There is no correlation between a delayed gastric conduit emptying and the occurrence of an anastomotic leakage after Ivor-Lewis esophagectomy

Introduction Esophagectomy is the gold standard in the surgical therapy of esophageal cancer. It is either performed thoracoabdominal with a intrathoracic anastomosis or in proximal cancers with a three-incision esophagectomy and cervical reconstruction. Delayed gastric conduit emptying (DGCE) is the most common functional postoperative disorder after Ivor-Lewis esophagectomy (IL). Pneumonia is significantly more often in patients with DGCE. It remains unclear if DGCE anastomotic leakage (AL) is associated. Aim of our study is to analyze, if AL is more likely to happen in patients with a DGCE. Patients and methods 816 patients were included. All patients have had an IL due to esophageal/esophagogastric-junction cancer between 2013 and 2018 in our center. Intrathoracic esophagogastric end-to-side anastomosis was performed with a circular stapling device. The collective has been divided in two groups depending on the occurrence of DGCE. The diagnosis DGCE was determined by clinical and radiologic criteria in accordance with current international expert consensus. Results 27.7% of all patients suffered from DGCE postoperatively. Female patients had a significantly higher chance to suffer from DGCE than male patients (34.4% vs. 26.2% vs., p = 0.040). Pneumonia was more common in patients with DGCE (13.7% vs. 8.5%, p = 0.025), furthermore hospitalization was longer in DGCE patients (median 17 days vs. 14d, p < 0.001). There was no difference in the rate of type II anastomotic leakage, (5.8% in both groups DGCE). All patients with ECCG type II AL (n = 47; 5.8%) were treated successfully by endoluminal/endoscopic therapy. The subgroup analysis showed that ASA ≥ III (7.6% vs. 4.4%, p = 0.05) and the histology squamous cell carcinoma (9.8% vs. 4.7%, p = 0.01) were independent risk factors for the occurrence of an AL. Conclusion Our study confirms that DGCE after IL is a common finding in a standardized collective of patients in a high-volume center. This functional disorder is associated with a higher rate of pneumonia and a prolonged hospital stay. Still, there is no association between DGCE and the occurrence of an AL after esophagectomy. The hypothesis, that an DGCE results in a higher pressure on the anastomosis and therefore to an AL in consequence, can be refuted. DGCE is not a pathogenetic factor for an AL.

188 Right Hemicolectomy with End-To-Side Circular Stapled Ileo-Colic Anastomosis: Evaluation of Outcomes in A Series Of 55 Consecutive Patients

Background Stapled ileo-colic anastomosis is a well-established alternative to hand-sewn anastomosis after right hemicolectomy. A side-to-side configuration (SSA) is the option commonly practiced. This study describes our experience using a less well described technique, using an end-to-side circular stapled ileo-colic anastomosis (ESSA). Method Consecutive adult patients undergoing a right or extended- right hemicolectomy with ESSA for colonic cancer between July 2013 and March 2020 were included. Perioperative outcomes including anastomotic leak and anastomotic bleeding were extracted from a prospectively maintained institutional database. The Clavien-Dindo classification was used to stratify post-operative complications. Data are presented in medians and IQR. Results Right hemicolectomy with circular stapled ESSA ileo-colic anastomosis was performed in 55 consecutive patients (M:F 26:29) by a single surgeon at a tertiary referral centre. Over half of patients (54.5%, 30/55) were in the 8th and 9th decades of age with a median BMI of 26.5 (IQR:24-30.7). Median postoperative length of stay was 6 days (IQR:4-8) and the overall morbidity rate was 34.5% (19/55). Anastomotic leak and anastomotic bleeding were seen in 5.45% (3/55) and 3.64% (2/55), respectively. None of the patients with leak or bleeding needed a re-operation. Conclusions In comparison to the widely used SSA type of ileo-colic anastomosis, the ESSA configuration using a circular stapling device is a viable option for restoring bowel continuity after right colonic resections with comparable results. Potential advantages of this approach include avoidance of cross stapling and improved ileo-colic anatomical fidelity.

History of mechanical staple surgical suture (review of literature)

Modern surgery is difficult to imagine without mechanical stapling devices. The objective of the study was to trace the continuity of the development of mechanical stapling technology by European and American surgeons. The main step that led to this technological development was the idea of using a simple paper staple for suturing of human tissue. The first time the mechanical stapling device was used on a human was 9th May, 1908 in Budapest. Subsequently, surgeons and engineers of Europe, primarily Hungary (Austria-Hungary) (H. Hultl, V. Fischer, A. von Petz, etc), Germany (H. Friedrich, etc.) and the USSR (V. Gudov, V. Demikhov, P. Androsov, etc) refined the mechanical principles and practical implications of this new technology. By the mid-1950s, two types of devices were manufactured in the USSR for simple suturing tissues such as the pulmonary parenchyma or bronchus and for the construction of anastomosis. The disadvantages of these devices could be attributed the requirement of delicate manual loading of small metal staples into the cartridge and assembling of sterile parts immediately prior to application. A group of surgeons and engineers led by an American thoracic surgeon, Mark Ravitch, managed to overcome these disadvantages by making devices user-friendly, launched their production in the USA and even organized a training network for surgeons wishing to use the new instruments. The history of mechanical stapling devices illustrates the successful realization of novel ideas that were supported by technological advances and the professional ambitions of surgeons.

Small Bowel Obstruction due to Meckel's Diverticulitis Presenting in pregnancy

Meckel’s diverticulitis is an extremely rare cause of acute abdomen during pregnancy. Depending on the clinical presentation it can be managed either by laparoscopy or laparotomy. We report the case of a 29-year-old pregnant female, presenting with abdominal pain and distension in the early second trimester. The abdominal ultrasound was inconclusive. Magnetic resonance imaging showed small bowel obstruction with a dilated ileal loop due to an inflamed Meckel’s diverticulum adherent to the fundus of the gravid uterus was identified during laparotomy. Diverticular resection was carried out with a stapling device. The diagnosis of Meckel’s diverticulitis can be challenging, especially in pregnancy, and a delay in diagnosis can be detrimental to the mother and foetus. Although laparoscopic management has been reported to be safe in the second trimester, in this case, the abdominal distension would have made access challenging and unsafe, and hence the decision to perform a laparotomy was taken.

Robotic natural-orifice IntraCorporeal anastomosis with Extraction (NICE procedure) for complicated diverticulitis

Background Totally intracorporeal surgery for left-sided resection carries numerous potential advantages by avoiding crossing staple lines and eliminating the need for an abdominal incision. For those with complicated diverticulitis, minimally invasive surgery is known to be technically challenging due to inflamed tissue, distorted pelvic anatomy, and obliterated tissue planes, resulting in high conversion rates. We aim to illustrate the stepwise approach and modifications required to successful complete the robotic Natural-orifice IntraCorporeal anastomosis with transrectal specimen Extraction (NICE) procedure in this cohort. Methods Consecutive, elective, unselected patients presenting with complicated diverticulitis defined as fistula, abscess and stricture underwent the NICE procedure over a 24-month period. Demographic and intraoperative data were collected, and video recordings were reviewed and edited on encrypted server. Results A total of 60 patients (50% female) underwent the NICE procedure for complicated diverticulitis with a mean age of 58.9 years and mean BMI of 30.7 kg/m2. The mean operative time was 231.6 min. All cases (100%) were achieved with intracorporeal anastomosis using a circular stapling device. All but one patient (98.3%) had successful transrectal extraction of the specimen. Forty-four (73%) of the specimens required a specimen-thinning maneuver to successfully extract the specimen and there were no conversions. We identified seven key technical modifications and considerations to facilitate successful completion of the procedure which are illustrated, including early release of the disease, mesentery-sparing dissection, dual instrument control of the mesenteric vasculature, release of the rectal reflection, use of NICE back table, specimen-thinning maneuver, and closure of the rectal cuff. Conclusion We present a stepwise approach with key modifications to successfully achieve totally robotic intracorporeal resection for those presenting with complicated diverticulitis. This approach may help overcome the technical challenges and provide a foundation for reproducible results.

Minimally invasive video-assisted sphincter-sparing treatment of complex rectal fistulas using the VAAFT technique

Background. Video-assisted anal fistula treatment (VAAFT) is a new minimally invasive sphincter-sparing technology.Objective: to describe technical characteristics of VAAFT and evaluate short-term outcomes.Materials and methods. We used a specialized surgical video system (VAAFT®; Karl Storz) for the treatment of complex high rectal fistulas. This technology allows a surgeon to use a special fistuloscope to perform visual examination of the fistula, find its internal opening, and detect secondary fistula passages and inflows. In addition to visual inspection, it is possible to simultaneously conduct a cytological brush through the working channel of the endoscope in order to clear the fistula from detritus and desquamate lining mucosa, and then perform fistula ablation using a monopolar electrode. The internal opening of the fistula can be either closed by a flap or sutured using a linear stapling device or closed using an endoscopic clip with additional sealing of the suture line with biological glue.Results. Between September 2017 and August 2019, a total of 112 patients underwent VAAFT® surgeries. Ninety-three patients (83 %) were followed up for 6 months postoperatively. We observed no significant complications during the follow-up period. The majority of study participants (85 %) did not experience severe pain (>2–4 points on a visual-analog scale) in the early postoperative period. Primary healing was achieved in 98 patients (87.5 %) within 2–3 months. Eighty-nine individuals (79.5 %) were followed up for more than 1 year. Rectal fistula healing within 1 year after VAAFT® surgery was observed in 82 % of patients.Conclusions. The main advantage of the VAAFT® technique is the combination of the diagnostic stage for fistula visualization and identification of the internal opening with the possibility of simultaneous surgical treatment.

Doughnut bother! Histopathological examination of anastomotic doughnuts following colorectal anastomosis does not change patient management

Introduction The use of a circular stapling device to create an anastomosis following colonic or rectal resection is common practice in the United Kingdom. Histopathological analysis of the anastomotic doughnuts produced takes time and resources, but does it ever change patient management? The aim of this study was to review the examination of doughnuts and whether patient treatment was altered by the findings. Method A retrospective case note review of all cases involving anastomotic doughnuts in a single trust between December 2010 and January 2018, was performed. Results There were 435 cases identified, male to female ratio was 2.0:1, age range 20–86 years and a median age of 66 years. 376 Doughnut samples were received by the pathology department (86.4%) and 354 were examined (81.4%). The disease processes involved were adenocarcinoma (n = 352, 80.9%), diverticular disease (n = 47, 10.8%), no residual disease/complete response (n = 22, 5.1%), adenoma (n = 7, 1.6%), mucinous (n = 5, 1.1%), Crohn’s disease (n = 1, 0.2%) and neuroendocrine (n = 1, 0.2%). Benign adenomatous change was identified in 4 cases (0.9%). No doughnuts examined contained dysplastic or malignant changes. Conclusion The histological examination of anastomotic doughnuts is extremely unlikely to identify malignant change and subsequently does not change patient management. Pathology departments could save time and resources by not routinely examining doughnuts.

Who needs a stapling device for haemorrhoidectomy, if one has the radiofrequency device?

Background Multiple operations exist to treat haemorrhoids. Although comparisons of conventional excision and other techniques have been performed, there are less comparative outcome data available for stapled haemorrhoidopexy (SH) and radiofrequency haemorrhoidectomy (RFH). Use of a radiofrequency energy device for haemorrhoidectomy is an alternative to standard diathermy, scissors or scalpel. It provides vessel sealing between the jaws of the instrument and aims to minimise wider tissue damage. Objective To systematically review the literature comparing SH and RFH, assessing complications, outcomes, patient experience and costs. Methods A tailored search of medical databases identified literature containing relevant primary and secondary data comparing SH and RFH. Papers were screened for relevance and completeness of published data. Those missing methodological information, outcome data or statistical analysis were subsequently excluded. A narrative review was then performed. Results The primary data in this review originate from six randomised control trials (RCTs) and five meta-analyses. Evidence was conflicting, with a trend towards more early postoperative pain in the RFH vs. the SH group (three RCTs reported increased early pain scores in the RFH group). Significantly higher rates of residual and recurrent haemorrhoids and prolapse in the SH group were observed in two RCTs and four meta-analyses. Bleeding, urinary retention, incontinence and anal stenosis did not significantly differ. No detailed contemporary cost analysis was found. Conclusion The trials are small, with significant heterogeneity in the techniques used and outcome data recorded. However, despite the limited available evidence, RFH appears superior to SH due to significantly lower rates of residual and recurrent haemorrhoids and prolapse.