Modern surgery for Crohn's disease: When to divert, impact of biologics on infectious complications, and surgical techniques to decrease post-operative recurrence of Crohn's disease.

Crohn's disease is a complex condition that confers a significant risk of requiring multiple surgeries. Questions that surgeons must frequently answer include: which patients benefit from diversion? Does monoclonal antibody therapy increase post-operative complications? And, are there surgical techniques that can prevent the recurrence of Crohn's disease? This review examines current data to answer these questions.

Exploring the supremacy of microvascular coupling devices for arterial anastomosis in terms of added expeditiousness, safety concerns: A systematic review.

Background: Arterial anastomoses are still most commonly performed using orthodox hand sewing technique. Various rationale such as non-pliable, atherosclerotic, thick-walled or irradiated vessels limit the competency of coupler devices for arterial micro-anastomosis. Microvascular coupling devices (MCD) are well known for venous anastomoses but arterial MCD have relatively been less navigated in reported literatures. This review outlines the current applications, troubleshooting, safety and efficiency of arterial MCD in free flaps. Methods: Comprehensive search of electronic databases (PUBMED/MEDLINE) in accordance with PRISMA guideline was performed. Data were extracted and collected in four groups of standardised variables. Results: Out of a total of 263 identified articles, 38 studies were analysed and 16 amidst these were included in final data synthesis. Included studies contained a combined total of 2416 patients who went through 521 arterial and 2460 venous anastomoses using 3 M/Synovis coupling devices. Among all coupled arterial anastomoses, 407 were conducted in head and neck free tissue transfer and 114 were performed in breast reconstruction. The aggregate coupled arterial micro-anastomosis success rate reported was 90.01 % (469/521). Only 9.98 % (52 out of 521) manifested pooled incidence of troubleshooting, thrombosis or flap failure. Conclusion: Microsurgeons are resisting the frequent use of arterial coupling devices owing to inherent arterial characteristics, but with suitable vessel selection, arterial coupling may be a powerful tool and can be executed in safe, expeditious and reliable fashion. This study embellishes collaborative suggestions and troubleshooting issues related to arterial coupling, however further assessment would be required with controlled trials.

Milestones in the History of Esophagectomy: From Torek to Minimally Invasive Approaches.

The history of esophagectomy reflects a journey of dedication, collaboration, and technical innovation, with ongoing endeavors aimed at optimizing outcomes and reducing complications. From its early attempts to modern minimally invasive approaches, the journey has been marked by perseverance and innovation. Franz J. A. Torek's 1913 successful esophageal resection marked a milestone, demonstrating the feasibility of transthoracic esophagectomy and the potential for esophageal cancer cure. However, its high mortality rate posed challenges, and it took almost two decades for similar successes to emerge. Surgical techniques evolved with the left thoracotomy, right thoracotomy, and transhiatal approaches, expanding the indications for resection. Mechanical staplers introduced in the early 20th century transformed anastomosis, reducing complications. The advent of minimally invasive techniques in the 1990s aimed to minimize complications while maintaining oncological efficacy. Robot-assisted esophagectomy further pushed the boundaries of minimally invasive surgery. Collaborative efforts, particularly from the Worldwide Esophageal Cancer Collaboration and the Esophageal Complications Consensus Group, standardized reporting and advanced the understanding of outcomes. The introduction of risk prediction models aids in making informed decisions. Despite significant improvements in survival rates and postoperative mortality, anastomotic leaks remain a concern, with recent rates showing an increase. Prevention strategies include microvascular anastomosis and ischemic preconditioning, yet challenges persist.

Persistent descending mesocolon as a vital risk factor for anastomotic failure and prolonged operative time for sigmoid colon and rectal cancers.

BACKGROUND: The diagnostic criteria and effect of persistent descending mesocolon (PDM) on sigmoid and rectal cancers (SRCs) remain controversial. This study aims to clarify PDM patients' radiological features and short-term surgical results. METHOD: From January 2020 to December 2021, radiological imaging data from 845 consecutive patients were retrospectively analyzed using multiplanar reconstruction (MRP) and maximum intensity projection (MIP). PDM is defined as the condition wherein the right margin of the descending colon is located medially to the left renal hilum. Propensity score matching (PSM) was used to minimize database bias. The anatomical features and surgical results of PDM patients were compared with those of non-PDM patients. RESULTS: Thirty-two patients with PDM and 813 patients with non-PDM were enrolled into the study who underwent laparoscopic resection. After 1:4 matching, patients were stratified into PDM (n = 27) and non-PDM (n = 105) groups. The lengths from the inferior mesenteric artery (IMA) to the inferior mesenteric vein (1.6 cm vs. 2.5 cm, p = 0.001), IMA to marginal artery arch (2.7 cm vs. 8.4 cm, p = 0.001), and IMA to the colon (3.3 cm vs. 10.2 cm, p = 0.001) were significantly shorter in the PDM group than those in the non-PDM group. The conversion to open surgery (11.1% vs. 0.9%, p = 0.008), operative time (210 min vs. 163 min, p = 0.001), intraoperative blood loss (50 ml vs. 30 ml, p = 0.002), marginal arch injury (14.8% vs. 0.9%, p = 0.006), splenic flexure free (22.2% vs. 3.8%, p = 0.005), Hartmann procedure (18.5% vs. 0.0%, p < 0.001) and anastomosis failure (18.5% vs. 0.9%, p = 0.001) were significantly higher in the PDM group. Moreover, PDM was an independent risk factor for prolonged operative time (OR = 3.205, p = 0.004) and anastomotic failure (OR = 7.601, p = 0.003). CONCLUSION: PDM was an independent risk factor for prolonged operative time and anastomotic failure in SRCs surgery. Preoperative radiological evaluation using MRP and MIP can help surgeons better handle this rare congenital variant.

Does Intestinal Peristalsis Cause Suture Failure After Instrument Suture?

BACKGROUND/AIM: Gastrectomy with lymphadenectomy is a standard treatment for gastric cancer. Anastomotic leakage remains a potentially fatal complication of gastrectomy. Forceful stapler extraction may cause anastomotic complications. We focused on the duodenal peristalsis, as we hypothesized that it might cause forceful stapler extraction. We then retrospectively investigated duodenal peristalsis and reviewed videos of Da Vinci system cases to clarify the relationship between peristalsis and anastomotic complications. PATIENTS AND METHODS: Forty-nine cases with stored videos of laparoscopic surgery using the Da Vinci system from 2015 to March 2021 were included. Peristalsis was defined by repeated contraction and expansion that was clearly visible three or more times in a row. The duodenum was investigated because it is frequently observed during gastrectomy. Suture failure was evaluated in cases with and without peristalsis. RESULTS: The study population included 49 patients [male, n=32; female, n=17; median age, 71 (42-82) years]. Duodenal peristalsis was observed in 14 (28.6%) cases. Three patients experienced complications. A comparative study of cases with and without complications showed significant peristalsis in cases with complications (p=0.0198). CONCLUSION: A new definition to evaluate duodenal peristalsis was established. Anastomotic complications were significantly more frequent in cases with peristalsis (p=0.0198). Our results suggest the utility of manual over-sewing or the use of reinforcement material.

Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era.

BACKGROUND: Intestinal anastomoses in military settings are performed in severely injured patients who often undergo damage control laparotomy in austere environments. We describe anastomotic outcomes of patients from recent wars. METHODS: Military personnel with combat-related intra-abdominal injuries (June 2009-December 2014) requiring laparotomy with resection and anastomosis were analyzed. Patients were evacuated from Iraq or Afghanistan to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals. RESULTS: Among 341 patients who underwent 1053 laparotomies, 87 (25.5%) required ≥1 anastomosis. Stapled anastomosis only was performed in 57.5% of patients, while hand-sewn only was performed in 14.9%, and 9.2% had both stapled and hand-sewn techniques (type unknown for 18.4%). Anastomotic failure occurred in 15% of patients. Those with anastomotic failure required more anastomoses (median 2 anastomoses, interquartile range [IQR] 1-3 vs. 1 anastomosis, IQR 1-2, P = .03) and more total laparotomies (median 5 laparotomies, IQR 3-12 vs. 3, IQR 2-4, P = .01). There were no leaks in patients that had only hand-sewn anastomoses, though a significant difference was not seen with those who had stapled anastomoses. While there was an increasing trend regarding surgical site infections (SSIs) with anastomotic failure after excluding superficial SSIs, it was not significant. There was no difference in mortality. DISCUSSION: Military trauma patients have a similar anastomotic failure rate to civilian trauma patients. Patients with anastomotic failure were more likely to have had more anastomoses and more total laparotomies. No definitive conclusions can be drawn about anastomotic outcome differences between hand-sewn and stapled techniques.

Intracorporeal gastrojejunostomy in Roux-en-Y reconstruction with its efferent loop located on the patient's left side following totally laparoscopic distal gastrectomy: A case report.

The drawback of intracorporeal gastrojejunostomy using only endoscopic linear staplers in antecolic Roux-en-Y (R-Y) reconstruction with its efferent loop located on the patient's left side following totally laparoscopic distal gastrectomy (TLDG) is the occurrence of anastomotic failure, even though this reconstruction system is assumed to prevent intraoperative and postoperative twisting of the gastrojejunostomy and lifted jejunum. This case report presents two patients with gastric cancer who underwent intracorporeal gastrojejunostomy consisting of linear stapling and hand suturing in antecolic R-Y reconstruction with its efferent loop located on the patient's left side following TLDG to prevent anastomotic failure of the gastrojejunostomy. After the sacrificed jejunum was created, linear stapling of the greater curvature of the remnant stomach and the lifted jejunum without dividing the jejunum was performed. After removing the sacrificed jejunum and creating a good view of the posterior side of the stapler entry hole, the stapler entry hole was closed from the posterior side to the anterior side, using a single-layer full-thickness and serosubmucosal hand suturing technique with knotted sutures and a knotless barbed suture. No anastomotic failure of the gastrojejunostomy occurred in either patient. Intracorporeal gastrojejunostomy consisting of linear stapling and hand suturing could be an option for gastrojejunostomy in antecolic R-Y reconstruction with its efferent loop located on the patient's left side following TLDG because it can aid in the prevention of anastomotic failure.

Axillary pullout syndrome: A novel approach to managing a devastating complication.

OBJECTIVES: Axillary pullout syndrome is a complex, potentially fatal complication following axillary-femoral bypass graft creation. The re-operative nature, in addition to ongoing hemorrhage, makes for a complicated and potentially morbid repair. METHODS: We present the case of a 57-year-old man with history of a previous left axillary-femoral-femoral bypass who presented with acute limb-threatening ischemia as a result of bypass thrombosis managed with a right axillary-femoral bypass for limb salvage. His postoperative course was complicated by an axillary anastomotic dehiscence while recovering in inpatient rehabilitation resulting in acute, life-threatening hemorrhage. He was managed utilizing a novel hybrid approach in which a retrograde stent graft was initially placed across the anastomotic dehiscence for control of hemorrhage. He then underwent exploration, decompression, and interposition graft repair utilizing the newly placed stent graft to reinforce the redo axillary anastomosis. RESULTS AND CONCLUSION: Compared with a traditional operative approach, the hybrid endovascular and open approach limited ongoing hemorrhage while providing a more stable platform for repair and graft revascularization. A hybrid approach to the management of axillary pullout syndrome provides a safe, effective means to the management of axillary anastomotic dehiscence while minimizing the morbidity of ongoing hemorrhage.

The impact of gastrointestinal anastomotic leaks on survival of patients undergoing cytoreductive surgery and heated intraperitoneal chemotherapy.

BACKGROUND: Gastrointestinal (GI) leaks after cytoreductive surgery and hyperthermic Intraperitoneal Chemotherapy (CRS/HIPEC) is a known life-threatening complication that may alter patients' outcomes. Our aim is to investigate risk factors associated with GI leaks and evaluate the impact of GI leaks on patient's oncological outcomes. METHODS: A retrospective analysis of perioperative and oncological outcomes of patients with and without GI leaks after CRS/HIPEC. RESULTS: Out of 191 patients included in this study, GI leaks were identified in 17.8% (34/191) of patients. Small bowel anastomoses were the most common site (44%). Most of the GI leaks were managed conservatively and re-operation was needed in 44.1% of cases. Univariate analysis identified higher PCI (p = 0.03), higher number of packed cells transfused (p = 0.036), pelvic peritonectomy (p = 0.013), high number of anastomoses (p = 0.003) and colonic resection (p = 0.042) as factors associated with GI leaks. Multivariate analysis identified stapled anastomoses (OR 2.59, p = 0.001) and pelvic peritonectomy (OR 2.33, p = 0.044) as independent factors associated with GI leaks. Disease-free survival tended to be worse in the leak group but did not reach statistical significance (p = 0.235). The 3- and 5-year OS was 73.2% and 52.9% in the leak group compared to 75.8% and 73.2% in the non-leak group (p = 0.236). CONCLUSIONS: GI leak showed no impact on overall and disease free survival after CRS/HIPEC.Avoidance of stapled reconstruction in high risk patients with high tumor burden and large number of anastomoses may yield improved outcomes.

Microvascular anastomotic arterial coupling: A systematic review.

INTRODUCTION: There are several reasons microsurgeons may not use a coupler device in arterial anastomosis: may be thick-walled, non-pliable due to atherosclerotic calcification or present vessel geometrical discrepancies. This review summarises the current applications, efficacy and troubleshooting of microvascular coupler devices in arterial end-to-end anastomosis. METHODS: A systematic review of the literature was performed in November 2020 across 4 electronic databases and in accordance with the PRISMA guidelines. All studies comprised the data synthesis that reported the use of a microvascular coupler device for arterial end-to-end anastomosis. Data were extracted and collected in three groups of standardised variables: study, anastomosis-related and technical characteristics. RESULTS: Out of the 7,690 articles identified, 20 were included in the final data synthesis. Included studies involved a total of 1639 patients, who underwent 670 arterial and 1,124 venous anastomoses. Out of all arterial anastomoses, 351 were performed in free tissue transfers in head and neck, 117 in breast, 4 in upper extremity and 5 in lower extremity reconstruction, whereas the remaining were not specified. The total arterial coupler anastomosis success rate reported was 92.1% (617/670). Fifty-three (8%) arterial anastomoses were reported to result in either troubleshooting events or intra- or post-operative failures, most being reported in extremity reconstructions. CONCLUSIONS: Arterial coupling is not widespread with predominant use in head and neck and chest reconstructions, and total reported efficacy of 92.1%. Microsurgeons are reluctant to routinely use current widespread coupler devices as a result of inherent arterial characteristics. This study delivered collective recommendations, 'do's and don'ts' of microvascular arterial coupling.

How to reduce anastomotic leakage in colorectal surgery-report from German expert meeting.

AIMS: Anastomotic leakage is one of the most worrisome complications in colorectal surgery. An expert meeting was organized to discuss and find a consensus on various aspects of the surgical management of colorectal disease with a possible impact on anastomotic leakage. METHODS: A three-step Delphi-method was used to find consensus recommendations. RESULTS: Strong consensus was achieved for the use of mechanical bowel preparation and oral antibiotics prior to colorectal resections, the abundance of non-selective NSAIDs, the preoperative treatment of severe iron deficiency anemia, and for attempting to improve the patients' general performance in the case of frailty. Concerning technical aspects of rectal resection, there was a strong consensus in regard to routinely mobilizing the splenic flexure, to dividing the inferior mesenteric vein, and to using air leak tests to check anastomotic integrity. There was also a strong consensus on not to oversew the stapled anastomoses routinely, to use protective ileostomies for low rectal and intersphincteric, but not for high-rectal anastomoses. Furthermore, a consensus was reached in regard to using CT-scans with rectal contrast enema to evaluate suspected anastomotic leakage as well as measuring C-reactive protein routinely to monitor the postoperative course after colorectal resections. No consensus was found concerning the indication and technique for testing bowel perfusion, the routine use of endoscopy to check the integrity of the anastomosis, the placement of transanal drains for rectal anastomoses and the management of anastomotic leakage with peritonitis. CONCLUSION: Consensus could be found for several practice details in the perioperative management in colorectal surgery that might have an influence on anastomotic leakage.

Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis.

PURPOSE: Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients. METHODS: Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up. RESULTS: A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80-480 minutes), and the median blood loss was 80 mL (range, 30-1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444). CONCLUSION: In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.

[Meta-analysis of management of colorectal anastomotic leakage]. / Meta-analiz metodov lecheniia nesostoiatel'nosti kolorektal'nogo anastomoza.

AIM: To identify the most effective management of colorectal anastomosis failure via analysis of available literature sources. RESULTS: Systematic review included 20 original trials. Effectiveness of redo interventions for colorectal anastomosis failure including open, laparoscopic, minimally invasive techniques (transanal drainage, endoscopic vacuum therapy, endoscopic drainage) was described. Anastomotic failure rate was 6.5%. Medication was effective in 57% (95% CI 34-77%) of cases. Redo open surgery was applied in 43% (95% CI 23-66%) of patients. Postoperative mortality was 21-27%. Redo laparoscopic procedure was performed in 61% (95% CI 50-70%) of cases for anastomotic failure after previous laparoscopy, incidence of conversion was 12% (95% CI 4-28%). Transanal drainage was effective in 85% (95% CI 61-94%) of cases, endoscopic vacuum therapy - in 82% (95% CI 74-87%), healing of anastomosis without need for colostomy was achieved in 16% (95% CI 9-26%) of cases. Endoscopic clipping for colorectal anastomotic defect was effective in 73.3-77% of cases. CONCLUSION: Redo surgery for anastomotic failure is associated with advanced mortality and need for permanent colostomy. Laparoscopic approach reduces incidence of complications after redo surgery and followed by better functional outcomes. Minimally invasive procedures are advisable for colorectal anastomosis failure without need for redo surgery. However, effectiveness of these methods is controversial due to few reports and no comparative trials.

[Prevention of colorectal anastomotic leakage by using of intraoperative fluorescent angiography: prospective trial data]. / Primenenie intraoperatsionnoi fliuorestsentnoi angiografii v kachestve metoda profilaktiki nesostoiatel'nosti kolorektal'nogo anastomoza: rezul'taty prospektivnogo issledovaniia.

AIM: To evaluate the effect of intraoperative fluorescent angiography on the incidence of colorectal anastomosis failure. MATERIAL AND METHODS: Prospective, non-comparative study included 52 patients with rectal or sigmoid cancer who underwent surgery with stapled colorectal anastomosis. Intraoperative fluorescent angiography with indocyanine green was performed to determine colon perfusion. All patients underwent proctography with water-soluble contrast agent in 6-8 days after surgery in order to determine anastomotic leakage. RESULTS: Fluorescent angiography was followed by changed volume of proximal colectomy in 14 (27%) patients due to inadequate blood supply of intestinal wall at previous surgical level. Additionally, 1-5 cm of intestinal wall were excised. Postoperative anastomotic leakage occurred in 3 (5.8%) patients. CONCLUSION: Fluorescent angiography with indocyanine green is accompanied by reduced incidence of anastomotic failure in colorectal suregry.

Anastomotic Failure in Colorectal Surgery: Where Are We at?

Anastomotic leak (AL) can be a devastating complication in colorectal surgery. While it is less frequent in the modern era, it still results in significant morbidity and mortality, prolonged hospital stays and increases the costs and demands on health services. There is inevitable interplay between patient physiology and technical factors that predispose a patient to AL. Obesity, preoperative total proteins, male gender, ongoing anticoagulant treatment, intraoperative complication and number of hospital beds have been identified as independent risk factors. This has led to an online risk calculator for AL. Non-steroidal anti-inflammatory drugs and neoadjuvant chemoradiotherapy have also been implicated, but no significant evidence has yet been found to support causation. In addition, technical factors such as type of anastomosis, mechanical bowel preparation, drains, omentoplasty and faecal diversion have failed to show significant differences in AL rates. Early diagnosis and intervention in AL is essential in reducing the rates of morbidity and mortality. Clinical assessment has high sensitivity but low specificity and should be used in combination with imaging techniques to get a diagnosis. C-reactive protein is also a useful marker. The management will depend on the grade of AL and the clinical state of the patient. Management options include conservative measures such as antibiotics and/or percutaneous drainage to more invasion procedures such as open drainage and/or Hartmann's procedure. In conclusion, ALs will forever pose challenges to the surgeon in diagnosis and management. It is often the yardstick by which each surgeon is measured and is the source of significant morbidity to patients and health care services worldwide. As a result, a low threshold for investigation and intervention is mandatory to ensure better outcomes and lower overall mortality and morbidity.

Stented Pancreatico-duodenectomy: Does it lead to decreased pancreatic fistula rates? A prospective randomized study.

OBJECTIVE: To compare clinically relevant pancreatic fistula rates in patients with stented versus non-stented pancreatico-jejunostomies. METHODS: The randomised comparative clinical trial was conducted at Civil Hospital, Karachi, from September 2009 to August 2015, and comprised patients presenting to the Surgical Unit 4 with a diagnosis of resectable periampullary carcinoma, carcinoma of head of pancreas, duodenal carcinoma involving the second part, and distal cholangiocarcinomas. Pancreatic fistula or leakage was defined as amylase-rich fluid lasting over 5 days, collected from the peripancreatic drains on day 1, 3 and 7 postoperatively, and the rate of clinically relevant fistulas was taken as primary study endpoint. RESULTS: There were 102 patients with a male to female ratio of 2.4:1. The overall mean age was 53.16±12.11 years (range: 30-80 years). Of the total, 53(51.9%) patients had pancreatic duct stent and 49(48%) did not. Clinically relevant pancreatic leak was seen in 13(12.7%) patients of whom 8(61.5%) were stented (p=0.46), 9(69.2%) patients had soft pancreatic texture (p=0.54) and 7(53.8%) had pancreatic duct <3mm (p=0.11). CONCLUSIONS: Pancreatic fistula rates between stented and non-stented anastomosis did not show any significant difference.

Clinical Outcomes of a Redo for a Failed Colorectal or Coloanal Anastomosis

PURPOSE: Redo surgery in patients with a persistent anastomotic failure (PAF) is a rare procedure, and data about this procedure are lacking. This study aimed to evaluate the surgical outcomes of redo surgery in such patients. METHODS: Patients who underwent a redo anastomosis for PAF from January 2004 to November 2016 were retrospectively evaluated. Data from a prospective colorectal database were analyzed. Success was defined as the combined absence of any anastomosis-related complications and a stoma at the last follow-up. RESULTS: A total of 1,964 patients who underwent curative surgery for rectal cancer during this study period were included. Among them, 32 consecutive patients underwent a redo anastomosis for PAF. Thirteen patients of those 32 had major anastomotic dehiscence with a pelvic sinus, 12 had a recto-vaginal fistula, and 7 had anastomosis stenosis. There were no postoperative deaths. The median operation time was 255 minutes (range, 80–480 minutes), and the median blood loss was 80 mL (range, 30–1,000 mL). The overall success rate was 78.1%, and the morbidity rate was 40.6%. Multivariable analyses showed that the primary tumor height at the lower level was the only statistically significant risk factor for redo surgery (P = 0.042; hazard ratio, 2.444). CONCLUSION: In our experience, a redo anastomosis is a feasible surgical option that allows closure of a stoma in nearly 80% of patients. Lower tumor height (<5 cm from the anal verge) is the only independent risk factor for nonclosure of defunctioning stomas after primary rectal surgery.

Técnica con indocianina verde (ICG) como predictor de la falla de sutura: inicio de la experiencia en nuestro medio / Technical indocyanine green (ICG) as a predictor of suture failure

Objetivo: Valorar en el intraoperatorio en tiempo real, el flujo sanguíneo de los cabos anastomóticos y la anastomosis. El objetivo final de este trabajo busca que este sea el inicio de un estudio prospectivo, con el fin de auditar las anastomosis colónicas de forma intraoperatoria buscando así disminuir el número de fallas de suturas. Material y método: Se realizó un estudio prospectivo, observacional y descriptivo, desarrollado en el Hospital de Clínicas en el período comprendido entre enero de 2014 y julio 2015. Se incluyeron en el mismo pacientes sometidos a resección de colon y reconstrucción primaria del tránsito intestinal de coordinación. El indocianina verde (ICG) se empleó como colorante vital fluorescente para la valoración in situ de la anastomosis colónica. La presencia de falla de sutura en el postoperatorio en relación con la perfusión anastomótica objetivada con ICG constituye un parámetro de importancia en nuestro estudio. Resultados: En lo referente a la perfusión de la anastomosis, destacamos que en el primer caso la misma fue sensiblemente inferior en el cabo colónico, en tanto que en los 2 casos restantes la vascularización de los cabos fue óptima. Conclusiones: La técnica con ICG constituye una herramienta apropiada para poder auditar la calidad de las anastomosis intestinales realizadas de coordinación. Se trata de una técnica segura, aplicable en nuestro medio. Siendo un predictor de falla de sutura, permite un descenso de la morbimortalidad postoperatoria por esta causa.

Aim: Rate intraoperatively in real time, blood flow and ends anastomotic and anastomosis. The ultimate goal of this work seeks to make this the beginning of a prospective study in order to audit the colonic anastomosis intraoperatively and seeking to reduce the number of sutures failure. Material and method: A prospective, observational and descriptive study, to be held in the Clinics Hospital in the period between January 2014 and July 2015. They were included in the same patients undergoing resection of colon and intestinal transit reconstruction on primary coordination. Indocyanine green (ICG) was used as a fluorescent vital dye for in situ evaluation of colonic anastomosis. The presence of failure postoperative suture relative to the anastomotic objectified perfusion with ICG, is an important parameter in our study.Results:Regarding the perfusion of the anastomosis, in the first case it was significantly lower than in the colonic out. While in the remaining two cases the vascularization of the ends was optimal. Conclusions: The technique with indocyanine green is an appropriate tool to audit the quality of intestinal anastomoses performed coordination.

Low anterior resection combined with a covering stoma in the treatment of rectal cancer reduces the risk of permanent anastomotic failure.

PURPOSE: The adoption of the total mesorectum excision technique and circular stapler devices has enabled the performance of ultralow colorectal anastomosis in rectal cancer surgery. However, rupture of the anastomosis still usually leads to a permanent stoma. The aim of this study was to analyze the cumulative failure rate and risk factors associated with reversal of colorectal or coloanal anastomosis after sphincter-saving surgery for rectal cancer, using standardized surgical regimen with the routine use of covering stoma. Our secondary interest was the feasibilities of redo surgery after failure. METHODS: This was a retrospective study with 579 consecutive rectal cancer patients operated on at Helsinki University Hospital, Helsinki, Finland during 2005-2011. Data were collected from patient records. After exclusions, 273 consecutive patients treated with a low anterior resection with a protective stoma were included. RESULTS: In total, 23 out of 271 (8.5 %) of the colorectal/coloanal anastomoses were converted to a permanent stoma. In five patients (1.8 %), the covering stoma was not closed. The permanent stoma rate was thus 28 out of 271 (10.3 %). The risk factors associated with failure were the tumor distance from the anal verge (p = 0.03), coloanal anastomosis (p = 0.003), early anastomotic complication (p < 0.001), anastomotic fistula (p < 0.001), anal incontinence (p = 0.05), and local recurrence (p < 0.001). CONCLUSIONS: Our standardized surgical regimen with a covering stoma in low anterior resection for rectal cancer resulted in a minor anastomosis failure rate and a low risk of permanent stoma.

Decreased leakage rate of colonic anastomoses by tachosil coating: an experimental study.

Colorectal anastomotic coating has been proposed as a means to lower the leakage rate. Prior to clinical testing, coating materials need thorough experimental evaluation to ensure safety and efficacy. The aim of this study was to evaluate Tachosil as an anastomotic coating agent. Technically insufficient colon anastomoses were created in 80 C57BL/6 mice, and in half of the animals the anastomoses were covered with Tachosil. The animals were examined for clinical signs of anastomotic leakage, and the breaking strength of the anastomoses was evaluated. The number of leakages was reduced by Tachosil coating (10/40 versus 20/40 in controls; P=0.037). However, more cases of large bowel obstruction were found in the Tachosil group (12/40 versus 0/40 in controls; P<0.0005). Breaking strength was comparable between the Tachosil and control groups (0.49 N versus 0.52 N, respectively; P=0.423). Clinical studies are needed to clarify the efficacy of Tachosil anastomotic coating.