Autonomous robotic laparoscopic surgery for intestinal anastomosis.

Autonomous robotic surgery has the potential to provide efficacy, safety, and consistency independent of individual surgeon's skill and experience. Autonomous anastomosis is a challenging soft-tissue surgery task because it requires intricate imaging, tissue tracking, and surgical planning techniques, as well as a precise execution via highly adaptable control strategies often in unstructured and deformable environments. In the laparoscopic setting, such surgeries are even more challenging because of the need for high maneuverability and repeatability under motion and vision constraints. Here we describe an enhanced autonomous strategy for laparoscopic soft tissue surgery and demonstrate robotic laparoscopic small bowel anastomosis in phantom and in vivo intestinal tissues. This enhanced autonomous strategy allows the operator to select among autonomously generated surgical plans and the robot executes a wide range of tasks independently. We then use our enhanced autonomous strategy to perform in vivo autonomous robotic laparoscopic surgery for intestinal anastomosis on porcine models over a 1-week survival period. We compared the anastomosis quality criteria-including needle placement corrections, suture spacing, suture bite size, completion time, lumen patency, and leak pressure-of the developed autonomous system, manual laparoscopic surgery, and robot-assisted surgery (RAS). Data from a phantom model indicate that our system outperforms expert surgeons' manual technique and RAS technique in terms of consistency and accuracy. This was also replicated in the in vivo model. These results demonstrate that surgical robots exhibiting high levels of autonomy have the potential to improve consistency, patient outcomes, and access to a standard surgical technique.

Video-Urodynamic Characteristics and Predictors of Switching from Botulinum Neurotoxin a Injection to Augmentation Enterocystoplasty in Spinal Cord Injury Patients.

Botulinum neurotoxin type A (BoNT-A) injection and augmentation enterocystoplasty (AE) are alternative and effective management strategies for neurogenic detrusor overactivity (NDO) refractory to pharmacotherapy. A great majority of patients with spinal cord injury (SCI) may, however, prefer BoNT-A injections to AE, due to the less invasive characteristics. In this study we evaluated the influence of various video-urodynamic study (VUDS) parameters in SCI patients who continuously received repeat BoNT-A detrusor injections or switched to AE to improve their bladder conditions. We compared the changes in the urodynamic parameters before and after each mode of treatment. In this retrospective study, all SCI patients with refractory NDO who had received at least one BoNT-A injection were enrolled. VUDS was performed before and after both BoNT-A injection and AE. All of the urodynamic parameters of the storage and micturition-including the bladder capacity of every sensation, maximal flow rate (Qmax), post-voiding residual volume, detrusor pressure at Qmax, and bladder contractility index-were recorded. A total of 126 patients, including 46 women and 80 men, with a mean age of 41.8 ± 13.1 years, were recruited for this study. All of the patients receiving either BoNT-A injection or AE had a statistically significant increase of bladder capacity at every time-point during filling and a decrease in detrusor pressure at Qmax during voiding. Patients who switched from BoNT-A to AE had greater improvements in their urodynamic parameters when compared with those who continued with BoNT-A injections. Accordingly, SCI patients receiving BoNT-A injections but experiencing few improvements in their urodynamic parameters should consider switching to AE to achieve a better storage function and bladder capacity.

Esophageal Interventions in Infants Born with Esophageal Atresia: A Comprehensive Analysis of a National Database.

INTRODUCTION: Esophageal atresia (EA) is a rare malformation that often requires a series of procedures, including surgical primary anastomosis, staged repair, and endoscopic procedures. Actual numbers and trends in interventions and variety in treatment strategies remain unclear. MATERIALS AND METHODS: Data from the German federal bureau of statistics containing all EA-related inpatient procedures encoded from 2005 until 2018 were analyzed for children during the first year of life. The sum of esophageal anastomoses and replacements was used to calculate an estimate of incidence of EA. RESULTS: Over 14 years, 12,627,888 inpatient cases were recorded in infants in Germany. The mean incidence of EA was 1 per 4,217 live births. On average, 163.3 (95% confidence interval [CI]: 150.8-176.1) esophageal anastomoses, 11.2 (95% CI: 8.7-13.7) esophageal lengthening procedures, and 6.7 (95% CI: 5.42-8.00) esophageal replacements were recorded annually. Overall, 187.8 (95% CI: 147.1-200.4) endoluminal treatments (ballon dilatation, bougienage, stent placement, or injection) were performed per 100 anastomoses. Over the years, bougienage was increasingly replaced by ballon dilatation as primary treatment. Boys had a significantly higher number of esophageal procedures than girls, but the incidence of endoscopic treatments in relation to anastomoses was the same for both genders. CONCLUSION: The low incidence of EA in relation to a relatively large number of units treating those patients in Germany may pose challenges for maintaining competency and training of all specialists involved. The number of esophagoscopic treatments for esophageal stricture per anastomosis is lower than previously estimated.

Comparison of Diversion Strategies for Management of Acute Complicated Diverticulitis in a US Nationwide Cohort.

Importance: Diverticulitis of the colon is an increasingly prevalent disease with significant implications for patient quality of life and health system resource expenditure. Although several randomized clinical trials and meta-analyses of Hartman procedure (HP) and primary anastomosis and proximal diversion (PAPD) have found surgical equipoise, questions regarding the relative performance of these treatments when applied broadly remain. Objective: To examine use of and outcomes after urgent sigmoid colectomy with end colostomy (ie, HP) vs PAPD in management of complicated diverticulitis. Design, Setting, and Participants: This retrospective cross-sectional study was a multicenter, population-based examination of inpatient hospitalizations, not including long-term rehabilitation facilities, using data from the 2014 to 2017 Nationwide Readmissions Database. It was performed from November 2020 to January 2021. Included patients were adults admitted with acute diverticulitis requiring HP or PAPD within 48 hours of admission. Exposures: Undergoing HP vs PAPD. Main Outcomes and Measures: Inverse probability treatment analysis was used to compare outcomes, including index mortality, composite complications (ie, neurologic, infectious, and cardiovascular complications), length of stay, and readmissions within 90 days. Results: During the study period, an estimated 1 072 395 adults (615 954 [57.4%] women; median [IQR] age, 64 [52-76] years) required nonelective hospitalization for acute colonic diverticulutus. A total of 34 126 patients required diversion, with 32 326 patients (94.7%) undergoing HP and 1800 patients (5.3%) undergoing PAPD within 48 hours of admission. Patients undergoing PAPD had a decreased median (IQR) age (60 [51-70] years vs 65 [54-74] years; P < .001) and decreased rates of end organ dysfunction (520 patients [28.9%] vs 11 514 patients [35.6%]; P < .001). In inverse probability treatment weight analysis, the odds of mortality (adjusted odds ratio [aOR], 0.63; 95% CI, 0.32-1.40), complications (aOR, 0.86; 95% CI, 0.66-1.13), and nonhome discharge (aOR 1.15; 95% CI, 0.83-1.60) were similar for PAPD compared with HP. Among 1772 patients who underwent PAPD and survived index hospitalization, there was an increased incidence of 90-day readmission compared with 30 851 patients who underwent HP and survived index hospitalization (393 patients [22.2%] vs 4384 patients [14.2%]; P < .001) with increased hazard of ostomy reversal (hazard ratio, 1.46; 95% CI, 1.08-1.99). Conclusions and Relevance: This study found that the use of PAPD was associated with comparable index hospitalization outcomes vs use of HP, while readmission rate and ostomy risk were statistically significantly increased among patients who underwent PAPD compared with patients who underwent HP. These findings suggest that further delineation of criteria for appropriate application of PAPD in the urgent setting are warranted.

The Transition to Microsurgical Technique for Hepatic Artery Reconstruction in Pediatric Liver Transplantation.

BACKGROUND: Hepatic artery thrombosis represents a potentially fatal complication following liver transplantation. Rates of hepatic artery thrombosis are significantly higher in children, with mortality reported up to 80 percent. Microsurgical anastomosis has been shown to decrease the rate of hepatic artery thrombosis and now represents the standard of care at the authors' institution. In this article, the authors present the largest study of its type directly comparing rates of hepatic artery thrombosis with and without microsurgical reconstruction of the hepatic artery. METHODS: All pediatric patients who underwent primary orthotopic liver transplantation between 1989 and 2018 were included. Patients were divided into two cohorts: standard anastomosis with loupes, and microsurgical anastomosis under the operating microscope. The authors' primary outcome was the rate of hepatic artery thrombosis. Secondary outcomes were graft survival, patient survival, retransplantation rate, requirement for intraoperative blood products, and length of stay. RESULTS: Two hundred thirty-one children met criteria for inclusion. One hundred eighty cases were performed with loupe magnification and 51 cases were performed under the microscope. The hepatic artery thrombosis rate was lower, but not significantly so (p = 0.114), in the microsurgical group [n = 1 (2.0 percent)] compared with the standard cohort [n = 15 (8.3 percent)]. Survival analysis revealed a significant increase in graft survival with microsurgical anastomosis (p = 0.020), but not patient survival (p = 0.196). The retransplantation rate was significantly lower with microsurgical anastomosis (p = 0.021). CONCLUSIONS: Microsurgical anastomosis was associated with a clinically important decrease in hepatic artery thrombosis compared with standard loupe anastomosis. The graft survival rate was significantly higher in the microsurgical cohort, with a reduced retransplantation rate at 1 year. On this basis, the authors recommend microsurgical hepatic artery anastomosis in cases of pediatric liver transplantation. . CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, III.

Functional Outcomes and Quality of Life after Redo Anastomosis in Patients With Rectal Cancer: An International Multicenter Comparative Cohort Study.

BACKGROUND: Redo anastomosis can be considered in selected patients with persistent leakage, stenosis, or local recurrence. It is technically challenging, and little is known about the functional outcomes after this seldomly performed type of surgery. OBJECTIVE: The aim of this study was to compare functional outcomes and the quality of life between redo anastomosis and primary successful anastomosis following total mesorectal excision for rectal cancer. DESIGN: This study was designed as an international multicenter comparative cohort study. SETTINGS: The study was conducted in 3 tertiary referral centers in the Netherlands, Belgium, and France. PATIENTS: Patients undergoing redo anastomosis were compared with patients with a primary successful anastomosis after total mesorectal excision for rectal cancer. MAIN OUTCOME MEASURES: Low anterior resection syndrome score, European Organization for the Research and Treatment of Cancer Quality of Life Questionnaire (EORTC QLQ) C30, and EORTC QLQ-CR29 questionnaires were used to assess outcomes. RESULTS: In total, 170 patients were included; 52 underwent redo anastomosis and 118 were controls. Major low anterior resection syndrome occurred in 73% after redo anastomosis compared with 68% following primary successful anastomosis (p = 0.52). The redo group had worse EORTC QLQ-CR29 mean scores for fecal incontinence (p = 0.03) and flatulence (p = 0.008). There were no differences in urinary (p = 0.48) or sexual dysfunction, either in men (p = 0.83) or in women (p = 0.76). Significantly worse scores in the redo group were found for global health (p = 0.002), role (p = 0.049) and social function (p = 0.006), body image (p = 0.03), and anxiety (p = 0.02). LIMITATIONS: This study is limited by the possible response bias. CONCLUSIONS: Redo anastomosis is associated with significantly worse quality of life compared with primary successful anastomosis. However, major low anterior resection syndrome was comparable between groups and should not be a reason to preclude restoration of bowel continuity in highly motivated patients. See Video Abstract at http://links.lww.com/DCR/B565. RESULTADOS FUNCIONALES Y DE CALIDAD DE VIDA POSTERIOR A LA RECONSTRUCCIN DE LA ANASTOMOSIS EN PACIENTES CON CNCER DE RECTO ESTUDIO INTERNACIONAL MULTICNTRICO DE COHORTE COMPARATIVO: ANTECEDENTES:Se puede considerar reconstruir la anastomosis en pacientes seleccionados con fuga persistente, estenosis o recidiva local. Esto es técnicamente desafiante y poco se sabe sobre los resultados funcionales después de este tipo de cirugía que rara vez se realiza.OBJETIVO:El objetivo de este estudio fue comparar resultados funcionales y la calidad de vida entre reconstrucción de la anastomosis y la anastomosis primaria exitosa posterior de la escisión total de mesorrecto (TME) por cáncer de recto.DISEÑO:Este estudio fue diseñado como un estudio internacional multicéntrico de cohorte comparativo.ENTORNO CLINICO:El estudio se llevó a cabo en tres centros de referencia terciarios en Holanda, Bélgica y Francia.PACIENTES:Los pacientes sometidos a reconstrucción de anastomosis fueron comparados con pacientes con anastomosis primaria exitosa después de TME por cáncer de recto.PRINCIPALES MEDIDAS DE VALORACION:Los cuestionarios; Escala de Síndrome de Resección Anterior Baja (LARS), EORTC QLQ-C30, y QLQ-CR29, fueron utilizados para evaluar los resultados.RESULTADOS:En total, se incluyeron 170 pacientes; 52 reconstrucción de anastomosis y 118 controles. LARS ocurrió en el 73% posterior a la reconstrucción de la anastomosis en comparación con el 68% posterior a la anastomosis primaria exitosa (p = 0,52). El grupo de reconstrucción tuvo peores puntuaciones medias de EORTC QLQ-CR29 para incontinencia fecal (p = 0,03) y flatulencia (p = 0,008). No hubo diferencias en disfunción urinaria (p = 0,48) o sexual, ni en hombres (p = 0,83) ni en mujeres (p = 0,76). Se encontraron puntuaciones significativamente peores en el grupo de reconstrucción para salud global (p = 0,002), desempeño (p = 0,049) y función social (p = 0,006), imagen corporal (p = 0,03) y ansiedad (p = 0,02).LIMITACIONES:La limitación de este estudio es el posible sesgo de respuesta.CONCLUSIONES:La reconstrucción de la anastomosis se asocia con una calidad de vida significativamente peor en comparación con los pacientes con anastomosis primaria exitosa. Sin embargo, LARS fue comparable entre los grupos y no debería ser una razón para impedir la restauración de la continuidad intestinal en pacientes muy motivados. Consulte Video Resumen en http://links.lww.com/DCR/B565.

Open vs Minimally Invasive Approach for Emergent Colectomy in Perforated Diverticulitis.

BACKGROUND: Traditionally, perforated diverticulitis has been managed with an open approach, with a Hartmann procedure or a colectomy with primary anastomosis. Minimally invasive surgery is associated with postoperative advantages in the elective setting and may show a benefit in the emergent setting. OBJECTIVE: The aim of this study was to compare postoperative outcomes of open vs minimally invasive approaches for emergent perforated diverticulitis. DESIGN: This was a retrospective review of the American College of Surgeons National Surgical Quality Improvement Program targeted colectomy database using propensity score matching. SETTINGS: Interventions were performed in hospitals participating in the national database. PATIENTS: Patients who underwent emergent colectomy from 2012 to 2017 were included. Procedures were divided into Hartmann procedure and primary anastomosis. Open vs minimally invasive groups were defined by intention to treat. MAIN OUTCOME MEASURES: Outcomes measures included length of stay and overall morbidity and mortality. RESULTS: Of 130,616 patients, 7105 met inclusion criteria (4486 Hartmann procedure and 2619 primary anastomosis). A total of 1989 open Hartmann procedure cases were matched to 663 minimally invasive cases. The minimally invasive group underwent longer operations and had lower rates of respiratory failure. There were no differences in overall complications, mortality, length of stay, or home discharge. In the primary anastomosis group, 1027 cases were matched 1:1. The minimally invasive approach was associated with longer operative times, but reduced wound dehiscence, sepsis, bleeding, overall complications, and length of stay. No difference was detected in anastomotic leak, mortality, reoperation, or readmission rates. LIMITATIONS: Limitations include retrospective nature, data loss, nonuniformity, selection bias, and coding errors. CONCLUSIONS: Emergent minimally invasive primary anastomosis results in a shorter length of stay and decreased 30-day morbidity in comparison with open primary anastomosis for perforated diverticulitis. Emergent open and minimally invasive Hartmann procedures for perforated diverticulitis have comparable outcomes, perhaps because of a 40% conversion rate. See Video Abstract at http://links.lww.com/DCR/B421. ABORDAJE ABIERTO VERSUS MNIMAMENTE INVASIVO PARA COLECTOMA DE EMERGENCIA EN DIVERTICULITIS PERFORADA: ANTECEDENTES:Tradicionalmente, la diverticulitis perforada se ha tratado con un abordaje abierto, con un procedimiento de Hartmann o una colectomía con anastomosis primaria. La cirugía mínimamente invasiva se asocia con ventajas posoperatorias en el escenario electivo y puede mostrar beneficio en el escenario emergente.OBJETIVO:El objetivo de este estudio fue comparar los resultados posoperatorios del abordaje abierto versus el mínimamente invasivo para la diverticulitis perforada emergente.DISEÑO:Ésta fue una revisión retrospectiva de la base de datos de colectomía dirigida del Programa Nacional de Mejoramiento de la Calidad Quirúrgica del Colegio Americano de Cirujanos utilizando el pareamiento por puntaje de propensión.ESCENARIO:Las intervenciones se realizaron en los hospitales participantes en la base de datos nacional.PACIENTES:Se incluyeron pacientes que fueron sometidos a colectomía emergente de 2012 a 2017. Los procedimientos se dividieron en procedimiento de Hartmann y anastomosis primaria. Los grupos abierto versus mínimamente invasivo se definieron por intención de tratar.PRINCIPALES MEDIDAS DE RESULTADO:Las medidas de resultado incluyeron la duración de la estancia, la morbilidad general y la mortalidad.RESULTADOS:De 130,616 pacientes, 7,105 cumplieron los criterios de inclusión (4,486 procedimiento de Hartmann y 2,619 anastomosis primaria). 1,989 casos abiertos de procedimientos de Hartmann se emparejaron con 663 casos mínimamente invasivos. El grupo mínimamente invasivo se sometió a operaciones más prolongadas y tuvo tasas más bajas de insuficiencia respiratoria. No hubo diferencias en las complicaciones generales, la mortalidad, la duración de la estancia o el alta domiciliaria. En el grupo de anastomosis primaria, 1,027 casos se emparejaron 1: 1. El abordaje mínimamente invasivo se asoció con tiempos quirúrgicos más prolongados, pero también con tasas reducidas de dehiscencia de herida, sepsis, sangrado, complicaciones generales y la duración de la estancia. No se detectaron diferencias en las tasas de fuga anastomótica, mortalidad, reintervención o reingreso.LIMITACIONES:Las limitaciones incluyen la naturaleza retrospectiva, pérdida de datos, falta de uniformidad, sesgo de selección y errores de codificación.CONCLUSIONES:La anastomosis primaria mínimamente invasiva emergente resulta en una estancia más corta y una disminución de la morbilidad a los 30 días en comparación con la anastomosis primaria abierta para la diverticulitis perforada. El procedimiento de Hartmann abierto y mínimamente invasivo de emergencia para la diverticulitis perforada tiene resultados comparables, quizás debido a una tasa de conversión del 40%. Consulte el Video Resumen en http://links.lww.com/DCR/B421.

Anastomosis quality score during robot-assisted radical prostatectomy: a new simple tool to maximize postoperative management.

PURPOSE: The urethro-vesical anastomosis represents one of the most challenging steps of robotic prostatectomy (RARP). To maximize postoperative management, we specifically designed our anastomosis quality score (AQS), based on the intraoperative characteristics of the urethra and bladder neck. METHODS: This is a prospective study, conducted from April 2019 to March 2020. All the patients were classified into three different AQS categories (low, intermediate, high) based on the quality of the anastomosis. The postoperative management was modulated accordingly. RESULTS: We enrolled 333 patients. According to AQS, no differences were recorded in intraoperative complications (p = 0.9). Median hospital stay and catheterization time were longer in AQS 1 group (p < 0.001). Additionally, the occurrence of postoperative complication was higher in AQS 1 category (p = 0.002) but, when focusing on the complications related to the quality of the anastomosis, no differences were found neither for acute urinary retention (p = 0.12) nor urine leakage (p = 0.11). Finally, concerning the continence recovery, no significant differences were found among the three groups for each time point. The highest potency recovery rate at one month of follow-up was recorded in AQS 3 category (p = 0. 03). CONCLUSION: The AQS proposed revealed to be a valid too to intraoperatively categorize patients who underwent RARP on the basis of the urethral and bladder neck features. The modulated postoperative management for each specific score category allowed to limit the occurrence of complications and to maximize the functional outcomes.

Experimental Devices Versus Hand-Sewn Anastomosis of the Aorta: A Systematic Review and Meta-Analysis.

BACKGROUND: To minimize complications associated with the construction of the hand-sewn aortic anastomosis, alternative experimental methods have been pursued. This study aimed to evaluate the efficacy of experimental anastomotic devices in relation to time and point of rupture of the anastomosis in comparison to the conventional technique. MATERIALS AND METHODS: An electronic search was performed using MEDLINE, Scopus, Science Direct, and Cochrane Library databases by two independent authors. Our exclusion criteria referred to studies reporting results solely from end-to-side anastomosis, results on vessels other than the aorta, studies that did not involve animal experiments, and non-English publications. The last search date was January 1, 2020. RESULTS: The meta-analysis included 22 studies with 34 anastomosis samples and a total of 316 animals. The pooled mean automated anastomosis time was 10.38 min, and the mean point of rupture was 32.7 N. In the subgroup analysis of automated anastomosis time by device category, the anastomotic stenting technique reported significantly lower anastomosis time but also showed significantly lower point of rupture. Comparing the efficacy of experimental devices and the hand-sewn technique, our pooled analysis showed that automated devices significantly decrease the time needed to perform the anastomosis (weighted mean difference -7.24 min). On the other hand, the automated anastomosis is also associated with decreased tensile strength (weighted mean difference -20.68 N). CONCLUSIONS: Although experimental devices seem to offer a faster anastomosis, they lack endurance when compared with the hand-sewn technique. Further research is needed for the development of an "ideal" anastomotic technique.

Magnetic Compression Anastomosis in Laparoscopic Pancreatoduodenectomy: A Preliminary Study.

BACKGROUND: Laparoscopic pancreatoduodenectomy (LPD) is a minimally invasive technique widely developed in the last few decades. Although magnetic compression anastomosis (magnamosis) is used during cholangiojejunostomy, its applicability in LPD has not yet been reported. Herein, we evaluated the feasibility and effectiveness of magnamosis in LPD. METHODS: Between January 2018 and December 2019, seven patients who underwent laparoscopic magnetic compression choledochojejunostomy (LMC-CJ) or laparoscopic magnetic compression pancreatojejunostomy (LMC-PJ) in LPD were enrolled. After LPD, a parent magnet with or without a drainage tube was placed in the proximal bile duct and pancreatic duct of each patient. Daughter magnets were introduced to couple with the parent magnets at the desired sites. A close postoperative surveillance of magnet movements was performed. Various relevant data were collected, and all patients were followed up until February 2020. RESULTS: LPD was successfully completed in all seven patients, of which seven underwent LMC-CJ and two received LMC-PJ. The median time needed for completion of LMC-CJ was 11 min (range, 8-16). The cost time for the two cases of LMC-PJ was 12 and 15 min, respectively. After a median time of 50 d (range, 40-170) postoperation, all magnets were expelled. No leakages of LMC-CJ or LMC-PJ were observed after operation. After a median follow-up period of 11 mo (range, 4-18), there was no incidence of anastomotic stricture.

Association between intraoperative application of microfibrillar collagen hemostat and anastomotic leakage after anterior resection for rectal cancer: A retrospective case-control study.

BACKGROUND: The purpose of the study was to evaluate the association between microfibrillar collagen hemostat and anastomotic leakage after anterior resection. METHOD: Between March 2015 and December 2019, a total of 203 consecutive rectal cancer patients who underwent elective anterior resection were included. Patient parameters were analyzed. The relevant risk factors were identified by univariate and multivariate analysis. Propensity score matching was performed to reduce the selection bias. RESULTS: In total, 26 (12.8%) of the 203 study patients developed clinical anastomotic leakage. The length of hospital stay was significantly prolonged by anastomotic leakage. In univariate analysis and multivariate analysis, male sex, low tumor location, and intraoperative application of microfibrillar collagen hemostat significantly increased the risk of anastomotic leakage. Furthermore, analysis after propensity score matching confirmed the independent role of microfibrillar collagen hemostat in anastomotic leakage. In addition, the median time of anastomotic leakage occurrence from the initial operation in patients with microfibrillar collagen hemostat was 9.00 days, which was significantly later than that in patients without microfibrillar collagen hemostat. CONCLUSION: In addition to male sex and low tumor location, intraoperative application of microfibrillar collagen hemostat was demonstrated to be a significant risk factor for anastomotic leakage. This finding suggested that surgeons should be fully aware of this potential risk in anterior resection. Because of the limitation of retrospective study, however, randomized controlled trials are needed to confirm this association in the future.

Using Artificial Intelligence to Predict Surgical Shunts in Men with Ischemic Priapism.

PURPOSE: Ischemic priapism is a urological emergency that requires prompt intervention to preserve erectile function. Characteristics that influence escalation to surgical intervention remain unclear. We identified factors and developed machine learning models to predict which men presenting with ischemic priapism will require shunting. MATERIALS AND METHODS: We identified men with ischemic priapism admitted to the emergency department of our large county hospital between January 2010 and June 2019. We collected patient demographics, etiology, duration of priapism prior to intervention, interventions attempted and escalation to shunting. Machine learning models were trained and tested using R to predict which patients require surgical shunting. RESULTS: A total of 334 encounters of ischemic priapism were identified. The majority resolved with intracavernosal phenylephrine injection and/or cavernous aspiration (78%). Shunting was required in 10% of men. Median duration of priapism before intervention was longer for men requiring shunting than for men who did not (48 vs 7 hours, p=0.030). Patients with sickle cell disease as the etiology were less likely to require shunting compared to all other etiologies (2.2% vs 15.2%, p=0.035). CONCLUSIONS: Men with longer duration of priapism before treatment more often underwent shunting. However, phenylephrine injection and aspiration remained effective for priapism lasting more than 36 hours. Having sickle cell disease as the etiology of priapism was protective against requiring shunting. We developed artificial intelligence models that performed with 87.2% accuracy and created an online probability calculator to determine which patients with ischemic priapism may require shunting.

Indications and practice of diverting ileostomy after colorectal resection and anastomosis in ovarian cancer cytoreduction.

OBJECTIVE: To determine the factors related with diverting ileostomy performance after colorectal resection and anastomosis, in advanced ovarian cancer cytoreductive surgery. METHODS: We have previously demonstrated the risk factors associated with anastomotic leak after colorectal anastomosis: Advanced age at surgery, low serum albumin level, additional bowel resections, manual anastomosis and distance of the anastomosis from the anal verge. However, use of diverting ileostomy is strongly variable and depends on individual surgeon preferences and training. Eight hospitals participated in this retrospective study. Data of 695 patients operated for ovarian cancer with primary colorectal anastomosis were included (January 2010-June 2018). Fourteen pre-/intraoperatively defined variables were identified and analysed as justification factors for use of diverting ileostomy. RESULTS: The rate of diverting ileostomy in the entire cohort was 19.13% (133/695; range within individual centers 4.6-24.32%). Previous treatment with bevacizumab [OR 2.8 (1.3-6.1); p=0.01]; additional bowel resections [OR 3.0 (1.8-5.1); p<0.001]; extended operating time [OR 1.005 (1.003-1.006); p<0.001] and intra-operative red blood transfusion [OR 2.7 (1.4-5.3); p<0.001] were found to be independently associated with diverting ileostomy performance. Assuming a 7% AL rate cut-off, up to 51.8% of DI presented an AL risk below 7% and might have been spared. CONCLUSIONS: The risk factors that drive the gynecologic oncology surgeons to perform a diverting ileostomy, seem to differ from the actual risk factors that we have identified to be associated with postoperative anastomotic leak. Broader awareness of the risk factors that contribute to a higher perioperative risk profile, will facilitate a better risk stratification process and possibly avoid unnecessary stoma formation in ovarian cancer patients.

Desarrollo y validación de una herramienta para la evaluación de la anastomosis intestinal laparoscópica en simulación / Development and Validation of a Tool for the Evaluation of Laparoscopic Intestinal Anastomosis in Simulation

INTRODUCCIÓN: La anastomosis intestinal laterolateral laparoscópica es una práctica habitual en la clínica y entrenada en simulación. El objetivo del estudio es el diseño y posterior validación de una herramienta fiable y reproducible para su evaluación. MÉTODOS: Se utilizó un método Delphi modificado para desarrollar los elementos de evaluación al que finalmente incluyeron 5 apartados (separación entre puntos, eversión, tensión, estanqueidad y iatrogenia). Se incluyeron 21 participantes, 10 residentes quirúrgicos de primer año y 11 expertos. Realizaron anastomosis enteroentéricas laterolateral laparoscópica en víscera ex-vivo porcina de 5 cm. Las evaluaciones fueron ciegas y realizadas por 2 evaluadores de forma independiente. RESULTADOS: Las medias obtenidas por noveles y expertos fueron respectivamente: separación entre puntos 3,2 vs.5,7 (p < 0,001), eversión 3,3 vs.5,9 (p = 0,004), tensión 2,9 vs.5,9 (p = 0,001), estanqueidad 3,2 vs.5,7 (p = 0,005), iatrogenia 6,9 vs.7 (p = 0,47). El parámetro iatrogenia no es discriminatorio, por lo que fue eliminado de la herramienta. Los resultados totales fueron 12,5 los noveles y 23,2 los expertos (p = 0,001). La correlación entre observadores presenta un coeficiente de correlación intraclase de 0,99 para la separación entre puntos, 0,94 la eversión, 0,98 la tensión y 0,99 la estanqueidad. La relación entre la puntuación y la fuga anastomótica sin presión: presenta una R de Rosenthal de -0,71 (p < 0,001); con presión se obtiene una R = 0,55 (p = 0,01). CONCLUSIONES: La herramienta diseñada es válida para discriminar entre participantes noveles y expertos, presenta muy alta concordancia entre observadores y se correlaciona con el riesgo de fuga

INTRODUCTION: Laparoscopic side-to-side intestinal anastomosis is a common in clinic practice and training simulation. The aim of this study is to design and validate a reliable and reproducible tool for its evaluation. METHODS: A modified Delphi method was used to design a tool with elements that determine quality, including 5 items: separation between stiches, eversion, tension, leak and iatrogenesis. The study included 21 participants (10 first-year residents and 11 experts) who performed a 5 cm laparoscopic intestinal side-to-side anastomosis with porcine viscera. The evaluations were blinded and done independently by 2 evaluators. RESULTS: The means obtained by novice and expert participants were, respectively: separation between stiches 3.2 vs.5.7 (P < .001), eversion 3.3 vs.5.9 (P = .004), tension 2.9 vs.5.9 (P = .001), leak tightness 3.2 vs.5.7 (P = .005), iatrogenesis 6.9 vs.7 (P = .47). The iatrogenesis parameter was not discriminatory, so it was removed from the tool. The total results were 12.5 for novices and 23.2 for experts (P = .001). The correlation between observers presented an intraclass correlation coefficient of 0.99 for the separation between stiches, 0.94 for eversion, 0.98 for tension and 0.99 for leak. The correlation between the score and the leak without pressure presented a Rosenthal's R of -0.71 (P < .001); with pressure R = -0.55 (P = .01). CONCLUSIONS: The designed tool is valid to discriminate between novice and expert participants, presents very high concordance between observers and correlates with the risk of leak

Optimal Operative Strategy for Hinchey III Sigmoid Diverticulitis: A Decision Analysis.

BACKGROUND: Operative approaches for Hinchey III diverticulitis include the Hartmann procedure, primary resection and anastomosis, and laparoscopic lavage. Several randomized controlled trials and meta-analyses have compared these approaches; however, results are conflicting and previous studies have not captured the complexity of balancing surgical risks and quality of life. OBJECTIVE: This study aimed to determine the optimal operative strategy for patients with Hinchey III sigmoid diverticulitis. DESIGN: We developed a Markov cohort model, incorporating perioperative morbidity/mortality, emergency and elective reoperations, and quality-of-life weights. We derived model parameters from systematic reviews and meta-analyses, where possible. We performed a second-order Monte Carlo probabilistic sensitivity analysis to account for joint uncertainty in model parameters. SETTING: This study measured outcomes over patients' lifetime horizon. PATIENTS: The base case was a simulated cohort of 65-year-old patients with Hinchey III diverticulitis. A scenario simulating a cohort of highly comorbid 80-year-old patients was also planned. INTERVENTIONS: Hartmann procedure, primary resection and anastomosis (with or without diverting ileostomy), and laparoscopic lavage were performed. MAIN OUTCOME MEASURES: Quality-adjusted life years were the primary outcome measured. RESULTS: Following surgery for Hinchey III diverticulitis, 39.5% of patients who underwent the Hartmann procedure, 14.3% of patients who underwent laparoscopic lavage, and 16.7% of patients who underwent primary resection and anastomosis had a stoma at 12 months. After applying quality-of-life weights, primary resection and anastomosis was the optimal operative strategy, yielding 18.0 quality-adjusted life years; laparoscopic lavage and the Hartmann procedure yielded 9.6 and 13.7 fewer quality-adjusted life months. A scenario analysis for elderly, highly comorbid patients could not be performed because of a lack of high-quality evidence to inform model parameters. LIMITATIONS: This model required assumptions about the long-term postoperative course of patients who underwent laparoscopic lavage because few long-term data for this group have been published. CONCLUSIONS: Although the Hartmann procedure is widely used for Hinchey III diverticulitis, when considering both surgical risks and quality of life, both laparoscopic lavage and primary resection and anastomosis provide greater quality-adjusted life years for patients with Hinchey III diverticulitis, and primary resection and anastomosis appears to be the optimal approach. See Video Abstract at http://links.lww.com/DCR/B223. ESTRATEGIA OPERATIVA ÓPTIMA EN DIVERTICULITIS HINCHEY III DE SIGMOIDES: UN ANÁLISIS DE DECISION: Los enfoques quirúrgicos para la diverticulitis Hinchey III incluyen el procedimiento de Hartmann, la resección primaria y anastomosis, y el lavado laparoscópico. Varios ensayos controlados aleatorios y metanálisis han comparado estos enfoques; sin embargo, los resultados son contradictorios y los estudios previos no han captado la complejidad de equilibrar los riesgos quirúrgicos y la calidad de vida.Determinar la estrategia operativa óptima para pacientes con diverticulitis Hinchey III de sigmoides.Desarrollamos un modelo de cohorte de Markov, incorporando morbilidad / mortalidad perioperatoria, reoperaciones electivas y de emergencia, y pesos de calidad de vida. Derivamos los parámetros del modelo de revisiones sistemáticas y metaanálisis, cuando fue posible. Realizamos un análisis de sensibilidad probabilístico Monte Carlo de segundo orden para tener en cuenta la incertidumbre conjunta en los parámetros del modelo.Seguimiento de por vida.El caso base fue una cohorte simulada de pacientes de 65 años con diverticulitis de Hinchey III. También se planeó un escenario que simulaba una cohorte de pacientes de 80 años altamente comórbidos.Procedimiento de Hartmann, resección primaria y anastomosis (con o sin desviación de ileostomía) y lavado laparoscópico.Años de vida ajustados por calidad.Después de la cirugía para la diverticulitis de Hinchey III, el 39.5% de los pacientes que se sometieron al procedimiento de Hartmann, el 14.3% de los pacientes que se sometieron a un lavado laparoscópico, y el 16.7% de los pacientes que se sometieron a resección primaria y anastomosis tuvieron un estoma a los 12 meses. Después de aplicar el peso de la calidad de vida, la resección primaria y la anastomosis fueron la estrategia operativa óptima, que dio como resultado 18.0 años de vida ajustados en función de la calidad; el lavado laparoscópico y el procedimiento de Hartmann arrojaron 9.6 y 13.7 meses de vida ajustados en función de la calidad, respectivamente. No se pudo realizar un análisis de escenarios para pacientes de edad avanzada altamente comórbidos debido a la falta de evidencia de alta calidad para informar los parámetros del modelo.Este modelo requirió suposiciones sobre el curso postoperatorio a largo plazo de pacientes que se sometieron a lavado laparoscópico, ya que se han publicado pocos datos a largo plazo para este grupo.Aunque el procedimiento de Hartmann se usa ampliamente para la diverticulitis de Hinchey III, cuando se consideran tanto los riesgos quirúrgicos como la calidad de vida, tanto el lavado laparoscópico como la resección primaria y la anastomosis proporcionan una mayor calidad de años de vida ajustada para los pacientes con diverticulitis de Hinchey III y la resección primaria y anastomosis parece ser el enfoque óptimo. Consulte Video Resumen en http://links.lww.com/DCR/B223.

Limb Salvage Rates and Functional Outcomes Using a Longitudinal Slit Arteriotomy End-to-Side Anastomosis for Limb-Threatening Defects in a High-Risk Patient Population.

BACKGROUND: Limb salvage techniques using free tissue transfer in patients with chronic wounds caused by longstanding osteomyelitis, diabetes, and peripheral vascular disease are technically challenging. The longitudinal slit arteriotomy end-to-side anastomosis is the authors' preferred technique because it is the least invasive arteriotomy and is especially important for diseased recipient arteries. The authors reviewed highly comorbid patients who underwent free tissue transfer with this technique to understand the success rates, overall outcomes, and long-term limb salvage rates. METHODS: A retrospective review was performed to analyze outcomes of free tissue transfer using longitudinal slit arteriotomy end-to-side anastomosis between 2012 and 2018 performed by the senior surgeon (K.K.E.). RESULTS: One hundred fifteen free flaps were identified. Patients were, on average, 55.9 years old, with a body mass index of 29.2 kg/m. Comorbidities included osteomyelitis (83.5 percent), hypertension (60.9 percent), tobacco use (46.1 percent), diabetes (44.3 percent), peripheral vascular disease (44.3 percent), hypercoagulability (35.7 percent), and arterial calcifications (17.4 percent). Overall flap success was 93.0 percent; 27.8 percent required reoperation perioperatively because of complications. On univariate analysis, diabetes mellitus, hypertension, and hypercoagulability were significantly associated with eventual amputation (p < 0.05). Multivariate analysis showed that intraoperative thrombosis and take back was independently associated with flap failure. There was an overall limb salvage rate of 83.5 percent, and of those salvaged, 92.7 percent were ambulating without a prosthesis at a mean follow-up of 1.53 years. CONCLUSIONS: This is the largest series of longitudinal slit arteriotomy end-to-side anastomosis for patients undergoing free tissue transfer for limb-threatening defects in the compromised host. Overall flap success, limb salvage rates, and functional outcomes are high using this technique. CLINICAL QUESTION/LEVEL OF EVIDENCE: Therapeutic, IV.

The influence of anastomotic leakage for rectal cancer oncologic outcome: A systematic review and meta-analysis.

BACKGROUND AND OBJECTIVE: Anastomotic leakage is a serious complication after arterial resection of rectal cancer. It has been found that anastomotic leakage is related to the oncological outcome. The purpose of the study is to evaluate the long-term outcome of the rectal tumor after anastomotic leakage. METHODS: The effect of anastomotic leakage on the oncological outcome of rectal cancer was studied by electronic literature retrieval. Using the DerSimonian Laird random effect model to calculate the odds ratio and 95% confidence interval. Research heterogeneity was evaluated by Q statistics and I2 , and bias was evaluated by funnel plot and Begg's test. RESULTS: A total of 35 studies and 44 698 patients were included in the study. The studies have shown that anastomotic leakage is associated with local recurrence (OR = 1.93; 95% CI, 1.57-2.38; P < .0001), overall survival (OR = 1.64; 95% CI, 1.37-1.95; P < .00001), disease-free survival (OR = 2.07; 95% CI, 1.50-2.87; P < .00001) and cancer-specific survival (OR = 1.32; 95% CI, 1.02-1.70; P = .012), while it was not related to distant recurrence (OR = 1.25; 95% CI, 0.95-1.65; P = .12). CONCLUSIONS: The results showed that anastomotic leakage after anterior resection increased the risk of local recurrence, decreased the overall survival, cancer-specific survival and disease-free survival.

Risk Factors for Postoperative Anastomosis Leak After Esophagectomy for Esophageal Cancer.

BACKGROUND/AIM: The present study aimed to identify risk factors for anastomosis leak (AL) after esophagectomy for esophageal cancer. PATIENTS AND METHODS: One-hundred twenty-two patients who underwent esophagectomy for esophageal cancer between 2008 and 2018 were included. The rate of AL was measured based on the definition of leak as adapted from the Surgical Infection Study Group. To identify the risk factors for AL, logistic regression analysis was used. RESULTS: AL was found in 44 of the 122 patients (36.1%). Among the factors examined, the lymph node dissection status (p=0.007) and preoperative serum albumin level (p=0.022) were significant independent risk factors for AL. The incidence of AL was 26.7% (20 of 75) among patients who received 2-field lymph node dissection and 51.1% (24 of 47) among those who received 3-field lymph node dissection. The incidence of AL was 29.9% (23 of 77) in the preoperative serum albumin levels ≥4.0 g/dl group and 46.7% (21 of 45) in the serum albumin levels <4.0 g/dl group. CONCLUSION: Lymph node dissection status and preoperative serum albumin levels were risk factors for AL in patients who received esophagectomy for esophageal cancer.

Uso de la sutura barbada para el cierre de la enterocolotomía tras hemicolectomía derecha con anastomosis intracorpórea. Estudio prospectivo descriptivo / Use of barbed suture for the closure of enterocolotomy after laparoscopic right hemicolectomy with intracorporeal anastomosis. A prospective descriptive study

INTRODUCCIÓN: Posiblemente la parte técnica que más destreza precisa en laparoscopia es la realización de anastomosis y suturas intracorpóreas. La aparición de las nuevas suturas barbadas durante los últimos años parece facilitar dichos gestos quirúrgicos. El objetivo de nuestro estudio es evaluar los resultados a corto plazo en pacientes con neoplasias de colon derecho, tras hemicolectomía derecha laparoscópica con anastomosis intracorpórea mediante la utilización de sutura barbada en el cierre de la enterocolotomía. MÉTODOS: Se trata de un estudio descriptivo prospectivo multicéntrico en el que se incluyen pacientes que han sido intervenidos mediante hemicolectomía derecha laparoscópica por patología neoplásica colónica entre junio del 2015 y diciembre del 2018. En todos ellos se realizó la anastomosis intracorpórea mediante el uso de endocortadora y el cierre de la enterocolotomía mediante una doble capa de sutura barbada. RESULTADOS: Se ha intervenido a un total de 80 pacientes (47,5% mujeres), con una edad media de 70,6 ± 9 (49-92) años. El tiempo operatorio medio fue 99,5 ± 38 min. Un 2,5% de la muestra presentó dehiscencia de anastomosis y se tuvo que reintervenir a 5 pacientes (6,2%) como consecuencia de 2 dehiscencias, 2 cuadros obstructivos y un sangrado peritoneal. La mediana de estancia hospitalaria fue de 7 (3-173) días. CONCLUSIONES: El uso de la sutura barbada en la hemicolectomía derecha laparoscópica con anastomosis intracorpórea parece presentar una morbilidad similar a las series descritas en la literatura. En cualquier caso, serían necesarios estudios con mayor número de pacientes, prospectivos, controlados y aleatorizados para confirmar estos hallazgos

INTRODUCTION: Performing intracorporeal anastomoses and sutures is possibly the technique that requires the greatest skill in laparoscopic surgery. The appearance of the new barbed sutures in recent years has seemed to facilitate this surgical step. The aim of our study is to evaluate short-term results in patients with neoplasms of the right colon, after laparoscopic right hemicolectomy with intracorporeal anastomosis using barbed suture at the closure of the enterocolotomy. METHODS: This is a multicenter, prospective, descriptive study that includes patients who underwent laparoscopic right hemicolectomy for neoplastic colonic pathologies between June 2015 and December 2018. In all patients, the intracorporeal anastomosis was performed using the endocutter, and closure of the enterocolotomy was done with a double layer of barbed suture. RESULTS: A total of 80 patients were treated (47.5% women), with an average age of 70.6 ± 9 (49-92) years. The average operative time was 99.5 ± 38 minutes Anastomotic dehiscence was observed in 2.5% of the sample, and 5 patients required re-operation (6.2%) as a result of 2 leaks, 2 obstructive symptoms and one peritoneal bleeding. Mean hospital stay was 7 (3-173) days. CONCLUSIONS: The use of barbed suture in laparoscopic right hemicolectomy with intracorporeal anastomosis seems to present a morbidity similar to series described in literature. Prospective, controlled and randomized studies with a larger number of patients would be necessary to confirm these findings

Shunt intention during carotid endarterectomy in the early symptomatic period and perioperative stroke risk.

OBJECTIVE: Whether recent stroke mandates planned shunting during carotid endarterectomy (CEA) is controversial. Our goal was to determine associations of various shunting practices with postoperative outcomes of CEAs performed after acute stroke. METHODS: The Vascular Quality Initiative database (2010-2018) was queried for CEAs performed within 14 days of an ipsilateral stroke. Surgeons who prospectively planned to shunt either shunted routinely per their usual practice or shunted selectively for preoperative indications. Surgeons who prospectively planned not to shunt either shunted selectively for intraoperative indications or did not shunt. Univariable and multivariable analyses compared shunting approaches. RESULTS: There were 5683 CEAs performed after acute ipsilateral stroke. Surgeons planned to shunt in 56.1% of cases. Patients whose surgeons planned to shunt vs planned not to shunt were more likely to have severe contralateral stenosis (8.8% vs 6.9%; P = .008), to receive general anesthesia (97.5% vs 89.1%; P < .001), and to undergo conventional CEA (94% vs 81.8%; P < .001). Unadjusted outcomes were similar between the cohorts for operative duration (124.3 ± 48.1 minutes vs 123.6 ± 47 minutes; P = .572) and 30-day stroke (3.4% vs 3%; P = .457), myocardial infarction (1.1% vs 0.8%; P = .16), and mortality (1.6% vs 1.3%; P = .28). On multivariable analysis, planning to shunt vs planning not to shunt was associated with similar risk of 30-day stroke (odds ratio [OR], 1.17; 95% confidence interval [CI], 0.82-1.67; P = .402). On subgroup analysis, in 38.4% patients, no shunt was placed, whereas the remainder received routine shunts (44.4%), preoperatively indicated shunts (11.6%), and intraoperatively indicated shunts (5.5%). Compared with no shunting, shunting by surgeons who routinely shunt was associated with a similar stroke risk (OR, 1.39; 95% CI, 0.91-2.13; P = .129), but shunting by surgeons who selectively shunt on the basis of preoperative indications (OR, 2.11; 95% CI, 1.22-3.63; P = .007) or intraoperative indications (OR, 3.34; 95% CI, 1.86-6.01; P < .001) was associated with increased stroke risk. Prior coronary revascularization independently predicted increased intraoperatively indicated shunting (OR, 1.37; 95% CI, 1.05-1.8; P = .022). CONCLUSIONS: In CEAs performed after acute ipsilateral stroke, there is no difference in postoperative stroke risk when surgeons prospectively plan to shunt or not to shunt. Shunting is often not necessary; however, when shunting is performed, routine shunters achieve better outcomes.