Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era

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

O-OGC08 The Impact of Anastomotic Techniques on Post-operative Anastomotic Complications: Results of the Oesophago-Gastric Anastomosis Audit (OGAA)

Background The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage (AL) and conduit necrosis (CN) are not known. The aim of this study was to assess whether anastomotic technique is associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit (OGAA) cohort. Methods This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over nine months in 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled or circular stapled. The primary outcome was a composite of AL and CN, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modelling was used to identify the strength of association between anastomotic techniques and anastomotic failure. Results Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0% and circular stapled in 51.9%. Anastomotic techniques differed significantly between the anastomosis site (p < 0.001), with the majority of neck anastomoses being handsewn (69.9%), whilst most chest anastomoses were stapled (66.3% circular stapled, 19.3% linear stapled). Rates of AL/CN differed significantly between the anastomotic techniques (p < 0.001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled, and 12.1% in circular stapled. This was confirmed by multivariable analysis (Odds ratio (OR): 0.63, 95% CI: 0.46 - 0.86) for circular stapled vs. handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with AL/CN rates of 23.2% vs. 14.6% vs 5.9% for handsewn vs. linear stapled anastomoses vs circular stapled, compared to 13.7% vs. 13.8% vs 12.2% in chest anastomoses. Conclusions Handsewn anastomoses appear to be associated with higher rates of anastomotic failure for anastomoses in the neck. However, anastomotic failure rates in the chest were similar across techniques and there was no significant difference on multivariable analysis. Further research into standardization of approach and techniques may further improve outcomes.

Unusual Anastomotic Failure in Patients with COVID-19: A Case Report of 2 Patients

Introduction: A newly appeared challenge for the healthcare system is the variety of clinical symptoms of COVID-19. In this research, we report 2 cases admitted to Modarres Hospital with unusual postoperative anastomotic failure. Case Presentation: In a 72-year-old man with a perforated peptic ulcer in D2 and signs of leakage after the first operation and during the second operation due to massive unexpected hemorrhage, we found fully disrupted anastomosis on the second part of the duodenum. Accordingly, the suture ligature of the bleeding ulcer with the closure of the duodenal stump and loop gastrojejunostomy and tube duodenostomy were performed. During the postoperative period, he developed dyspnea, and the diagnostic test of SARS-CoV-2 confirmed him as a case of COVID-19. Unfortunately, 1 week after the second surgery, evidence of anastomotic leakage appeared again by bile discharge from drains; although it was managed conservatively, he died because of respiratory failure. In another case, a 65-year-old woman was admitted to the emergency ward with closed-loop small bowel obstruction. After emergency laparotomy, resection of ischemic bowel with primary anastomosis was performed. The same as the previous case, she developed dyspnea, and the diagnostic test resulted positive for COVID-19. After 2 weeks, she was admitted to the hospital with signs of anastomotic leakage that was subsequently confirmed by abdominal computed tomography (CT); although it was managed conservatively, she died because of respiratory failure due to COVID-19. Conclusions: These cases were unique in that intestinal microangiopathies can cause very severe problems, weaken the body, and eventually death, as we have seen in these 2 cases.

Management of Post Cholecystectomy Bile Duct Injury: Pertinent Factors Contributing to Good Surgical Outcomes

Objective: Surgical management remains the mainstay treatment for bile duct injury (BDI) post-cholecystectomy. Achieving long-term patency and lessening anastomotic failure depends on important factors including the types of repairs, timing of repairs, and surgical expertise. The present study focused on the impact of these factors on the surgical outcomes of BDI repair. Materials and Methods: Fifty-nine patients who were treated with BDI post cholecystectomy at the surgical department between January 2003 and December 2018 were retrospectively reviewed. The patients were categorized as 11 in-house and 48 referral patients, of which 22 patients had bile duct repairs prior to referral. Surgical outcomes and factors, including types of repairs, timing of repairs, and surgical expertise, impacting on the treatment results were analyzed. Results: The mean age of the patients was 47.6 years. The BDI incidence in the authors’ hospital was 0.14%. Complications occurred in 21 patients (35.6%), of which intraabdominal collection was the most common at 10 patients (16.9%). The median length of hospital stay was 16 days for in-house patients and 17 days for the referral group (p=0.542). The mortality rate was 1.7%. The overall patency was 93% with mean follow up 106.4 months. Concerning the primary patency rate, the partial segments IV/V liver resection and hepaticojejunostomy techniques had better long-term patency compared to primary repairs at 92.3% versus 37.5% (p=0.017), and biliary bypass at 92.3% versus 80% (p=0.44). BDI repairs performed by primary surgeons increased the risk of anastomotic failure in comparison to those done by hepatobiliary surgeons with 10-year patency at 53.3% versus 95.4% (p=0.014). Delayed repairs longer than six weeks after injury offered positive long-term outcomes compared to early repairs done within six weeks after injury, with a 10-year patency at 85.4% versus 31.3% (p<0.001). Conclusion: Delayed repair performed by the hepatobiliary surgeon with appropriate surgical techniques decreased anastomosis stricture and achieved good overall surgical outcomes in the management of post cholecystectomy BDI. Keywords: Bile duct injury; Cholecystectomy; Surgical management

Outcomes Assessment between Hand Sewn and Stapled Intestinal Anastomosis

Objective: This study was conducted at the Department of Surgery of Liaquat University of Medical & Health Sciences, Jamshoro, Sindh, Pakistan for comparing the effectiveness of both methods: hand sewn and stapled intestinal anastomosis and to find a better comparatively to be more efficient. Methods: A total of 70 patients were encompassed who underwent intestinal anastomoses from proximal jejunum to 2/3rd of proximal distal rectum. All patients were assigned to two different groups A and B each encompassing of 35 cases. In group A, the single layer continuous and in group B single layer patients intervallic serosubmucosal anastomosis was made by implementing the stitches approximately 6 mm at a distance integrating around 5.5 mm of the gut in its stretched direction axis evading individual mucosa. The patients were observed post operatively for anastomotic fiasco such as leakage. Results: Fourteen (14) out of 35 (2.5%) patients in group A developed anastomotic leakage . In group B, the interrupted serosubmucosal anastomoses were made in 26 patients in emergency and remaining were operated schedule wise. Five (7%) patients exhibited anastomotic leakage in group B. In group A, the continuous leakage in serousubmucosal anastomosis was 2.5% while in group B interrupted serousubmucosal anastomosis was 7%. Conclusion: It has observed in past studies that single layer interrupted stitches leakage is higher as compared to continuous. It is clear that anastomotic failure in group A is greater than group B but it not considerably substantial and hence both are remarkably efficient.

THE CAUSES OF INTESTINAL ANASTOMOTIC LEAKAGE IN EXPERIMENTAL PERITONITIS

Objective. To determine the leading factor in the pathogenesis of intestinal anastomotic failure in peritonitis. Methods. The experiment was carried out on non-linear white rats (n=40), divided into 4 equal groups: with peritonitis (group 1), with hypovolemia (group 2), with peritonitis in combination with hypovolemia (group 3) and comparison (group 4). Colonic “end-to-end” anastomosis was performed in all rats. Peritonitis caused by injection of 10% unfiltered feces into the abdominal cavity. Hypovolemia was modeled during the operation by creating bleeding from the branch of the iliocolic artery.The rats were taken out of the experiment on the 3^rd day after the operation, the state of the anastomosis and the abdominal cavity was assessed. The histological examination of the anastomotic sites was performed. The content of hypoxia biomarkers (HIF-1a, VEGF-C, VEGF-R1) in the intestinal tissue was also evaluated by ELISA. The experiment was approved by the local ethics committee. Results. In group 1, anastomotic failure was detected in rats characterized by a severe general condition due to peritonitis. In groups 2 and 3 statistically significant relationship was found between a decrease of rectal temperature (>2 °C) due to bleeding and colonic anastomotic failure (p<0.05). Morphological analysis showed the most pronounced inflammatory and microcirculatory changes in the group 3. Statistically significant differences in the level of the VEGF-C (p=0.0034) and VEGF-R1 (p=0.04795) were found between groups. Maximal ischemia of the anastomotic zone was found in rats of group 3. Conclusion. The leading factor in the pathogenesis of intestinal anastomotic failure is considered to be as a result of impairedblood supply of the anastomotic zone due to hypovolemia and depletion of mesenteric blood flow. Monitoring and successful correction of hemodynamic disturbances in the perioperative period may become a prospect for the treatment of patients with peritonitis requiring intestinal anastomosis under these conditions. What this paper adds For the first time determination of the leading factor in the pathogenesis of intestinal anastomotic failure in peritonitis has been studied. The leading factor in the pathogenesis of intestinal anastomotic failure has been found out to be the impairedblood supply of the anastomotic zone due to hypovolemia and depletion of mesenteric blood flow.

Primary Medical Effects and Economic Impact of Anastomotic Leakage in Patients with Colorectal Cancer. A Middle-Income Country Perspective

Introduction: Anastomotic leakage is one of the most serious surgical complications that can increase the potential postoperative morbidity, mortality, and overall costs of patient care. Aim of study: To assess the economic burden of anastomotic leakage and to estimate its major clinical effects on patient evaluation.Materials and methods: We retrospectively reviewed single-surgeon data about patients who underwent surgical intervention for colorectal cancer at the 2nd Surgery Department of the Mureș County Emergency Clinical Hospital between January 2019 and July 2020. We assessed general characteristics, surgical data, postoperative information, oncologic results, and financial aspects for each patient. Depending on the presence of anastomotic leakage, patients were divided into two groups: a study group (SG) – patients with postoperative anastomotic failure, and a control Group (CG) – patients without postoperative anastomotic failure.Results: Patients with anastomotic leakage presented increased use of antibiotics, greater number of surgical reinterventions, longer period of intensive care treatment, prolonged hospitalization, increased overall costs, and significantly greater financial loss for the hospital.Conclusion: Anastomotic leakage leads to important negative effects, including longer hospitalization, prolonged intensive care unit stay, greater incidence of surgical reintervention, increased hospitalization costs, and significant financial loss.