Slow and Steady Wins the Race: A Solid Case for a 3-Stage Approach in Ulcerative Colitis.

BACKGROUND: Approximately 10% to 20% of patients with ulcerative colitis require surgery during their disease course, of which the most common is the staged restorative proctocolectomy with IPAA. OBJECTIVE: The aim was to compare the rates of anastomotic leaks among all staged restorative proctocolectomy with IPAA procedures. DESIGN: This was a retrospective cohort study. SETTINGS: This study was conducted at a single tertiary care IBD center. PATIENTS: All patients with ulcerative colitis or IBD-unspecified who underwent a primary total proctocolectomy with IPAA for medically refractory disease or dysplasia between 2008 and 2017 were identified. MAIN OUTCOME MEASURES: The primary outcome was anastomotic leak within a 6-month postoperative period. Univariate and multivariate logistic regression were used to compare patients with and without anastomotic leaks. RESULTS: The sample was composed of 584 nonemergent patients, of whom 50 (8.6%) underwent 1-stage, 162 (27.7%) underwent 2-stage, 58 (9.9%) underwent modified 2-stage, and 314 (53.7%) underwent a 3-stage total proctocolectomy with IPAA. The primary indication was medically refractory disease in 488 patients and dysplasia/cancer in 101 patients. Anastomotic leak occurred in 10 patients (3.2%) after 3-stage, 14 patients (8.6%) after 2-stage, 6 patients (10.3%) after modified 2-stage, and 10 patients (20.0%) after a 1-stage procedure. A 3-stage procedure had fewer leaks and additional procedures for leaks compared with 1- and modified 2-stage procedures (p < 0.03). The 3-stage procedure had fewer combined anastomotic leaks and pelvic abscesses than all of the other staged procedures (p < 0.05). LIMITATIONS: This study was limited by its retrospective design and evolving electronic medical charts system. CONCLUSIONS: The 3-stage total proctocolectomy with IPAA is the optimal staged method in ulcerative colitis to reduce leaks and related complications. See Video Abstract at http://links.lww.com/DCR/B693. LENTO Y CONSTANTE GANA LA CARRERA UN CASO SLIDO PARA UN ENFOQUE DE TRES ETAPAS EN LA COLITIS ULCEROSA: ANTECEDENTES:Aproximadamente el 10-20% de los pacientes con colitis ulcerosa requieren cirugía durante el curso de su enfermedad, de los cuales la más común es la proctocolectomía restauradora escalonada con anastomosis con bolsa ileo-anal.OBJETIVO:El objetivo fue comparar las tasas de fugas anastomóticas entre todos los procedimientos de proctocolectomía restauradora por etapas con procedimiento de anastomosis con bolsa ileo-anal.DISEÑO:Este fue un estudio de cohorte retrospectivo.ENTORNO CLÍNICO:Este estudio se llevó a cabo en un único centro de atención terciaria de tercer nivel para enfermedades inflamatorias del intestino.PACIENTES:Se identificaron todos los pacientes con colitis ulcerosa o enfermedad inflamatoria intestinal inespecífica que se sometieron a una proctocolectomía total primaria mas anastomosis con bolsa ileo-anal por enfermedad médicamente refractaria o displasia entre 2008 y 2017.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue la fuga anastomótica dentro de un período posoperatorio de seis meses. Se utilizó regresión logística univariante y multivariante para comparar pacientes con y sin fugas anastomóticas.RESULTADOS:La muestra estuvo compuesta por 584 pacientes no emergentes, de los cuales 50 (8,6%) se sometieron a una etapa, 162 (27,7%) se sometieron a dos etapas, 58 (9,9%) se sometieron a modificación en dos etapas y 314 (53,7%) se sometieron a una proctocolectomía total en tres tiempos mas anastomosis con bolsa ileo-anal. La indicación principal fue enfermedad médicamente refractaria en 488 pacientes y displasia / cáncer en 101 pacientes. Se produjo una fuga anastomótica en 10 (3,2%) pacientes después de tres etapas, 14 (8,6%) pacientes después de dos etapas, 6 (10,3%) pacientes después de dos etapas modificadas y 10 (20,0%) pacientes después de una etapa procedimiento. Un procedimiento de tres etapas tuvo menos fugas y procedimientos adicionales para las fugas en comparación con los procedimientos de una y dos etapas modificadas (p <0.03). El procedimiento de tres etapas tuvo menos fugas anastomóticas y abscesos pélvicos combinados que todos los demás procedimientos por etapas (p <0,05).LIMITACIONES:Este estudio estuvo limitado por su diseño retrospectivo y su sistema de registros médicos electrónicos en evolución.CONCLUSIONES:La proctocolectomía total en tres etapas mas anastomosis con bolsa ileo-anal es el método óptimo por etapas en la colitis ulcerosa para reducir las fugas y las complicaciones relacionadas. Consulte Video Resumen en http://links.lww.com/DCR/B693.

Comparison of the incidences of anastomotic leakage when PDSII or LACLON are used in esophago-gastric conduit handsewn anastomosis after esophagectomy.

The incidence of anastomotic leakage after esophagectomy remains around 10%. It was previously reported that PDSII rapidly loses tensile strength at pH 1.0 and pH 8.5. By contrast, LACLON degradation is reportedly insensitive to pH. We therefore compared LACLON with PDSII for esophago-gastric conduit, layer-to-layer, handsewn anastomosis. Between January 2016 and January 2020, 90 patients who received posterior mediastinal gastric conduit reconstruction with layer-to-layer handsewn anastomosis (51 using PDSII and 39 using LACLON) at Akita University Hospital were enrolled. The incidence of anastomotic leakage was significantly lower in the LACLON (2.6%, 1/39 patients) than PDSII group (15.7%, 8/51 patients) (p = 0.0268). Multivariable logistic analysis showed the risk of anastomotic leakage was significantly greater with PDSII than LACLON (odds ratio 11.01; 95% CI 1.326-277.64; p = 0.024). The percentages of time the pH was higher than 8 on the gastric conduit side of the anastomosis were 3.1%, 5.7%, 20.9% and 80.5%, respectively, in the four most recent patients. The present study showed that pH at the anastomosis soon after esophagectomy tends to be alkaline rather than acidic, which raises the possibility that this alkalinity facilitates the deterioration of surgical sutures including PDSII.

A single blinded randomized controlled trial comparing semi-mechanical with hand-sewn cervical anastomosis after esophagectomy for cancer (SHARE-study).

OBJECTIVE: The aim was to compare leak rate between hand-sewn end-to-end anastomosis (ETE) and semi-mechanical anastomosis (SMA) after esophagectomy with gastric tube reconstruction. BACKGROUND DATA: The optimal surgical technique for creation of an anastomosis in the neck after esophagectomy is unclear. METHODS: Patients with esophageal cancer undergoing esophagectomy with gastric tube reconstruction and cervical anastomosis were eligible for participation after written informed consent. Patients were randomized in 1:1 ratio. Primary endpoint was anastomotic leak rate defined as external drainage of saliva from the site of the anastomosis or intra-thoracic manifestation of leak. Secondary endpoints included anastomotic stricture rate at one year follow up, number of endoscopic dilatations, dysphagia-score, hospital stay, morbidity, and mortality. Patients were blinded for intervention. RESULTS: Between August 2011 and July 2014, 174 patients with esophageal cancer underwent esophagectomy. Ninety-three patients were randomized to ETE (n = 44) or SMA (n = 49). Anastomotic leak occurred in 9 of 44 patients (20%) in the ETE group and 12 of 49 patients (24%) in the SMA group (absolute difference 4%, 95% CI -13% to +21%; p = .804). There was no significant difference in dysphagia at 1 year postoperatively (ETE 25% vs. SMA 20%; p = .628), in stricture rate (ETE 25% vs. 19% in SMA, p = .46), nor in median hospital stay (17 days in the ETE group, 13 days in the SMA group), morbidity (82% vs. 73%, p = .460) or mortality (0% vs. 4%, p = .175) between the groups.

Longer coronary anastomosis provides lower energy loss in coronary artery bypass grafting.

Distal anastomosis technique affects graft patency and long-term outcomes in coronary artery bypass grafting, however, there is no standard for the appropriate length of distal anastomosis. The purpose of this study is to evaluate whether longer distal anastomosis provides higher quality of distal anastomosis and better hemodynamic patterns. Off pump CABG training simulator, YOUCAN (EBM Corporation, Japan), was used for distal anastomosis model. Two lengths of distal anastomosis model (10 versus 4 mm) were prepared by end-to-side anastomosis technique. After CT scan constructed three-dimensional inner shape of distal anastomosis, computational flow dynamics (CFD) was used to analyze hemodynamic patterns. The working flow was defined as Newtonian fluid with density of 1050 kg/m3 and viscosity of 4 mPa s. The boundary condition was set to 100 mmHg at inlet, 50 ml/min at outlet, and 100 % stenosis of proximal coronary artery. Three-dimensional CT imaging showed quality of distal anastomosis in 10 mm model was more uniform without vessel wall inversion or kinking compared to 4 mm model. Anastomotic flow area was significantly larger in 10 mm model than that in 4 mm model (28.67 ± 4.91 versus 8.89 ± 3.18 mm2, p < 0.0001). Anastomotic angle was significantly smaller in 10 mm model compared to 4 mm model (10.2 ± 5.65° versus 20.6 ± 3.31°, p < 0.0001). CFD analysis demonstrated 10 mm model had streamlined flow with smooth graft curvature, whereas 4 mm model had abrupt blood flow direction changes with flow separation at the toe. 10 mm model had significantly lower energy loss than 4 mm model (34.78 ± 6.90 versus 77.10 ± 21.47 µW, p < 0.0001). Longer distal anastomosis provided higher quality of distal anastomosis, larger anastomotic flow area, smaller anastomotic angle, and smoother graft curvatures. These factors yielded lower energy loss at distal anastomosis.

Identification of technique variations among microvascular surgeons and cases using hierarchical task analysis.

A hierarchical taxonomy was developed for identifying differences among microvascular surgeons and cases and for investigating the impact of those differences on case outcome. Hierarchical task analysis was performed on eight microvascular anastomosis cases. The analysis was simplified by redefining subtasks and elements to only describe actions and adding attributes to describe the work object, method, tool, material, conditions and ergonomics factors. The resulting taxonomy was applied to 64 cases. Differences were found among cases for the frequency and duration of subtask, elements, attributes and element sequences. Observed variations were used to formulate hypotheses about the relationship between different methods and outcomes that can be tested in future studies. The taxonomy provides a framework for comparing alternative methods, determining the best methods for given conditions and for surgical training and retraining. PRACTITIONER SUMMARY: A hierarchical taxonomy, created from a hierarchical task analysis and work attributes, was applied to describe technique variations among microsurgery cases. Variations in time, frequency and sequence were used to form hypotheses on best methods for standardising procedures.

Marginal ulcer after Roux-en-Y gastric bypass: what have we really learned?

BACKGROUND: The definition of marginal ulcer after Roux-en-Y gastric bypass (RYGB) is widely debated. This study reviewed findings of upper endoscopy in symptomatic patients at a quaternary bariatric referral center. Further investigation included symptom constellation, potential etiologies, and efficacy of treatment for patients found to have marginal ulcer. METHODS: Patients presenting for upper gastrointestinal endoscopy after Roux-en-Y gastric bypass were included in this study. An institutional review board-approved database was queried for the period 1 June 2010 to 31 August 2011. Subgroup analysis was performed for patients with marginal ulcer. Statistical analysis was performed using PASW version 18 for Windows. RESULTS: During the study period, 455 upper gastrointestinal endoscopies were performed for 328 consecutive symptomatic patients. Marginal ulcer, found in 112 patients (34 %), was diagnosed for 59 of the patients (53 %) within 12 months after surgery and for 53 of the patients (47 %) more than 12 months after surgery. In patients found to have marginal ulcer, the most common presenting symptoms were pain, dysphagia, nausea, and vomiting. All the patients with marginal ulcer underwent acid suppression and cytoprotective therapy. Using uni- and multivariate analyses for healing, nonhealing, and healing with recurrence, tobacco use was found to be the solitary significant risk factor for recurrence (p = 0.01). CONCLUSION: Patients with pain or dysphagia after gastric bypass warrant upper endoscopy given the high yield for abnormalities. Although the risk factors for the development of marginal ulcer remain multifactorial, a thorough investigation for potential etiologies including tobacco, alcohol, and nonsteroidal antiinflammatory drug (NSAID) usage should be determined and eliminated. The presence of multiple risk factors may pose a higher challenge in ulcer resolution, leading to increased recurrence. In the current series, prior or current tobacco use remained the sole independent risk factor for ulcer persistence.

Basal FSH level changes after different types of uterine vessel occlusion in the management of uterine fibroids.

OBJECTIVE: To assess the effect on FSH of the application of different types of uterine vessel blockage (uterine artery occlusion alone [UAO] or with blockage of vessel anastomosis [UVO]) in the management of women with fibroids. DESIGN: Case-control study. SETTING: Medical center. PATIENT(S): One hundred ten women with uterine fibroids. INTERVENTION(S): Forty-four consecutive patients undergoing UAO were compared with 66 matched subjects who underwent UVO during the same period. MAIN OUTCOME MEASURE(S): Surgery types and FSH levels were compared. RESULT(S): At the first month after surgery, FSH levels were elevated from 5.5 mIU/mL to 14.2 and 8.7 mIU/mL in the UVO and UAO groups, respectively. The difference between the 2 groups continued up to 6 months and disappeared thereafter. More patients (38%) in the UVO group had an increased FSH level of >10 mIU/mL, compared with 5% in the UAO group at the first month after surgery, which contributed to the high percentage of women with irregular menstruation. CONCLUSION(S): Women treated with UVO were associated with a greater risk of a significant increase in FSH level at the first month after operation than those treated with UAO, which may be a reflection of diminished ovarian function. The long-term effect was uncertain, because of the lack of difference in the FSH levels between the two groups.

Toward improving uniformity and standardization in the reporting of pancreatic anastomoses: a new classification system by the International Study Group of Pancreatic Surgery (ISGPS).

BACKGROUND: To date, there is no uniform and standardized manner of defining pancreatic anastomoses after pancreatic resection. METHODS: A systematic search was performed to determine the various factors, either related to the pancreatic remnant after pancreatic resection or to types of pancreatoenteric anastomoses that have been shown to influence failure rates of pancreatic anastomoses. RESULTS: Based on the data obtained, we formulated a new classification that incorporates factors related to the pancreatic remnant, such as pancreatic duct size, length of mobilization, and gland texture, as well as factors related to the pancreatoenteric anastomosis, such as the use of pancreatojejunostomy/pancreatogastrostomy; duct-to-mucosa anastomosis; invagination (dunking) of the remnant into the jejunum or stomach; and the use of a stent (internal or external) across the anastomosis. CONCLUSION: By creating a standardized classification for recording and reporting of the pancreatoenterostomy, future publications would allow a more objective comparison of outcomes after pancreatic surgery. In addition, use of such a classification might encourage studies evaluating outcomes after specific types of anastomoses in certain clinical situations that could lead to the formulation of best practice guidelines of anastomotic techniques for a particular combination of findings in the pancreatic remnant.

Clinical results of various reconstructions employed after total gastrectomy.

Methods of restoring continuity after total gastrectomy, particularly those creating a "reservoir," have led to many publications over the last 20 years. These publications are herein reviewed in an attempt to answer questions regarding the clinical value of a jejunal "reservoir". The conclusion we reached from this review was that such a reconstruction does reduce unpleasant symptoms, aids weight maintenance, and is a valuable operative approach.

Mechanical bowel preparation for elective colorectal surgery: a multicentre randomised trial.

BACKGROUND: Mechanical bowel preparation is a common practice before elective colorectal surgery. We aimed to compare the rate of anastomotic leakage after elective colorectal resections and primary anastomoses between patients who did or did not have mechanical bowel preparation. METHODS: We did a multicentre randomised non-inferiority study at 13 hospitals. We randomly assigned 1431 patients who were going to have elective colorectal surgery to either receive mechanical bowel preparation or not. Patients who did not have mechanical bowel preparation had a normal meal on the day before the operation. Those who did were given a fluid diet, and mechanical bowel preparation with either polyethylene glycol or sodium phosphate. The primary endpoint was anastomotic leakage, and the study was designed to test the hypothesis that patients who are given mechanical bowel preparation before colorectal surgery do not have a lower risk of anastomotic leakage than those who are not. The median follow-up was 24 days (IQR 17-34). We analysed patients who were treated as per protocol. This study is registered with ClinicalTrials.gov, number NCT00288496. FINDINGS: 77 patients were excluded: 46 who did not have a bowel resection; 21 because of missing outcome data; and 10 who withdrew, cancelled, or were excluded for other reasons. The rate of anastomotic leakage did not differ between both groups: 32/670 (4.8%) patients who had mechanical bowel preparation and 37/684 (5.4%) in those who did not (difference 0.6%, 95% CI -1.7% to 2.9%, p=0.69). Patients who had mechanical bowel preparation had fewer abscesses after anastomotic leakage than those who did not (2/670 [0.3%] vs 17/684 [2.5%], p=0.001). Other septic complications, fascia dehiscence, and mortality did not differ between groups. INTERPRETATION: We advise that mechanical bowel preparation before elective colorectal surgery can safely be abandoned.

[Anatomohistologic study of von Oort's vestibulocochlear anastomosis]. / Etude anatomo-histologique de l'anastomose vestibulo-cochléaire de von Oort.

OBJECTIVES: The vestibulocochlear anastomosis was first described in 1918 by von Oort. It is situated deeply at the bottom of the internal acoustic meatus, and spreads from the saccular nerve before its terminal ramifications, to the cochlear nerve before its penetration into the cochlea. Nerve fibers of the cochlear efferent system are thought to pass through it. The aim of our study was to investigate the anatomy of the vestibulocochlear anastomosis and characterize its histological features. METHOD: [corrected] Ten human temporal bones were dissected. Serial sections were obtained for histological evaluation. RESULTS: The vestibulocochlear anastomosis was found in seven of the specimens, perfectly visualized in six. Average diameter was 0.5 mm with lengths varying from 0.5 to 1 mm. Serial histological sections demonstrated the nervous nature of the anastomosis and its relations with the saccular and cochlear nerves. The epinevrium of the saccular nerve was continuous with the supposed anastomosis in five of the specimens, demonstrating the distinct nature of the anastomosis from the saccular and cochlear nerves. We did not find any evidence linking these fibers to the cochlear efferent system. DISCUSSION: The vestibulocochlear anastomosis was found in seven of our ten dissections. The anastomosis is probably an anatomic reality composed of nerve fibers. The efferent function of these fibers remains to be demonstrated.

[About classification of anterior resections of the rectum]. / O klassifikatsii perednikh rezektsii priamoi kishki.

Results of anterior resections of rectum are analyzed. It is demonstrated that results of treatment and surgical policy depend on level of resection and anastomosis creation. Own classification of anterior resections of rectum are developed. This classification may be used as the base of coherent treatment policy.

[Classification of colorectal anastomoses]. / Klassifikatsiia kolorektal'nykh anastomozov.

The authors propose to classify colorectal anastomoses by anatomical signs: high (supraampular), medial (ampular), low (subampular), utmost low (suprasphincteral) and sphincteral. Forty colorectal one row suture anastomoses were performed in patients with carcinoma of the rectum. Incompetent sutures were registered in 3 (7.5%) patients with subampular anastomoses. There were no lethal outcomes.

Geometric design improvements for femoral graft-artery junctions mitigating restenosis.

The present study is based on the hypothesis that nonuniform hemodynamics, represented by large time-averaged wall shear stress gradients, trigger abnormal biological processes leading to rapid restenosis, i.e. excessive tissue overgrowth and renewed plaque formation, and hence early graft failure. It implies that this problem may be significantly mitigated by finding graft-artery bypass configurations for which the wall shear stress gradient is approximately zero and hence nearly uniform hemodynamics is achieved. These fluid flow and geometric design considerations are applied to four different end-to-side anastomoses for the distal end of a femoral artery bypass with an appropriate test input pulse and a typical 20-80 flow division. A validated finite-volume code has been used to compute the transient three-dimensional velocity vector fields, wall shear stress distributions and surface contours of the wall shear stress gradients. It is shown that large anastomotic flow areas, small continuously changing bifurcation angles, and smooth junction wall curvatures reduce local time-averaged wall shear stress gradients significantly and hence should mitigate restenosis.

Hairline reconstruction utilizing modified winged V-plastic hair-bearing flaps and focal anastomotic line excisions.

BACKGROUND: A large, recurrent basal cell carcinoma involving the left forehead and suprajacent hair-bearing scalp was excised, following which an esthetically acceptable reconstruction of the scalp and hairline margin was accomplished. OBJECTIVE: A method of utilizing two hair-bearing flaps to cover a large defect at the hair-bearing scalp margin will be photographically demonstrated, and the maneuvers to precisely reconstruct the scalp's anastomotic margin with the forehead will be shown and discussed. METHODS: Dual hair-bearing "winged" V-plastic flaps were evolved anteriorly, the two flaps joined, an M-plasty (Webster) was then incorporated to spare hair-bearing scalp posteriorly, and the entire conjoined scalp flap then advanced anteriorly to the forehead. The precise curvatures of the anastomotic line were reestablished by exact excisions of forehead skin underlying the hair-bearing scalp flaps, or amputations of overlying hair-bearing scalp in excess of forehead needs. RESULTS: An esthetically pleasing and reasonably exact reconstruction of the hair-bearing scalp and forehead anastomotic line was accomplished. CONCLUSION: A precise reconstruction of the forehead/scalp margin can be accomplished utilizing a combination of techniques, including hair-bearing "winged" V-plastic flaps, an M-plasty, and the serial removal of segments of both glabrous and nonglabrous skin to reestablish the frontal hairline margin.

Anastomosis intestinal en un sólo plano / Intestinal anastomosis in a level only

Quince niños con edades comprendidas entre 0 y 10 años, fueron operados de resección intestinal con anatomosis en un solo plano, en el Servicio de Cirugía Pediátrica del Hospital Universitario "Dr. Antonio Pineda", de la Ciudad de Barquisimeto; entre el lapso comprendido de mayo de 1993 a febrero de 1995. se utilizó la técnica de puntos separados en "U" con bordes invaginados. La mediana de hospitalización fue 5 días. No hubo complicaciones inherentes a la técnica en estudio; concluyéndose que es segura y confiable

Protector de anastomosis colo-recto-anales / Intestinal anastomosis protector

Presentamos un trabajo de investigación clínica de protección de anastomosis colo-colónica, colo-rectal, y colo-anal, con la colocación endoluminal de un preservativo que se fija al cabo proximal y se desliza al cabo distal para proteger el sitio anastomótico durante los primeros 10 o 15 días, impidiendo durante ese tiempo el contacto de la materia fecal con la línea de sutura. Cumplido dicho plazo el preservativo se elimina espontáneamente por el ano. Colocamos el protector en 39 anastomosis: 12 colo-cólicas, 25 colo-rectales y 2 colo-anales, sin morbi-mortalidad. En el 90 por ciento las cirugías fueron programadas y en el 10 por ciento restante de urgencia