Anastomotic bleeding from invaginated pancreaticogastrostomy following pancreatoduodenectomy: incidence, risk factors, treatment and prevention.

BACKGROUND: Meta-analysis of 10 randomized prospective trials demonstrated a higher risk of postoperative bleeding from pancreaticogastrostomy (PG) compared with pancreatojejunostomy following pancreatoduodenectomy (PD). This study evaluated the incidence, risk factors, and treatment of anastomotic bleeding from invaginated PG. METHODS: We retrospectively evaluated all consecutive PDs performed between April 1, 2011 and December 31, 2022 using invaginated PG by the double purse-string technique. Multivariate analysis identified risk factors for anastomotic PG bleeding. RESULTS: During the study, 695 consecutive patients with a median age of 66 years underwent PD; the majority was performed for ductal pancreatic adenocarcinomas. Simultaneous vascular resections were performed in 328 patients. Postoperative mortality was 4.1%. Bleeding from PG occurred in 33(4.6%) patients at a median interval of 5 days (range, 1-14) from surgery, leading to reoperation in 21(63%). PG bleeding-related mortality was 9.0%. Multivariate analyses identified a soft pancreatic texture and Wirsung duct > 3 or ≤ 3 mm (Class C and D, respectively, of the ISGPS) (odds ratio [OR]: 2.17, 95% confidence interval [95% CI]: 1.38-3.44; P = 0.0009) and wrapping of the invaginated pancreas (OR: 0.37, 95% CI: 0.17-0.84; P = 0.01) as independent risk factors for PG bleeding. CONCLUSIONS: In a large volume setting, anastomotic bleeding from invaginated PG occurred in ~ 5% of patients and was associated with soft pancreatic parenchyma and small wirsung duct. The reduced rate of PG bleeding observed with wrapping of the invaginated pancreatic stump warrants further evaluation in a prospective randomized study.

Impact of powered circular stapler on anastomotic leak after anastomosis to the rectum: a propensity score matched study.

PURPOSE: The aim of the present study is to assess the impact of Echelon Circular™ powered stapler (PCS) on left-sided colorectal anastomotic leaks and to compare results to conventional circular staplers (CCS). METHODS: A single center cohort study was carried out on 552 consecutive patients, who underwent laparoscopic colorectal resection and anastomosis to the rectum between December 2017 and September 2022. Patients who underwent powered circular anastomosis to the rectum were matched to those who had a conventional stapled anastomosis using a propensity score matching. Main outcomes were anastomotic leak (AL) rate, anastomotic bleeding, and postoperative outcomes. RESULTS: After adjusting cases with propensity score matching, two new groups of patients were generated: 145 patients in the PCS and 145 in the CCS. The two groups were homogeneous with respect to demographics and comorbidities on admission. Overall, AL occurred in 21 (7.3%) patients. No significant differences were observed with respect to AL (5.5% in PCS vs 9% in CCS; p = 0.66), fistula severity (p = 0.60) or reoperation rate (p = 0.65) in the two groups in study. A higher rate of anastomotic bleeding was observed in the CCS vs PCS (5.5% vs 0.7%, p = 0.03). At univariate analysis performed after propensity score matching, stapler diameter ≥ 31mm and age ≥ 70 years were the only variable significantly associated with anastomotic leak (p = 0.001 and p = 0.031; respectively). CONCLUSIONS: The powered circular stapler has no impact on AL, while it could affect bleeding rate at the anastomotic site.

Endoscopic Management of Bleeding in Altered Anatomy after Upper Gastrointestinal Surgery.

Postoperative non variceal upper gastrointestinal haemorrhage may occur early or late and affect a variable percentage of patients-up to about 2%. Most cases of intraluminal bleeding are an indication for urgent Esophagogastroduodenoscopy (EGD) and require endoscopic haemostatic treatment. In addition to the approach usually adopted in non-variceal upper haemorrhages, these cases may be burdened with difficulties in terms of anastomotic tissue, angled positions, and the risk of further complications. There is also extreme variability related to the type of surgery performed, in the context of oncological disease or bariatric surgery. At the same time, the world of haemostatic devices available in digestive endoscopy is increasing, meeting high efficacy rates and attempting to treat even the most complex cases. Our narrative review summarises the current evidence in terms of different approaches to endoscopic haemostasis in upper bleeding in altered anatomy after surgery, proposing an up-to-date guidance for endoscopic clinicians and at the same time, highlighting areas of future scientific research.

Endoscopic management of postoperative anastomotic bleeding in patients with colorectal cancer.

BACKGROUND: Postoperative anastomotic bleeding is considered a rare but life-threatening complication. There is no standard treatment strategy for this emergency condition. The aim of this study was to report our experiences in the management of postoperative anastomotic bleeding in patients with colorectal cancer. METHODS: We analyzed the general characteristics, treatments, and outcomes of patients with anastomotic bleeding after surgery for colorectal carcinoma at the Sixth Affiliated Hospital of Sun Yat-Sen University between July 2013 and September 2019 retrospectively. A univariate and multivariate analysis was performed to find protective factors for endoscopic hemostasis. Risk factors for anastomotic leakage after colonoscopy were also analyzed. RESULTS: A total of 9870 patients underwent surgeries for colorectal carcinoma between July 2013 and September 2019. Colonoscopies were performed in 78 cases with postoperative anastomotic bleeding. The effective rate of initial endoscopic hemostasis was 81% (63/78). In univariate and multivariate analysis, hemoclip therapy (odds ratio = 4.572; 95%CI 1.305-16.017; P = 0.017) and postoperative anastomotic bleeding within 5 days (odds ratio = 3.639; 95%CI 1.045-12.675; P = 0.042) are protective factors for endoscopic hemostasis. Comorbidity was associated with an increased risk for anastomotic leakage. CONCLUSIONS: Colonoscopy seems to be an effective way to achieve hemostasis for patients with anastomotic bleeding after surgery for colorectal carcinoma. It may be more effective in the early postoperative period, and hemoclip appears to be the first choice to control postoperative anastomotic bleeding.

Anastomotic bleeding following ileocolic end-to-side anastomosis using a circular stapler: incidence and risk factors.

PURPOSE: To identify the incidence of and risk factors for postoperative bleeding after ileocolic end-to-side anastomosis using a circular stapler. METHODS: We analyzed, retrospectively, the risk factors for postoperative anastomotic bleeding in patients who underwent right-sided colectomy with end-to-side anastomosis done using a circular stapler during colon tumor surgery at our institute between January 2015 and March 2019. RESULTS: Anastomotic bleeding developed in 10 (3.6%) of the total 279 patients. Univariate analysis revealed that age ≥ 80 years (8.8% vs. 1.9%; P = 0.008) and Eastern Cooperative Oncology Group performance status (ECOG PS) ≥ 1 (12.5% vs. 2.8%; P = 0.014) were significant risk factors for anastomotic bleeding. Postoperative anticoagulation therapy was not a risk factor for anastomotic bleeding. Multivariate analysis revealed that only age ≥ 80 years was an independent risk factor (odds ratio 4.12, 95% confidence interval 1.02-16.68, P = 0.047). Six of the ten patients with anastomotic bleeding were treated conservatively, three were treated by colonoscopic clipping, and one required surgery. CONCLUSION: End-to-side anastomosis is safe and feasible, but must be performed carefully in the elderly, who are at higher risk of anastomotic bleeding.

Does intra-operative flexible endoscopy reduce anastomotic complications following left-sided colonic resections? A systematic review and meta-analysis.

AIM: Postoperative anastomotic leakage (AL) or bleeding (AB) significantly impacts on patient outcome following colorectal resection. To minimize such complications, surgeons can utilize different techniques perioperatively to assess anastomotic integrity. We aim to assess published anastomotic complication rates following left-sided colonic resection, comparing the use of intra-operative flexible endoscopy (FE) against conventional tests used to assess anastomotic integrity. METHODS: PubMed/MEDLINE and Embase online databases were searched for non-randomized and randomized case-control studies that investigated postoperative AL and/or AB rates in left-sided colonic resections, comparing intra-operative FE against conventional tests. Data from eligible studies were pooled, and a meta-analysis using Review Manager 5.3 software was performed to assess for differences in AL and AB rates. RESULTS: Data from six studies were analysed to assess the impact of FE on postoperative AL and AB rates (1084 and 751 patients respectively). Use of FE was associated with reduced postoperative AL and AB rates, from 6.9% to 3.5% and 5.8% to 2.4% respectively. Odds ratios favoured intra-operative FE: 0.37 (95% CI 0.21-0.68, P = 0.001) for AL and 0.35 (95% CI 0.15-0.82, P = 0.02) for AB. CONCLUSION: This meta-analysis showed that the use of intra-operative FE is associated with a reduced rate of postoperative AL and AB, compared to conventional anastomotic testing methods.

Management of postoperative bleeding after laparoscopic left colectomy.

BACKGROUND: Lower gastrointestinal bleeding after left colectomy is an uncommon complication that can lead to critical situation. Diagnostic and therapeutic manoeuvres should be performed in emergency with step-by-step strategy in order to avoid reoperation. This study aims to identify bleeding risks factors and describe a management strategy. METHODS: This is a retrospective study of patients who underwent left colectomy with primary anastomosis, from May 2004 to December 2013. We studied their demographic characteristics, surgical procedures and postoperative courses, more specifically hemorrhagic complications, management of bleeding and outcomes. RESULTS: Hemorrhagic anastomotic complication occurred in 47 of the 729 (6.4 %) patients after left colectomy. Neither anticoagulant nor antiaggregant treatment was associated with postoperative bleeding. Among the 47 patients with bleeding, endoscopy was performed in 37 (78.7 %). At the time of endoscopy, the bleeding was spontaneously stopped in nine (24.3 %). Therapeutic strategy used clips in 10 (27.0 %) cases, mucosal sclerosis in 11 (29.7 %) and both in 7 (18.9 %) cases. Four (8.5 %) patients required blood transfusion for treatment of this gastrointestinal bleeding. Five (10.6 %) patients with bleeding were reoperated in this group because early endoscopy showed associated anastomotic leakage. Based on a multivariate analysis, stapled anastomosis and diverticular disease were independent factors associated with anastomotic bleeding. CONCLUSIONS: Postoperative anastomotic bleeding is not so uncommon after left colectomy. This complication should be particularly dreaded in patients who underwent stapled colorectal anastomosis for diverticular disease. With the use of clip or mucosal sclerosis, early endoscopy is a safe and efficient treatment.

Endovascular embolization for managing anastomotic bleeding after stapled digestive tract anastomosis.

BACKGROUND: Anastomotic bleeding is an infrequent but life-threatening complication after stapled digestive tract anastomosis. Endovascular embolization is one of the available treatments, but precise clinical outcomes are yet to be evaluated. PURPOSE: To evaluate the efficacy and safety of endovascular embolization for managing anastomotic bleeding after stapled digestive tract anastomosis. MATERIAL AND METHODS: Twenty-eight patients were diagnosed with anastomotic bleeding after stapled digestive tract anastomosis by digital subtraction angiography (DSA). Curative effect was summed for analysis. RESULTS: All bleeding arteries were located in the stoma and were identified by contrast agent spillover by DSA. The offending arteries were superselectively catheterized and embolized with microcoils and/or gelatin sponge particles. Laboratory examinations showed normal hemoglobin and red blood cell counts when the patients' abdominal cavity drainage tubes stopped draining blood. The follow-up period was 3.2-84.7 months (median, 19.7 months). Four patients died during this time, of which two had cholangiocarcinoma, one had gastric cancer with tumor recurrence and multiple organ failure, and the final patient had a subarachnoid hemorrhage 4 months after embolization. In the surviving patients, no rebleeding occurred after embolization and no additional intervention or surgery was required. CONCLUSION: Endovascular embolization is safe and effective for managing anastomotic bleeding after stapled digestive tract anastomosis.

[Endoscopic management of complications of the upper and lower gastrointestinal tract]. / Endoskopisches Komplikationsmanagement am oberen und unteren Gastrointestinaltrakt.

Even when wide-ranging measures for avoidance of complications by improved techniques, training and many other activities are undertaken, postoperative and postinterventional complications still represent a daily problem in clinical medicine. The outcome of the patient is not uncommonly decided by the management of the complications. The failure to rescue or to control complications is increasingly recognized as being decisive for the success of treatment. This article therefore provides a current overview of the endoscopic management of complications of the upper and lower gastrointestinal tract. It describes when endoscopy can be used to detect or exclude a complication. The most important principles of treatment including the indications, limits of performance and technique are presented.

Overview of Common Complications in Inflammatory Bowel Disease Surgery.

The complication rate after surgery in patients with inflammatory bowel disease is high owing to chronic inflammatory and suboptimal physiologic state, the effect of steroids and immunosuppressive medication, and the inherent complexity of the surgical procedures. Although some of the complications after surgery are similar for Crohn disease and ulcerative colitis, others are specific to the diagnosis. Complications are divided into early postoperative and late complications. Specific complications are related to more extensive surgery such as a proctocolectomy or reoperative procedures or with complex reconstructive procedures such as the ileoanal pouch and continent ileostomy.

Extracorporeal Hand-Sewn vs. Intracorporeal Mechanic Anastomosis During Laparoscopic Right Colectomy.

Background and Objectives: To compare the outcomes of extracorporeal hand-sewn side-to-side isoperistaltic ileocolic anastomosis (EHSIA) versus intracorporeal mechanic side-to-side isoperistaltic ileocolic anastomosis (IMSIA) during laparoscopic right hemicolectomy for adenocarcinoma. Methods: This is a retrospective propensity score-matched analysis of prospectively collected data. Fifty-four patients who underwent surgery with EHSIA (intervention group) were paired with 54 patients who underwent surgery with IMSIA (control group) based on patients' demographics and type of surgery (standard right hemicolectomy or extended right hemicolectomy). Results: Fifty-four patients were included for each group. Statistically significant differences between groups were not observed in patients' demographics and type of surgery. Conversion occurred in three patients of the intervention group due to intra-abdominal adhesions for previous surgery (5.6%) (p = 0.079). Median operative time was statistically significant shorter in the control group in comparison to the intervention group (85 and 117.5 minutes, respectively, p ≤ 0.0001). In both groups one anastomotic leakage was observed (1.9%) (Clavien-Dindo grade III-a). In the control group one patient (1.9%) underwent reintervention for acute postoperative anemia (Clavien-Dindo grade III-b). Median number of harvested lymph-nodes was 17 and 12 (p ≤ 0.0001), in the intervention and the control group, respectively. Median hospital stay was statistically significant lower in the control group in comparison to the intervention group (5 and 6.5 days, respectively, p ≤ 0.013). Conclusion: IMSIA showed lower operative time and hospital stay in comparison to EHSIA. Further randomized studies are required to draw definitive conclusions about the best anastomotic technique during laparoscopic right hemicolectomy.

Clinical study of use of large C suture in procedure for prolapse and hemorrhoids for treatment of mixed hemorrhoids.

OBJECTIVE: To investigate the clinical use of a large C suture in the procedure for prolapse and hemorrhoids (PPH) for treatment of mixed hemorrhoids. METHODS: Patients with mixed hemorrhoids (grade III or IV) who underwent treatment with a large C suture during PPH in the Affiliated Hospital (Group) of Putian University from 1 April 2018 to 31 March 2019 were enrolled in this retrospective study. The incidences of anastomotic stenosis and anastomotic hemorrhage after the operation were observed. RESULTS: The study population comprised 126 patients (46 men and 80 women) ranging in age from 30 to 78 years (mean, 46.1 ± 2.5 years). Of these patients, 60 had circular mixed hemorrhoids, 36 had grade III circular internal hemorrhoids, and 30 had grade IV circular internal hemorrhoids. The onset time among all patients ranged from 0.5 to 25 years. All patients underwent 6 months of postoperative follow-up. None of the patients with mixed hemorrhoids developed anastomotic stenosis, although two patients developed secondary anastomotic bleeding. CONCLUSION: Placement of a large C suture during PPH is a reliable technique for treatment of mixed hemorrhoids. It is simple, effective, and applicable and can be helpful for a large number of patients in primary hospitals.

[Investigation of prevention and treatment of anastomotic bleeding after colorectal surgery].

Anastomotic bleeding is a common complication after colorectal surgery, mainly manifesting as continuous or intermittent bloody stool. The risk factors for anastomotic bleeding mainly include suboptimal surgical skill, surgical methods (such as laparoscopic anastomosis), close distance between the tumor and the anal margin, benign colorectal diseases, anastomotic leakage after colorectal surgery, severe pelvic and abdominal infections, and the patient's own condition, etc. Anastomotic bleeding can be prevented by standardized operation and intraoperative endoscopic examination. Anastomotic bleeding is mostly a self-limited disease, which can be cured by conservative treatments such as fluid resuscitation, blood transfusion and endoscopic treatment. When serious anastomotic bleeding threatens the life of patients, surgical treatment should be taken into consideration decisively.

Clinical Significance of Intraoperative Colonoscopy for Anastomotic Assessment in Rectal Cancer Surgery.

BACKGROUND/AIM: To clarify the usefulness of intraoperative colonoscopy (CS) for preventing postoperative anastomotic leakage and bleeding in rectal cancer surgery. PATIENTS AND METHODS: The data of rectal cancer patients who underwent circular-stapled anastomosis from January 2008 to December 2016 were compared between 162 patients who received intraoperative CS (the CS group) and 23 patients who did not receive intraoperative CS (the non-CS group). RESULTS: Anastomotic leakage rate in the CS group (8.6%) was similar to that in the non-CS group (4.3%) (p=0.70). Postoperative anastomotic bleeding rate was also similar between the CS and non-CS groups (2.4% vs. 0%, p=0.50). Although a positive air leak test was observed in two patients in the CS group, no postoperative leakage developed by adding intraoperative treatment. CONCLUSION: Although intraoperative CS did not significantly reduce the incidence of postoperative anastomotic leakage or bleeding, it can be useful for certain cases.

Incidence and risk factors for anastomotic bleeding in lower gastrointestinal surgery.

OBJECTIVE: Although major anastomotic bleeding after lower gastrointestinal surgery is considered rare, it can be life-threatening if not properly managed. The objective of this study was to assess the incidence of postoperative lower gastrointestinal intraluminal bleeding and to identify its potential risk factors. This retrospective cohort study used data from charts of 314 patients who underwent digestive surgery of the colon or small intestine. Details are reported for their sociodemographic data, surgical approach, comorbidities, timing and presentation of intraluminal bleeding events, bleeding diagnosis, treatment strategies, hospital length of stay, and clinical complications. RESULTS: A total of 7 patients (2.3%) experienced intraluminal bleeding in the postoperative period. The average length of hospital stay before discharge was 12 days (median = 13 days). Patients with intraluminal bleeding had a significantly higher percentage of coronary artery diseases compared to patients without intraluminal bleeding (P value = .04), as well as having a cancer diagnosis (P value = .02). The clinical complications that were more likely in patients with intraluminal bleeding included requiring blood transfusions (P value = .01), reduction in hemoglobin (P value = .001), cardiac ischemia (P value = .02), and atrial fibrillations (P value = .02).

Acute bleeding obstruction pancreatitis after Roux-en-Y anastomosis in total gastrectomy: a single center experience.

Anastomotic intraluminal bleeding is a well-known complication after total gastrectomy. Nevertheless, few data are published on acute bleeding obstruction pancreatitis (BOP) due to a bleeding from the jejunojejunostomy (JJ). In this paper we describe our experience. A total of 140 gastrectomies for EGJ cancer were performed in our Institute from January 2012 to January 2017. All reconstructions were performed with a Roux-en-Y anastomosis: a mechanical end-to-side esophago-jejunostomy and a mechanical end-to-side JJ. Three patients suffered from a bleeding at the JJ with a consequent BOP. We analyzed the time of diagnosis, the treatment and the outcomes. The three patients presented anemia at the laboratory findings on postoperative day (POD) 1. In patient I laboratory findings of acute pancreatitis were found in POD 2. CT scan was performed and showed signs of BOP. Endoscopic treatment was tried without success. Therefore, patient underwent surgery: JJ take down, bleeding control and anastomosis rebuild were performed. In spite of this the patient died of MOF in POD 4. Patient II had a persistent anemia treated with blood transfusions until POD 3, when laboratory tests showed increased lipase and bilirubin levels. Patient was successfully treated with endoscopy but several blood transfusions and a prolonged recovery were necessary. Patient III had laboratory findings of acute pancreatitis on POD 1. Immediate surgery was performed and patient was discharged on POD 9 without sequelae. BOP is a rare but deadly complication after Roux-en-Y anastomosis. An early diagnosis and an aggressive treatment seem to improve the outcome.

Serie de casos de sangrado intraluminal postoperatorio en colectomía izquierda / Case series of postoperative intraluminal bleeding in left colectomy

Introducción: El sangrado digestivo intraluminal postoperatorio es una entidad poco frecuente y su manifestación clínica no difiere de la hemorragia digestiva baja de otra etiología. A pesar de que su presentación más habitual es la hematoquecia autolimitada en la primera deposición, en un discreto porcentaje puede requerir transfusiones, tratamiento endoscópico, hemodinámico, o incluso cirugía. Objetivo: Analizar los pacientes con sangrado digestivo intraluminal postoperatorio tratados en un centro de alta complejidad y realizar una revisión bibliográfica del tema. Diseño: Estudio retrospectivo, descriptivo. Material y métodos: Pacientes con sangrado anastomótico durante el post operatorio inmediato de una colectomía izquierda, operados en el Servicio de Cirugía General y Coloproctología desde enero del 2017 a diciembre del 2021. Las variables estudiadas fueron edad, sexo, anticoagulación y su causa, descenso de hemoglobina, cirugía realizada y su indicación, vía de abordaje, configuración de la anastomosis, electividad de la cirugía, complicaciones, días de internación y manejo terapéutico. Resultados: Se incluyeron 4 pacientes con una edad media de 72 (rango 54-87) años y una distribución por sexo de 1:1. En todos la colectomía izquierda fue programada y en 3 el abordaje fue laparoscópico. La anastomosis fue termino-terminal con sutura mecánica circular. Todos los pacientes presentaron sangrado en las primeras 24 horas postoperatorias. El tratamiento fue decidido de acuerdo a la condición hemodinámica: en los 2 pacientes con estabilidad hemodinámica fue suficiente el tratamiento conservador con reanimación y transfusiones. Los otros 2 que presentaron inestabilidad hemodinámica requirieron manejo intervencionista con endoscopía rígida, videocolonoscopía y cirugía. Conclusión: El sangrado intraluminal es una complicación poco frecuente de la anastomosis colorrectal que requiere manejo intervencionista solo en los pacientes que presentan inestabilidad hemodinámica. (AU)

Introduction: Postoperative intraluminal gastrointestinal bleeding is a rare entity and its clinical manifestation does not differ from lower gastro-intestinal bleeding of another etiology. Despite the fact that its most common presentation is self-limited hematochezia at the first stool, in a small percentage it may require transfusions, endoscopic or hemodynamic management, or even surgery. Aim: To analyze the patients with postoperative intraluminal gastrointestinal bleeding treated in a tertiary center and to carry out a bibliographic review of the subject. Design: Retrospective descriptive study. Material and methods: Patients with immediate postoperative anastomotic bleeding from a left colectomy, operated on at the General Surgery and Coloproctology Service from January 2017 to December 2021 were included. The variables recorded were age, sex, anticoagulation and its cause, decrease in hemoglobin, procedure performed and its indication, surgical approach, type of anastomosis, electiveness of surgery, complications, hospital stay and management. Results: Four patients with a mean age of 72 (range 54-87) years and a 1:1 gender distribution were included. All procedures were elective and 3 laparoscopic. All anastomoses were performed end-to-end with a circular stapler. All patients presented bleeding in the first 24 postoperative hours. The treatment was decided according to the hemodynamic condition; patients with hemodynamic stability (2) received medical treatment while those with hemodynamic instability (2) required interventional management with rigid endoscopy, colonoscopy and surgery. Conclusion: Intraluminal bleeding is a rare complication of colorectal anastomosis that requires interventional management only in patients with hemodynamic instability. (AU)

Research status of anastomotic complications of rectal cancer / 中华消化外科杂志

In colorectal cancer,the incidence of rectal cancer (RC) is relatively higher.Most of RC patients have chosen surgical treatment,while patient's own conditions,inadequate preoperative preparation,less surgical experiences of doctors,improper postoperative management and other factors lead to the appearance of anastomotic complications,such as anastomotic leakage,anastomotic stenosis and anastomotic bleeding.The risk of postoperative anastomotic complications is higher in low RC.However,it still has some controversies for the definition and classification of anastomotic complications,and the cause of complication is still not clear.The different treatment methods for anastomotic complications can be chosen,and most of them are effective.Since the anastomotic complications will affect the prognosis of patients,the prevention of complications is essential and some effective treatment methods should be used.

Successful Repair of Critical Anastomotic Bleeding after Surgery for Ruptured Infected Thoracic Aortic Aneurysm / 日本心臓血管外科学会雑誌

Infected aortic aneurysm is very difficult to treat and is associated with a high mortality rate. A 78-year-old man had been scheduled to undergo selective endovascular repair for distal aortic arch aneurysm. While standby, however, he was admitted to our emergency room because of hemoptysis. Rapid dilatation of the aneurysm shown on serial CT and elevated of inflammatory reactions yielded a diagnosis of infected aortic aneurysm. Because the aneurysm had ruptured into the left lung, emergency surgery was performed. Six days after the first operation, critical bleeding due to anastomotic disruption of the distal aorta caused by infection and subsequent cardiac arrest occurred. We immediately started open chest massage and controlled the bleeding manually in the ICU, while an operating room was prepared. In the redo operation, anastomotic disruption was repaired using the visceral pleura under deep hypothermic circulatory arrest. Anastomotic bleeding is a potentially life-threatening condition, therefore extremely prompt measures are vital. Appropriate management based on the assumption of anastomotic bleeding was very important in the postoperative course of this case of infectious aortic aneurysm.

Circular Stapled Gastrojejunostomy after Radical Subtotal Gastrectomy: Anastomotic Bleeding and Prevention

PURPOSE: Circular stapled gastrectomy has been the favored procedure with its feasibility and the shortened operative time, but anastomotic leakage, stenosis and bleeding have been reported as problems. The aim of this study was to identify what can be done to supplement the safety of this technique by examining the potential complications of performing circular stapled gastrojejunosomy after radical subtotal gastrectomy. MATERIALS AND METHODS: As subjects, this study selected 1,391 patients who underwent gastrojejunostomy after radical subtotal gastrectomy because of gastric cancer at our Department of Surgery from Jan. 1998 to Dec. 2007. The patients were divided into Group I (n=479) who underwent hand-sewn gastrojejunostomy, Group II (n=48) who underwent linear stapled gastrojejunostomy and Group III (n=864) who underwent circular stapled gastrojejunostomy. Group III was re-divided into two subgroups on the basis of the point of time that a visual check was intraoperatively performed at the anastomotic site: Group III-A (n=198) before and Group III-B (n=666) after. The characteristics and complications of the patients were then compared. RESULTS: For the comparison of the complications between Group I, Group II and Group III, anastomotic leakage was found in 7 cases (1.5%) in Group I, in 1 case (2.0%) in Group II and in 10 case (1.2%) in Group III, and anastomotic stenosis were found in 4 cases (0.8%) in Group I, 1 case (2.0%) in Group II and 5 case (0.6%) in Group III. Anastomotic bleeding was found in 32 cases (6.7%) in Group I, in 5 cases (10.4%) in Group II and in 67 cases (7.7%) in Group III. For the comparison of complications between Group III-A and Group III-B, anastomotic bleeding was found in 57 cases (28.8%) in Group III-A and 10 cases (1.5%) in Group III-B and the difference was statistically significant (P=0.037). CONCLUSION: Circular stapled gastrojejunostomy after radical subtotal gastrectomy is recommended because of the safety and feasibility of this technique, but bleeding at the anastomotic site may be the critical issue. In conclusion, direct inspection for bleeding at the anastomotic site during the operation will improve the safety of performing circular stapler anastomosis.