutional cohort of arterial interposition grafts for FTT reconstruction for head and neck defects. METHODS: A retrospective review was conducted at four tertiary care institutions for patients who underwent FTT reconstruction for head and neck defects which utilized an interposition artery graft for the arterial anastomosis. Charts were reviewed for type and length of artery grafts harvested, surgical indication, indication for artery graft, types of flaps harvested, and various preoperative characteristics (including history of radiation or previous FTT reconstruction surgery). Postoperative complications within postoperative day 30 were measured and reported. RESULTS: Nine patients met inclusion criteria. The lateral circumflex femoral artery (either transverse or descending branches) (n = 3) and facial artery (n = 3) were the most commonly harvested arteries. The scalp (n = 5) was the most common primary defect site. Seven grafts were harvested initially and in a planned fashion, while two were harvested as salvage techniques (either for flap salvage or vein graft failure). In planned grafts, arteries were the preferred interposition grafting method due to either size match preferences (n = 4) or similarities in wall thickness (n = 3) between graft and recipient artery. There were no reported cases of unplanned readmission, postoperative hematoma, fistula formation, wound infection, or donor site morbidities. Two patients required unplanned return to the operating room for flap compromise, both of which ultimately resulted in flap failure secondary to clot formation at both arterial and venous anastomoses. CONCLUSIONS: When arterial pedicle length is insufficient, interposition artery grafting is both a feasible and viable technique to achieve tension-free arterial anastomoses for select cases of highly complex head and neck free tissue reconstruction.

Potential of the Thoracoepigastric Vein as a Drainage Vein in Breast Reconstruction With a Free Flap: An Anatomical Study Using Computed Tomography.

BACKGROUND: The recipient vessel choice is very important when performing free-flap breast reconstructions. Usually, the concomitant vein of the recipient artery is anastomosed, and mismatches in the diameter are occasionally observed. We consider the thoracoepigastric vein (TEV) as a potential useful recipient vein. The use of the TEV is not a novel technique. It has been used by surgeons for free-flap anastomoses in the axillary region, but usually as an anastomotic site for the second vein. However, anatomical findings such as TEV diameter, its deficiency rate, and influence on mastectomy are not clear. In this study, computed tomography (CT) was performed to evaluate the use of the TEV as a recipient vein for breast reconstruction. METHODS: The medical records of patients who underwent breast reconstruction with free-flap transfer were retrospectively evaluated. In most cases, CT was performed using a tissue expander inserted after mastectomy. The TEV was considered suitable if its diameter on the mastectomy side was >1 mm and the vertical distance from the most distal slice level where the TEV could be seen at the third costal cartilage height of the parasternal region was <50 mm. RESULTS: Sixty-six sides of 33 patients were evaluated. The mean age of the patients was 49.3 ± 5.1 years. The TEV was used in five flaps. TEV diameters were not significantly different between the left and right sides (1.85 ± 0.53 vs. 1.82 ± 0.6, respectively, p = 0.836). On the mastectomy side, eight (25%) TEVs were injured, but only three (8.6%) were considered unavailable. On the healthy side, 96.4% TEVs were available. CONCLUSIONS: TEVs may be a good choice as vein anastomosis targets for breast reconstruction with a free flap because of their relatively large vessel diameter. TRIAL REGISTRATION: UMIN-CTR: R000061573.

EFFICACY AND SAFETY OF ONE ANASTOMOSIS GASTRIC BYPASS IN SURGICAL TREATMENT OF OBESITY: SYSTEMATIC REVIEW AND META-ANALYSIS OF RANDOMIZED CONTROLLED TRIALS.

BACKGROUND: One anastomosis gastric bypass (OAGB) has gained prominence in the search for better results in bariatric surgery. However, its efficacy and safety compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) remain ill-defined. AIMS: To compare the efficacy and safety of OAGB relative to RYGB and SG in the treatment of obesity. METHODS: We systematically searched PubMed, EMBASE, Cochrane Library, Lilacs, and Google Scholar databases for randomized controlled trials comparing OAGB with RYGB or SG in the surgical approach to obesity. We pooled outcomes for body mass index, percentage of excess weight loss, type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease. Statistical analyses were performed with R software (version 4.2.3). RESULTS: Data on 854 patients were extracted from 11 randomized controlled trials, of which 422 (49.4%) were submitted to OAGB with mean follow-up ranging from six months to five years. The meta-analysis revealed a significantly higher percentage of excess weight loss at 1-year follow-up and a significantly lower body mass index at 5-year follow-up in OAGB patients. Conversely, rates of type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease were not significantly different between groups. The overall quality of evidence was considered very low. CONCLUSIONS: Our results corroborate the comparable efficacy of OAGB in relation to RYGB and SG in the treatment of obesity, maintaining no significant differences in type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease rates.

Role of the serosa in intestinal anastomotic healing: insights from in-depth histological analysis of human and murine anastomoses.

BACKGROUND: Anastomotic leakage following colorectal surgery remains a significant complication despite advances in surgical techniques. Recent findings on serosal injury repair in coelomic cavities, such as the peritoneum, challenge the current understanding of the cellular origins and mechanisms underlying intestinal anastomotic healing. Understanding the contribution of each layer of the intestinal wall during anastomotic healing is needed to find new therapeutic strategies to prevent anastomotic leakage. The aim of this experimental study was to investigate the role of the serosal layer of the intestinal wall in anastomotic healing. MATERIALS AND METHODS: Comprehensive histologic analysis of human and murine anastomoses was performed to elucidate histologic changes in the different intestinal layers during anastomotic healing. In vivo staining of the extracellular matrix (ECM) in the serosal layer was performed using a fluorophore-conjugated N-hydroxysuccinimide-ester before anastomosis surgery in a murine model. RESULTS: Histological examination of both human and murine anastomoses revealed that closure of the serosal layer occurred first during the healing process. In vivo serosal ECM staining demonstrated that a significant portion of the newly formed ECM within the anastomosis was indeed deposited onto the serosal layer. Furthermore, mesenchymal cells within the anastomotic scar were positive for mesothelial cell markers, podoplanin and Wilms tumour protein. CONCLUSIONS: In this experimental study, the results suggest that serosal scar formation is an important mechanism for anastomotic integrity in intestinal anastomoses. Mesothelial cells may significantly contribute to scar formation during anastomotic healing through epithelial-to-mesenchymal transition, potentially suggesting a novel therapeutic target to prevent anastomotic leakage by enhancing physiological healing processes.

The Grade C Pancreatic Fistula.

Grade C pancreatic fistulas are associated with severe morbidity and a significant risk of mortality. High-risk pancreatic anastomoses can be predicted to allow best practice fistula mitigation techniques. In these high-risk glands, any deviation from a stable postoperative clinical course should prompt early computed tomography and aggressive, percutaneous drainage of the operative bed. If salvage surgery is necessary, drainage of the operative bed and/or external diversion of pancreatic juice via stenting while completion pancreatectomy should be avoided. Senior mentorship in the perioperative period offers an opportunity to decrease this complication even in early career surgeons.

Renal Transplant in a Child With the Donor Kidney Having 2 Renal Arteries.

Kidney transplant has become the preferred renal replacement therapy for children with end-stage renal disease. The results of kidney transplant have improved enormously due to advances in organ procurement, organ preservation, surgical techniques, and immunosuppressive regimens. Renal transplant is a more cost-effective method versus hemodialysis and provides better quality of life. Kidney allografts with multiple renal arteries are not uncommon and have been associated with a higherrisk to develop vascular and urologic complications. We report a case of a pediatric transplant recipient of donor kidney with 2 renal arteries. A 14-year-old female child (16 kg) diagnosed with end-stage renal disease presented to our hospital for renal transplant. The child's mother agreed to donate one of her kidneys. The mother's renal angiogram revealed 2 bilateral renal arteries. End-to-side anastomosis of the renal artery to the common iliac artery was performed. Postoperative recovery was normal. Postoperative color Doppler ultrasonography revealed normal blood flow in both the renal arteries. Double renal arteries in the donor kidney should not be a contraindication for transplant in a child. The outcome in such cases is excellent and similar to cases with a single renal artery.

Construction and Surgical Training of Coronary Anastomosis on a Low-Cost Portable Simulator: Experience in a Peruvian Multicenter Study.

INTRODUCTION: The operating room is no longer the ideal place for early surgica training of cardiothoracic surgery residents, forcing the search for simulation-based learning options. The study's aim was the construction and surgicaltraining of coronary anastomosis in a portable, low-cost, homemade simulator. METHODS: This is an observational, analytical, and multicenter study. The simulator was built with common materials and was evaluated with the Objective Structured Assessment ofTechnical Skills (or OSATS) Modified. All junior and senior residents from nine national cardiothoracic surgery centers were considered for 90 days. Operative skill acquisition and time in the creation of side-to-side (S-T-S), end-to-side (E-T-S), and end-to-end (E-T-E) coronary anastomoses were evaluated. All sessions were recorded and evaluated by a single senior cardiothoracic surgeon during two time periods. RESULTS: One hundred and forty residents were assessed in 270 sessions. In junior residents, a significant improvement in final scores was identified in S-T-S (use of Castroviejo needle holder, needle angles, and needle transfer) (P<0.05). In seniors, a significant improvement was identified in S-T-S (graft orientation, appropriate spacing, use of forceps, angles, and needle transfer) anastomoses (P<0.05). A significant improvement in the final anastomosis time of senior residents over junior residents was identified in S-T-S (8.11 vs. 11.22 minutes), E-T-S (7.93 vs. 10.10 minutes), and E-T-E (6.56 vs. 9.68 minutes) (P=0.039). CONCLUSION: Our portable and low-cost coronary anastomosis simulator is effective in improving operative skills in cardiothoracic surgery residents; therefore, skills acquired through simulation-based training transfer have a positive impact on the surgical environment.

Robotic purse-string suture technique for intracorporeal anastomosis using double-stapling technique in robotic resection of rectal and sigmoid colon cancer: a propensity score-matched analysis.

BACKGROUND: Robotic three-dimensional magnified visual effects and field of view stabilization have enabled precise surgical operations. Intracorporeal anastomosis in right-sided colorectal cancer surgery is expected to shorten operation times, avoid paralytic ileus, and shorten wound lengths; however, there are few reports of intracorporeal anvil fixation for intestinal anastomosis in left-sided colorectal cancer surgery. Herein, we introduce a simple, novel procedure for using robotic purse-string suture (RPSS) in intracorporeal anastomosis with the double-stapling technique in rectal and sigmoid cancer surgery and report short-term outcomes. METHODS: From September 2022 to April 2024, 105 consecutive patients underwent robotic surgery with double-stapling technique anastomosis for rectal or sigmoid colon cancer at our institution. Their data were retrospectively analyzed. Intracorporeal anastomosis with the double-stapling technique using RPSS was performed in 26 patients (the RPSS group), while the double-stapling technique anastomosis with extracorporeal anvil fixation was performed in 79 patients (the EC group). A 1:1 propensity score-matched analysis was performed (matching criteria: sex, age, body mass index (BMI), tumor location and tumor size) using a caliper 0.3. In the RPSS group, after tumor-specific or total mesorectal excision, specimens were extracted from the umbilical wound with simultaneous anvil placement in the body cavity. The oral colonic stump was robotically excised and robotically circumferentially stitched with 3-0 Prolene in all layers. After anvil insertion into the stump, the bowel wall of the colon was completely sewn onto the central rod of the anvil. Reconstructions were anastomosed using the double-stapling technique. RESULTS: The matched cohort contained 23 patients in each group. The RPSS group had significantly less bleeding than the EC group (p = 0.038). Super-low anterior resection (SLAR) in the RPSS group had shorter total operative times than those in the EC group (p = 0.045). The RPSS group experienced no perioperative complications greater than Clavien-Dindo grade III or any anastomosis-related complications. CONCLUSIONS: The RPSS technique can be performed safely without any anastomosis-related complications and reduces the total operative times in SLAR and blood loss through total robotic surgery. This may be a useful modality for robotic colorectal surgery.

Magnamosis improves the healing of gastrojejunal anastomosis and down-regulates TGF-ß1 and HIF-1α in rats.

This study elucidated the unique pathological features of tissue healing by magnamosis and revealed the changes in landmark molecule expression levels related to collagen synthesis and tissue hypoxia. Forty-eight male Sprague-Dawley rats were divided into the magnamosis and suture anastomosis groups, and gastrojejunal anastomosis surgery was performed. Rats were dissected at 6, 24, and 48 h and 5, 6, 8, 10, and 12 days postoperatively. Hematoxylin, eosin, and Masson's trichrome staining were used to evaluate granulation tissue proliferation and collagen synthesis density at the anastomosis site. Immunohistochemistry was used to measure TGF-ß1 and HIF-1α expression levels. Magnamosis significantly shortened the operation time, resulting in weaker postoperative abdominal adhesions (P < 0.0001). Histopathological results showed a significantly lower granulation area in the magnamosis group than in the suture anastomosis group (P = 0.0388), with no significant difference in the density of collagen synthesis (P = 0.3631). Immunohistochemistry results indicated that the magnamosis group had significantly lower proportions of TGF-ß1-positive cells at 24 (P = 0.0052) and 48 h (P = 0.0385) postoperatively and HIF-1α-positive cells at 24 (P = 0.0402) and 48 h postoperatively (P = 0.0005). In a rat model of gastrojejunal anastomosis, magnamosis leads to improved tissue healing at the gastrojejunal anastomosis, associated with downregulated expression levels of TGF-ß1 and HIF-1α.

Assessment of Combined Resection-Anastomosis and Urethropexy in Dogs with Urethral Prolapse.

The literature regarding surgical repair of urethral prolapse in dogs is limited and associated with a high recurrence rate. We hypothesized that combined resection and anastomosis (R&A) with urethropexy would be associated with less recurrence of urethral prolapse compared with R&A alone. Medical records of dogs managed surgically for urethral prolapse were reviewed (2013-2023) from three tertiary care hospitals. Inclusion criteria included complete medical records, including surgery reports, short-term postoperative complications, and longer-term follow-up. Forty-six male dogs successfully met the inclusion criteria (16 castrated; 30 intact). Brachycephalic breeds were overrepresented (37/46, 80%). Surgical repair by R&A alone (n = 27), urethropexy alone (n = 6), or a combined R&A and urethropexy (n = 13) was performed. Recurrence rates for these techniques were 13/27 (48%), 2/6 (33%), and 1/13 (8%), respectively. The recurrence rate of urethral prolapse treated by a combined R&A and urethropexy was significantly lower (P < .05) than R&A alone, despite more dogs being overweight and less surgeon experience (each P < .05). Interestingly, dogs neutered before initial diagnosis may be more likely to have postoperative recurrence. Considering general anesthesia risks, an initial combination procedure for urethral prolapse may help prevent recurrence.

Totally Intracorporeal Robot-Assisted Bilateral Ileal Ureter Replacement for the Treat-ment of Ureteral Strictures using Kangduo Surgical Robot 2000 Plus.

PURPOSE: Ureteroplasty using buccal or lingual mucosa graft Is feasible for complex proximal ureteral stricture (1, 2). Ileal ureter replacement is considered as the last resort for ureteral reconstruction. Totally intracorporeal robot-assisted ileal ureter replacement can be performed safely and effectively (3). In China, the KangDuo Surgical Robot 2000 Plus (KD-SR-2000 Plus) has been developed featuring two surgeon consoles and five robotic arms. This study aims to share our experience with totally intracorporeal robot-assisted bilateral ileal ureter replacement using KD-SR-2000 Plus. MATERIALS AND METHODS: A 59-year-old female patient underwent a complete intracorporeal robot-assisted bilateral ileal ureter replacement for the treatment of ureteral strictures using KD-SR-2000 Plus. The surgical procedure involved dissecting the proximal ends of the bilateral ureteral strictures, harvesting the ileal ureter, restoring intestinal continuity, and performing an anastomosis between the ileum and the ureteral end as well as the bladder. The data were prospectively collected and analyzed. RESULTS: The surgery was successfully completed with single docking without open conversion. The length of the harvested ileal ureter was 25 cm. The docking time, operation time and console time were 3.4 min., 271 min and 231 min respectively. The estimated blood loss was 50 mL. The postoperative hospitalization was 6 days. No perioperative complications occurred. CONCLUSIONS: It is technically feasible to perform totally intracorporeal robot-assisted bilateral ileal ureter replacement for the treatment of ureteral strictures using KD-SR-2000 Plus. A longer follow-up and a larger sample size are required to evaluate its safety and effectiveness.

Grade III Varicocele Surgical Treatment using Spermatic Vein-Superficial Abdominal Vein Shunt.

Microsurgical varicocelectomy is the most commonly used method for the treatment of varicocele (VC) in recent years. However, it is technically demanding with the risk of damaging the normal anatomical structure of the spermatic cord, such as the cremaster muscle, testicular artery, and vas deferens during the pampiniform plexus ligation. Also, traditional varicocelectomy hinders the drainage of the stagnant venous blood of the affected testicle, resulting in a persistent scrotal appearance of varicose veins and slower remission of swelling sensation in postoperative patients with grade III VC. Therefore, we developed a retroperitoneal varicocelectomy with a microscopical spermatic venous-superficial vein of the abdominal wall bypass procedure. The spermatic vein was transected and ligated proximally through the retroperitoneal space. Then, the distal spermatic vein was freed and passed through the internal ring; under the skin of the groin, a microscopic vascular anastomosis was performed to build the bypass of the distal spermatic vein and proximal inferior epigastric vein. The high ligation facilitates the protection of the normal anatomy of the spermatic cord, and the venous bypass allows rapid testicular blood drainage, which can effectively improve the degree of varicocele, testicular pain, and even spermatogenic function. In conclusion, the present protocol describes a promising way to reconstruct the spermatic return through high retroperitoneal ligation of the spermatic vein and anastomosis of the spermatic vein-inferior epigastric vein, which resulted in faster and more obvious improvement in symptoms and better prognosis of grade III VC.