Jejunal gastrointestinal stromal tumor (GIST) with profound anemia.

Gastrointestinal stromal tumors (GISTs) are uncommon tumors typically found in the stomach, with an even rarer appearance in the jejunum. These tumors are often discovered incidentally, given their nonspecific presentation. We present a case of chronic iron deficiency anemia in a patient with symptomatic GIST involving the proximal jejunum requiring robot-assisted resection with primary anastomosis. Pathological examination of the excised GIST revealed positive immunoreactivity for cKIT, DOG1, and CD37. This case highlights the importance of considering GIST as a differential diagnosis for chronic anemia and emphasizes the critical role of CT imaging in its detection and management.

Comparison Between Primary Anastomosis Without Diverting Stoma and Hartmann's Procedure for Colorectal Perforation: A Retrospective Observational Study.

Background Hartmann's procedure (HP) is performed for colorectal perforation to avoid the risk of anastomotic leakage. Few reports have compared the safety between primary anastomosis without diverting stoma (PAWODS) and HP for colorectal perforation, and whether PAWODS or HP should be performed has remained controversial. We aimed to investigate the feasibility and safety of performing PAWODS in comparison to HP for colorectal perforation. Methods The data of 97 consecutive patients with colorectal perforation who underwent surgery from April 2010 to December 2020 were collected retrospectively. PAWODS and HP were performed in 51 and 46 patients, respectively. Univariate and multivariate analyses were performed to compare the clinical characteristics and postoperative outcomes of patients treated with PAWODS with those treated with HP. Results In the multivariate analysis, low serum albumin (hazard ratio (HR)=3.49; 95%CI=1.247-9.757; P=0.017) and left-sided colon and rectum perforation (HR=16.8; 95%CI=1.792-157.599; P=0.014) were significantly associated with the decision to perform HP. There was a significant difference in the mortality of the two groups (PAWODS vs. HP: 0% vs. 8.7%; P=0.047). The severe morbidity rate (Clavien-Dindo III-V) was significantly higher in the HP group (PAWODS vs. HP: 10% vs. 30%; P=0.020). In the PAWODS group, anastomotic leakage occurred in five of 51 patients (9.8%), four (8.7%) of whom required re-operation. Conclusions In appropriately selected patients, PAWODS could be safely performed with an acceptable rate of anastomotic leakage. The serum albumin level and site of perforation may be simple and useful factors for guiding decision-making on the surgical procedure.

Successful Salvage of Partial Gastric Conduit Necrosis by Primary Anastomosis in a Post-Esophagectomy Patient.

Gastric conduit necrosis is a rare but severe complication of esophageal surgery, often associated with mediastinal sepsis and high morbidity and mortality rates, as well as reduced efficacy of conservative treatments. In most cases, management involves salvage therapy, including fluid resuscitation, antibiotics, aggressive debridement, drainage of infected collections, and proximal esophageal diversion. Primary anastomosis is rarely performed. We describe a successful case wherein we salvaged a patient following a McKeown esophagectomy and gastric pull-up, who developed partial full-thickness necrosis of the gastric conduit postoperatively, along with pleural and mediastinal sepsis. We managed this situation through thoracic debridement, take-down of the anastomosis, resection of the devitalized segment of the conduit, and primary esophagogastric anastomosis. Conduit perfusion was demonstrated using ICG fluorescent angiography. This case illustrates that, once debridement and sepsis control are achieved, a primary anastomosis, if feasible, can be safely performed, potentially avoiding a two-step procedure and a second laparotomy/thoracotomy.

Analysis of gap length as a predictor of surgical outcomes in esophageal atresia with distal fistula: a single center experience.

PURPOSE: Long-gap esophageal atresia (LGEA) is still a challenge for pediatric surgery. No consensus exists as to what constitutes a long gap, and few studies have investigated the maximum gap length safely repairable by primary anastomosis. Based on surgical outcomes at a single institution, we aimed to determine the gap length in LGEA with a high risk of complications. METHODS: The medical records of 51, consecutive patients with esophageal atresia (EA) with primary repair in the early neonatal period between 2001 and 2021 were retrospectively reviewed. Three, major complications were found in the surgical outcomes: (1) anastomotic leakage, (2) esophageal stricture requiring dilatation, and (3) GERD requiring fundoplication. The predictive power of the postsurgical complications was assessed using receiver operating characteristic analysis, and the area under the curve (AUC) and the cutoff value with a specificity of > 90% were calculated. RESULTS: Sixteen patients (31.4%) experienced a complication. The AUC of gap length was0.90 (p < 0.001), and the gap length cutoff value was ≥ 2.0 cm for predicting any complication (sensitivity: 62.5%, specificity: 91.4%). CONCLUSION: A gap length ≥ 2.0 cm was considered as defining LGEA and was associated with an extremely high complication rate after primary repair.

Long-gap esophageal atresia: gastric transposition or esophageal lengthening with delayed primary anastomosis? A systematic review.

PURPOSE: This study aims to evaluate different surgical approaches to long-gap esophageal atresia (LGEA) with or without tracheoesophageal fistula (TEF) is unclear. METHODS: A systematic literature review was done comparing gastric transposition versus esophageal lengthening with delayed primary anastomosis in infants with LGEA+/-TEF. The primary outcome was time to full oral feeds. Secondary outcomes were time to full enteric feeds, need for further surgery, growth, mortality, and postoperative adverse events. RESULTS: No comparative studies were found. However, the literature was re-interrogated for non-comparative studies. Four hundred thirty-eight articles were identified and screened, and 18 met the inclusion criteria. All were case series. Forty-three infants underwent gastric transposition, and 106 had esophageal lengthening with delayed primary anastomosis. One study on gastric transposition reported time to full oral feeds, and one study in each group reported growth. Time to full enteric feeds was reported in one study in each group. 30% of infants had further surgery following gastric transposition, including hiatus hernia repair (5/43, 12%) and esophageal dilation (7/43, 16%). Following esophageal lengthening, 62/106 (58%) had anti-reflux surgery, 58/106 (55%) esophageal dilatation and 11/106 (10%) esophageal stricture resection. Anastomotic complications occurred in 13/43 (30%), gastrointestinal in 16/43 (37%), respiratory in 17/43 (40%), and nerve injury in 2/43 (5%) of the gastric transposition group. In the esophageal lengthening group, anastomotic complications occurred in 68/106 (64%), gastrointestinal in 62/106 (58%), respiratory in 6/106 (6%), and none sustained nerve injury. Each group had one death due to a cause not directly related to the surgical procedure. CONCLUSIONS: This systematic review highlights the morbidity associated with both surgical procedures and the variety in reporting outcomes.

Goodbye Hartmann trial: a prospective, international, multicenter, observational study on the current use of a surgical procedure developed a century ago.

BACKGROUND: Literature suggests colonic resection and primary anastomosis (RPA) instead of Hartmann's procedure (HP) for the treatment of left-sided colonic emergencies. We aim to evaluate the surgical options globally used to treat patients with acute left-sided colonic emergencies and the factors that leading to the choice of treatment, comparing HP and RPA. METHODS: This is a prospective, international, multicenter, observational study registered on ClinicalTrials.gov. A total 1215 patients with left-sided colonic emergencies who required surgery were included from 204 centers during the period of March 1, 2020, to May 31, 2020. with a 1-year follow-up. RESULTS: 564 patients (43.1%) were females. The mean age was 65.9 ± 15.6 years. HP was performed in 697 (57.3%) patients and RPA in 384 (31.6%) cases. Complicated acute diverticulitis was the most common cause of left-sided colonic emergencies (40.2%), followed by colorectal malignancy (36.6%). Severe complications (Clavien-Dindo ≥ 3b) were higher in the HP group (P < 0.001). 30-day mortality was higher in HP patients (13.7%), especially in case of bowel perforation and diffused peritonitis. 1-year follow-up showed no differences on ostomy reversal rate between HP and RPA. (P = 0.127). A backward likelihood logistic regression model showed that RPA was preferred in younger patients, having low ASA score (≤ 3), in case of large bowel obstruction, absence of colonic ischemia, longer time from admission to surgery, operating early at the day working hours, by a surgeon who performed more than 50 colorectal resections. CONCLUSIONS: After 100 years since the first Hartmann's procedure, HP remains the most common treatment for left-sided colorectal emergencies. Treatment's choice depends on patient characteristics, the time of surgery and the experience of the surgeon. RPA should be considered as the gold standard for surgery, with HP being an exception.

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent? / Cirugía de control de daños en lesiones combinadas de intestino delgado y colon en trauma penetrante: ¿Es pertinente el uso de ostomías?

Abstract Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Resumen El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.

Damage control in penetrating duodenal trauma: less is better - the sequel / El control de daños en trauma penetrante de duodeno: "Menos es Mejor

Abstract The overall incidence of duodenal injuries in severely injured trauma patients is between 0.2 to 0.6% and the overall prevalence in those suffering from abdominal trauma is 3 to 5%. Approximately 80% of these cases are secondary to penetrating trauma, commonly associated with vascular and adjacent organ injuries. Therefore, defining the best surgical treatment algorithm remains controversial. Mild to moderate duodenal trauma is currently managed via primary repair and simple surgical techniques. However, severe injuries have required complex surgical techniques without significant favorable outcomes and a consequential increase in mortality rates. This article aims to delineate the experience in the surgical management of penetrating duodenal injuries via the creation of a practical and effective algorithm that includes basic principles of damage control surgery that sticks to the philosophy of "Less is Better". Surgical management of all penetrating duodenal trauma should always default when possible to primary repair. When confronted with a complex duodenal injury, hemodynamic instability, and/or significant associated injuries, the default should be damage control surgery. Definitive reconstructive surgery should be postponed until the patient has been adequately resuscitated and the diamond of death has been corrected.

Resumen El trauma de duodeno comúnmente se produce por un trauma penetrante que puede asociarse a lesiones vasculares y de órganos adyacentes. En el manejo quirúrgico se recomienda realizar un reparo primario o el empleo de técnicas quirúrgicas simples. Sin embargo, el abordaje de lesiones severas del duodeno es un tema controversial. Anteriormente, se han descrito técnicas como la exclusión pilórica o la pancreatoduodenectomía con resultados no concluyentes. El presente artículo presenta una propuesta del manejo de control de daños del trauma penetrante de duodeno, a través, de un algoritmo de cinco pasos. Este algoritmo plantea una solución para el cirujano cuando no es posible realizar el reparo primario. El control de daños del duodeno y su reconstrucción depende de una toma de decisiones respecto a la porción del duodeno lesionada y el compromiso sobre el complejo pancreatoduodenal. Se recomiendan medidas rápidas para contener el daño y se proponen vías de reconstrucción duodenal diferente a las clásicamente descritas. Igualmente, la probabilidad de complicaciones como fistula duodenales es considerable, por lo que proponemos, que el manejo de este tipo de fistulas de alto gasto se aborde por medio de una laparostomía retroperitoneal (lumbotomía). El abordaje del trauma penetrante de duodeno se puede realizar a través del principio "menos es mejor".

The Usefulness of Intraoperative Colonic Irrigation and Primary Anastomosis in Patients Requiring a Left Colon Resection

PURPOSE: The aim of this study is to assess the short-term outcome of intraoperative colonic irrigation and primary anastomosis and to suggest the usefulness of the procedure when a preoperative mechanical bowel preparation is inappropriate. METHODS: This retrospective study included 38 consecutive patients (19 male patients) who underwent intraoperative colonic irrigation and primary anastomosis for left colon disease between January 2010 and December 2016. The medical records of the patients were reviewed to evaluate the patients' characteristics, operative data, and postoperative short-term outcomes. RESULTS: Twenty-nine patients had colorectal cancer, 7 patients had perforated diverticulitis, and the remaining 2 patients included 1 with sigmoid volvulus and 1 with a perforated colon due to focal colonic ischemia. A diverting loop ileostomy was created in 4 patients who underwent a low anterior resection. Complications occurred in 15 patients (39.5%), and the majority was superficial surgical site infections (18.4%). Anastomotic leakage occurred in one patient (2.6%) who underwent an anterior resection due sigmoid colon cancer with obstruction. No significant difference in overall postoperative complications and superficial surgical site infections between patients with obstruction and those with peritonitis were noted. No mortality occurred during the first 30 postoperative days. The median hospital stay after surgery was 15 days (range, 8–39 days). CONCLUSION: Intraoperative colonic irrigation and primary anastomosis seem safe and feasible in selected patients. This procedure may reduce the burden of colostomy in patients requiring a left colon resection with an inappropriate preoperative mechanical bowel preparation.

Procedimiento de Hartmann vs resección y anastomosis primaria en peritonitis diverticular de colon izquierdo por cirugía abierta: revisión sistemática de la literatura / Hartmann’s procedure and resection with primary anastomosis in diverticular peritonitis

Introduction: colonic diverticulosis, as diverticulitis, is a frequent disease in different stages of evolution. There is uncertainty about treatment options that are used in secondary peritonitis. The aim of this study is to determine the best treatment option for patients with peritonitis secondary to diverticulitis of the left colon in terms of postoperative morbidity (POM) and mortality, comparing Hartmann's procedure (HP) and resection with primary anastomosis (RPA). Material and Methods: systematic review. Studies in adults with peritonitis secondary to diverticulitis of the left colon treated with HP and RPA published between 1990 and 2011 were analyzed. TRIPDATABSE, IWO, MEDLINE, SciELO and LILACS databases were consulted and search strategies were applied using MeSH and free terms. Selected studies were analyzed using a score of methodological quality (MQ). The following variables were considered: mortality, POM, hospital stay, percentage of bowel transit reconstitution in patients undergoing HP and MQ of primary studies. Results: 26 primary studies were analyzed (47 series). There were no significant differences in the variable mortality (p = 0.0805), but significant difference was observed in POM (incompletely reported) (p = 0.0187). The median of MQ of the studies was 11 points for HP series and 10 for RPA series. Conclusion: the available evidence to determine the best treatment option in terms of mortality and POM in this kind of patients is insufficient. Studies with better level evidence and MQ are needed to clarify the uncertain.

Introducción: la enfermedad diverticular del colon es una entidad frecuente, como también la diverticulitis en sus diferentes estadios de evolución. Existe incertidumbre respecto de las opciones terapéuticas que se utilizan en el tratamiento de la peritonitis diverticular de colon izquierdo (PDCI). El objetivo de este estudio es determinar la mejor opción de tratamiento para pacientes con PDCI entre procedimiento de Hart-mann (PH) y resección con anastomosis primaria (RAP), en términos de mortalidad y morbilidad postoperatoria (MPO). Material y Método: revisión sistemática de la literatura. Se analizaron estudios realizados en adultos con PDCI tratados con PH y RAP, publicados entre 1990 y 2011. Se consultó en las bases de datos TRIPDATABSE, IWO, MEDLINE, SciELO y LILACS, utilizando estrategias de búsqueda con términos MeSH, palabras libres y operadores booleanos. Los estudios seleccionados fueron analizados mediante un escore de calidad metodológica (CM). Se consideraron las variables mortalidad, MPO, estadía hospitalaria, porcentaje de reconstitución de tránsito en pacientes sometidos a PH y CM de los estudios primarios. Resultados: se analizaron 26 estudios primarios (47 series de pacientes). No se encontraron diferencias significativas respecto de la variable mortalidad (p = 0,0805); pero sí en la variable MPO, reportada de forma incompleta (p = 0,0187). La mediana de la CM de los estudios primarios fue de 11 puntos para las series de PH y de 10 para las de RAP. Conclusión: la evidencia disponible no permite determinar la mejor alternativa terapéutica en términos de mortalidad y MPO en este tipo de pacientes. Se requieren estudios de mejor nivel de evidencia y CM para aclarar esta incertidumbre.

Anastomosis primaria en enterocolitis necrotizante / Primary anastomosis in necrotizing enterocolitis

Introduction: Necrotizing Enterocolitis (NE) is the most frequent gastrointestinal emergency among newborns (NB). Thirty percent of them require surgical treatment, with resection of the damaged intestinal segment and stoma formation. In some cases, primary resection and anastomosis can be considered. Objective: To review the use of primary anastomosis on NE in 2 pediatric centers, one public hospital and one private clinic. Patients and Method: A retrospective, descriptive study of all NB with NE managed with primary anastomosis at Hospital Exequiel González Cortés y Clínica Las Condes between December 2004 and december 2009. The population was divided into Group A: Unifocal, and Group B: Multifocal intestinal involvement. The following variables were evaluated and compared: gestational age, weight, use of peritoneal drains, characteristics of the resected segment, number of anastomoses, requirement of parenteral nutrition, postoperatory complications. Results: Sixty NB were surgically repaired with primary anastomosis. 12 percent presented birth weight <1.000grams, 22 percent between 1000-1500 grams. In 18 patients 2 anastomoses were performed in different intestinal segments. Postoperatory complications included wound infection in 3 cases and dehiscence of the anastomosis in 1 case. 7 percent evolved with short loop syndrome. Mortality was 11,6 percent, secondary to sepsis. Conclusions: In this experience, Primary Anastomosis in NE appears to be a safe option, with low morbimortality despite the age, weight, IP contamination or extension of the disease.

Introducción: Enterocolitis Necrotizante (ECN) es la emergencia gastrointestinal más común del recién nacido (RN), 30 por ciento requiere tratamiento quirúrgico, con resección del segmento intestinal dañado, realizando luego una ostomía en la mayoría. En recientes casos la resección intestinal y anastomosis primaria han sido reportados en forma exitosa. Objetivo: Evaluar la experiencia del manejo con anastomosis primaria en ECN en 2 centros pediátricos, un Hospital público y una Clínica privada. Pacientes y Método: Estudio descriptivo retrospectivo. Se incluyó a RN del Hospital Exequiel González Cortés y Clínica Las Condes con ECN manejados con anastomosis primaria, entre diciembre de 2004 y diciembre de 2009. Se dividieron en Grupo A: Unifocal; Grupo B: Compromiso intestinal multifocal. Se comparó entre ambos grupos: edad gestacional, peso, utilización de drenajes peritoneales, características del segmento resecado, número de anastomosis, requerimientos de nutrición parenteral, complicaciones postoperatorias. Resultados: Se sometió a cirugía con anastomosis primaria a 60 recién nacidos. El peso de nacimiento fue < 1 000 g en el 12 por ciento, 1 000-1 500 g el 22 por ciento, y el resto >1 500 g. En 18 pacientes del grupo B se realizaron 2 anastomosis en segmentos intestinales diferentes. Las complicaciones postoperatorias fueron infección de herida operatoria (n:3) y dehiscencia de anastomosis (n:1). Un 7 por ciento evolucionó con síndrome de intestino corto. La mortalidad fue 11,6 por ciento, en todos los casos secundaria a sepsis. Conclusiones: En esta experiencia la Anastomosis Primaria en ECN aparece como una opción segura, con baja morbimortalidad independiente de la edad, peso, contaminación intraperitoneal o extensión de la enfermedad.

The Necessity for Mechanical Bowel Preparation before Colonic Resection and Primary Anastomosis

BACKGROUND: The results of recent reports suggest that mechanical bowel preparation before colonic resection and primary anastomosis may be unnecessary. To determine whether mechanical bowel preparation influences the incidence of postoperative complications following colorectal surgery, the records of patients who had undergone colonic or rectal resection were retrospectively reviewed. METHODS: Between March 1992 and October 1997, colonic resection and primary anastomosis without colostomy was performed on 56 patients. Among these, 27 patients had undergone mechanical bowel preparation (MBP) before surgery, and 29 patients had not. We compared the data from both groups with respect to wound infection, anastomotic leak, intra-abdominal sepsis and death. RESULTS: The postoperative complication and mortality rates were similar in the two groups. Wound infection occurred in seven patients (four with MBP, three without), and the incidence of wound infection was similar in the two groups (14.8% versus 10.3%, P=0.700). Wound disruption occurred in two patients (one with MBP, one without). Anastomotic leaks occurred in two patients who had undergone bowel preparation. The overall anastomotic leak rate was 3.6% (7.4% versus 0%), but the incidence of anastomotic leaks was not significantly different between the two groups (P=0.228). No intra-abdominal sepsis was clinically apparent in either group. There was one death, a patient who had undergone bowel preparation. The mortality rate was not significantly different between the two groups (P=0.482). CONCLUSIONS: We believe that mechanical bowel preparation before colonic resection and primary anastomosis may be unnecessary, so routine MBP should be further scrutinized.