Surgical Treatment of Low-Lying Rectal Cancer: Updates

Despite innovative advancements, distally located rectal cancer remains a critical disease of challenging management. The crucial location of the tumor predisposes it to a circumferential resection margin (CRM) that tends to involve the anal sphincter complex and surrounding organs, with a high incidence of delayed anastomotic complications and the risk of the pelvic sidewall or rarely inguinal lymph node metastases. In this regard, colorectal surgeons should be aware of other issues beyond total mesorectal excision (TME) performance. For decades, the concept of extralevator abdominoperineal resection to avoid compromised CRM has been introduced. However, the complexity of deep pelvic dissection with poor visualization in low-lying rectal cancer has led to transanal TME. In contrast, neoadjuvant chemoradiotherapy (NCRT) has allowed for the execution of more sphincter-saving procedures without oncologic compromise. Significant tumor regression after NCRT and complete pathologic response also permit applying the watch-and-wait protocol in some cases, now with more solid evidence. This review article will introduce the current surgical treatment options, their indication and technical details, and recent oncologic and functional outcomes. Lastly, the novel characteristics of distal rectal cancer, such as pelvic sidewall and inguinal lymph node metastases, will be discussed along with its tailored and individualized treatment approach.

Does intestinal peristalsis cause suture failure after instrument suture?

Introduction Gastrectomy with lymphadenectomy is a standard treatment for gastric cancer. Anastomotic leakage remains a potentially fatal complication of gastrectomy. Forceful stapler extraction may cause anastomotic complications. We focused on the duodenal peristalsis, as we hypothesized that it might cause forceful stapler extraction. We then retrospectively investigated duodenal peristalsis. We reviewed videos of Da Vinci system cases to clarify the relationship between peristalsis and anastomotic complications. Methods Forty-nine cases with stored videos of laparoscopic surgery using the Da Vinci system from 2015 to March 2021 were included. Peristalsis was defined by repeated contraction and expansion that was clearly visible three or more times in a row, and that there was no peristalsis in other cases. We investigated the duodenum because it is frequently observed during gastrectomy. We evaluated suture failure in cases with and without peristalsis. Results The study population included 49 patients (male, n=32; female, n=17; median age, 71 [42-82] years). Duodenal peristalsis was observed in 14 (28.6%) cases. Three patients experienced complications. A comparative study of cases with and without complications showed significant peristalsis in cases with complications (p=0.0198). Discussion Anastomotic leakage remains a serious and potentially fatal complication of gastrectomy, and surgeons should make efforts to prevent anastomotic leakage. Various risk factors associated with anastomotic leakage have been reported. This is the first retrospective study to evaluate duodenal peristalsis during gastrectomy for gastric cancer. We hypothesized that duodenal peristalsis would apply extreme tension on the stapler. Peristalsis would twist and increase the pressure on the stapler. In this study, we defined a new scale to evaluate duodenal peristalsis. Anastomotic complications were significantly more frequent in cases with peristalsis (p=0.0198). Our results suggest the utility of manual over-sewing or the use of reinforcement material.

Clinical Efficacy of Endoscopic Technique in the Treatment of Gastrointestinal Anastomotic Complications: a Retrospective Study

Background: To evaluate the safety and effectiveness of endoscopic technique in treating postoperative anastomotic complications of digestive tract. Methods: Clinical data of patients received endoscopic treatment in our hospital due to anastomotic complications after gastrointestinal surgery from January 2015 to December 2018 were collected for retrospective analysis. Endoscopic intervention was used for postoperative anastomotic complications in all the included cases. The time of the intervention measures, laboratory examination, incidence of complications and postoperative follow-up were observed and analyzed.Results: A total of 88 patients were included in the study, including 43 patients with anastomotic stenosis,22 with anastomotic obstruction,23 with anastomotic fistula. For anastomotic obstruction patients, 36 patients with anastomosis were successfully treated with endoscopy. For anastomotic obstruction patients, 18 cases were successfully treated with endoscopy. For anastomotic fistula patients, 21 cases were successfully treated with endoscopy.During follow-up after the endoscopic procedure, 4 patients with anastomotic stenosis needed endoscopic intervention again, 3 cases undertook surgical intervention and 2 cases maintained acceptable defecation function by intermittent dilation with a plastic dilater. one patients with anastomotic obstruction had stent displacement and was removed. For the anastomotic fistula patients,one case relapsed and then underwent endoscopic intervention again, three cases converted to surgical intervention.Preoperative and postoperative blood biochemical examination had no significant statistical significanceConclusion: Endoscopic treatment of anastomosis complications was effective for some of the patients, especially for those with anastomosis stenosis or stricture, considering its saftey, it might be the first choice for anastomosis complications.

544 MANAGEMENT OF ACUTE ANASTOMOTIC COMPLICATIONS AFTER IVOR-LEWIS ESOPHAGECTOMY

Anastomotic leak (AL) and conduit necrosis (CN) are among the most serious surgical complications after esophageal resection. Endoscopic, radiological and surgical methods are used in their treatment. The aim of this paper is to evaluate the results of the treatment of acute anastomotic complications after Ivor-Lewis esophagectomy in a single high-volume center. Methods We performed a retrospective audit of a consecutive cohort of 815 patients undergoing transthoracic esophagectomy with intrathoracic esophago-gastric anastomosis from 2005 to 2019. AL was graded according to Esophagectomy Complications Consensus Group recommendation. Results There were 79 patients with AL and 6 patients with CN (10%). AL type I, II and III was diagnosed in 33 (39%), 25 (29%) and 27 (32%) patients, respectively. Esophageal stent was used in 40 patients. Primary surgical revision (with/without stent insertion) was performed in 14 patients. Reoperation was necessary overall in 25 patients (29%). Seventeen patients (20%) ended-up with esophageal diversion. Treatment with esophageal stent was successful in 28/40 patients (70%). Endoscopic vacuum-therapy was successfully used in three patients for peristent leak after stent extraction. Mortality of severe AL (type II and III) was 10/52 patients (19%). Conclusion Successful management of acute anastomotic complications requires early diagnosis and an individual treatment approach with the use of endoscopic, radiological and surgical methods. The primary attempt for anastomosis preservation using esophageal stent is desirable. Considering the clinical condition and CT finding, we recommend not to hesitate with surgical revision with debridement and drainage of pleural cavity and mediastinum. If primary therapy fails, life-saving procedure is the esophageal diversion.

Does continuation of antifibrotics before lung transplantation influence post-transplant outcomes in patients with idiopathic pulmonary fibrosis?

Summary A best evidence topic was written according to a structured protocol. The question addressed was: ‘Does continuation of antifibrotics before lung transplantation (LTx) influence post-transplant outcomes in patients with idiopathic pulmonary fibrosis (IPF) with regard to mortality, bronchial anastomotic dehiscence, reoperation for bleeding and wound complications, primary graft dysfunction or longer-term survival and allograft rejection?’ A total of 261 articles were found using the reported search strategy, of which 7 represented the best evidence to answer the clinical question. Six out of 7 studies demonstrated equivalent post-transplant survival among IPF patients on antifibrotics before LTx compared with controls. Five out of 6 studies showed no increase in the risk of major bleeding, wound or bronchial anastomotic complications. One bi-institutional study found a higher incidence of early bronchial anastomotic dehiscence, but this difference was not statistically significant after longer term follow-up. In a study that only included IPF patients who underwent single LTx, a lower incidence of grade 3 primary graft dysfunction was reported in the antifibrotic group compared with controls. Overall, to date, only small (N < 40 in the antifibrotic group), non-risk-adjusted, retrospective observational studies have been published. Notwithstanding, the summation of available evidence suggests that, in IPF patients, continuation of antifibrotic therapy before LTx is likely safe, and the rates of perioperative bleeding, wound or bronchial anastomotic complications, as well as 30-day and 1-year survival, are similar to patients not on antifibrotics before LTx.

State-of-the-art surgery for ulcerative colitis

Ulcerative colitis (UC) is an autoimmune-mediated colitis which can present in varying degrees of severity and increases the individual’s risk of developing colon cancer. While first-line treatment for UC is medical management, surgical treatment may be necessary in up to 25–30% of patients. With an increasing armamentarium of biologic therapies, patients are presenting for surgery much later in their course, and careful understanding of the complex interplay of the disease, its management, and the patient’s overall health is necessary when considering he appropriate way in which to address their disease surgically. Surgery is generally a total proctocolectomy either with pelvic pouch reconstruction or permanent ileostomy; however, this may need to be spread across multiple procedures given the complexity of the surgery weighed against the overall state of the patient’s health. Minimally invasive surgery, employing either laparoscopic, robotic, or transanal laparoscopic approaches, is currently the preferred approach in the elective setting. There is also some emerging evidence that appendectomy may delay the progression of UC in some individuals. Those who treat these patients surgically must also be familiar with the numerous potential pitfalls of surgical intervention and have plans in place for managing problems such as pouchitis, cuffitis, and anastomotic complications.

Reliability of Temporal Vascular Anastomosis and Techniques for Better Outcomes

Background Although there are several potential recipient vessels in the neck, those in the temporal region are limited. In skull base reconstruction, there are difficulties associated with the anastomosing recipient vessels in the neck region since long nutrient vessels are needed in the flap. We evaluated the reliability of temporal vascular anastomosis by comparing surgical outcomes between reconstructive methods and examined which surgical procedures may achieve better results. Methods We examined the medical records of free tissue transfer cases between April 2007 and March 2018. Seventy-three surgeries were performed in the temporal region, including skull base reconstruction in 48, head and neck reconstruction (without skull base) in 16, and secondary surgery for head deformities in nine cases. In total, 445 neck surgeries were performed. Postoperative complications were retrospectively analyzed. Results The postoperative complication rates were 8.2 and 2.7% for all temporal and neck surgeries, respectively. There were no arterial complications in the temporal region and all of the six postoperative anastomotic complications were due to venous thrombosis. In contrast, there were 12 cases of vascular anastomotic complications, with six cases each of arterial and venous thrombosis in the neck. In the temporal region, the complication rate was 2.1% for skull base reconstruction, 11% for secondary revision, and 25% in head and neck reconstruction. The corresponding values for middle temporal vein (MTV) usage rates were 54, 22, and 25%. In skull base reconstruction, a coronal incision was made in all cases. A more frequent use of the MTV was associated with a reduced complication rate. Conclusion The low complication rate in the temporal region was attributed to the wide surgical field and low tension of anastomotic vessels. Multiple venous anastomoses, including those of the MTV, are recommended to prevent complications.