Dynamic endoluminal contrast enhanced ultrasound (CEUS) for display of drainages in inflammatory abdominal fluid collections1

AIM: To evaluate the additive clinical value of endoluminal contrast enhanced ultrasound (CEUS) after interventional placement of drainages in abdominal fluid collections. MATERIAL/METHOD: Examination of 30 patients using a 1–6 MHz convex probe (Resona 7, Mindray) to locate the fluid collection in B-Mode. Additionally, dynamic endoluminal CEUS with 1 ml sulphur-hexafluoride microbubbles was performed to measure the extent of the percutaneously drained abscesses. Independent assessment of dynamically stored images in PACS in DICOM format. Correlation to reference imaging using computed tomography (CT). RESULTS: A total of 30 patients were examined (17 m, 19–78 years, mean 56.1 years). Drainages were positioned in the liver in 15 cases, in the pelvis after kidney transplantation in 4 cases, close to the spleen in 1 case and in the abdomen in 10 cases. In all cases abscesses showed marginal hyperaemia with reactive septations in CEUS. The drainage position was assessed by means of B-mode in all cases first and then by CEUS. In 4 cases CEUS showed a fistula to the pleura, in 5 cases to the peritoneum, in 2 cases to the intestine, in 5 cases to the biliary tract, corresponding to the CT. In 2 cases there was a hint of an anastomotic leakage after intestinal anastomosis, which was reliably detected by CT. The drainage was removed in 11 cases within a period of 2 to 5 days after CEUS control, in 9 cases within a period of 5 to 10 days. Another operation was necessary in 3 cases. A new drainage was placed in 2 cases. The required amount of contrast medium is 1 ml endoluminally diluted to 9 ml sodium chloride. CONCLUSION: CEUS facilitates the exact localization and characterization of inflammatory abdominal fluid collections. Furthermore, possible fistulas can be detected that cannot be seen with conventional ultrasound.

LAPAROSCOPIC SANTULLI INTESTINAL ANASTOMOSIS IN AN INFANT WITH CYSTIC FIBROSIS

The aim of the study was to evaluate the technical feasibility of performing a Santulli-type side-toend inter-intestinal anastomosis in infants with cystic fibrosis (CF) using laparoscopy. A clinical case of a 3-month-old child with CF who was operated on in the neonatal period for meconium ileus is presented. The baby's gestational age was 32 weeks. The primary operation consisted of the formation of a terminal enterostomy. In the postoperative period, a malabsorption syndrome was noted, accompanied by a lack of growth. As a temporary measure to restore nutritional status, a Santulli-style side-to-end laparoscopic intestinal anastomosis was performed. The observed child was found to have the F508del mutation in both alleles of the CFTR gene. The patient's weight at the time of the Santulli anastomosis construction was 2900 g, the age – 3 months. During the operation, there were no difficulties associated with the mobilization of the separated segments of the ileum. The duration of the surgical intervention was 70 min. Enteral nutrition was started on the 3rd day after the operation. The recovery period for intestinal transit through the rectum was 15 days. The postoperative period was uneventful. The duration of hospitalization was 18 days. No electrolyte imbalance or excessive fluid loss or underweight associated with enterostomy was observed. Over the next 6 months, the normalization of age-related weight and height parameters was achieved, after which the continuity of the digestive tract was restored by closing the terminal enterostomy. Currently, the patient has minimal respiratory symptoms and is receiving adequate CF therapy with pancreatic enzyme replacement therapy included with each meal. The initial experience of performing laparoscopic Santulli inter-intestinal anastomosis in an infant with CF presented in the study showed the possibility and reproducibility of this technique, expanding the boundaries of laparoscopy in pediatric practice. The decision to close the enterostomy in these patients should be deferred until a full diet is introduced and should be made in conjunction with a pediatrician specializing in the treatment of CF.

Feasibility and Safety of Stentless Uretero-Intestinal Anastomosis in Radical Cystectomy with Ileal Orthotopic Neobladder

Background: We evaluated the feasibility and safety of stentless uretero-intestinal anastomosis (UIA) during radical cystectomy (RC) with an ileal orthotopic neobladder. Methods: We retrospectively reviewed 403 patients who underwent RC for bladder cancer between August 2014 and December 2018. The primary objective was to study the effect of stentless UIA on uretero-intestinal anastomosis stricture (UIAS), and the secondary objective was to evaluate the association between stentless UIA and other complications, including paralytic ileus, febrile urinary tract infection (UTI), and urine leakage. Kaplan–Meier survival analysis was used to estimate UIAS-free survival, and Cox proportional hazard models were applied to identify factors associated with the risk of UIAS. Results: Among 403 patients with 790 renal units, UIAS was identified in 39 (9.7%) patients and 53 (6.7%) renal units. Forty-four (83.0%) patients with UIAS were diagnosed within 6 months. The 1- and 2-year overall UIAS-free rates were 93.9% and 92.7%, respectively. Paralytic ileus was identified in 105 (26.1%) patients and resolved with supportive treatment. Febrile UTI occurred in 57 patients (14.1%). However, there was no leak of the UIA. Conclusions: Stentless UIA during RC with an ileal orthotopic neobladder is a feasible and safe surgical option. Further prospective randomized trials are required to determine the clinical usefulness of stentless UIA during RC.

Validation of the Dutch leakage score as a predictor of anastomotic leakage in intestinal surgery in a third level hospital

Background: Intestinal surgery can present multiple complications that can lead to patient death; therefore, it is important to design early detection strategies to reduce complications in patients with intestinal anastomosis and thus avoid patient death. The aim of this work is to evaluate the diagnostic performance of the Dutch leakage score in 125 patients with intestinal anastomosis as a predictor of anastomotic leakage.Methods: In a sample of 125 patients undergoing intestinal anastomosis, demographic variables were identified and the Dutch leakage score was applied. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy were obtained using a 2×2 table.Results: The Dutch leakage score was positive in 23.2% (29 patients) of whom 24 had anastomotic leakage and 5 had no anastomotic leakage. It presents a sensitivity in the test of 100%, a specificity of 95%, a positive predictive value of 82.7%, a negative predictive value of 100%. The diagnostic accuracy is 96%.Conclusions: The Dutch leakage score is a versatile tool, inexpensive, easy to apply and available in any hospital center. It is capable of early diagnosis of anastomotic leakage. It favors early re-intervention, improves prognosis and survival, decreases hospital stay and health care costs.

Stapled versus hand-sewn intestinal anastomosis in pediatric patients: a systematic review and meta-analysis

Background The safety and feasibility of stapled intestinal anastomosis have been widely reported in adults. However, the efficacy of stapled anastomosis (SA) in children is unclear. The aim of this study was to perform a systematic review and meta-analysis to evaluate the safety and effectiveness of SA compared with hand-sewn anastomosis (HA) in pediatric patients. Methods A systematic literature search was performed using PubMed, the Cochrane Library, and Scopus databases. Studies comparing outcomes of children aged < 7 years and subgroups of children aged < 1 year who underwent SA or HA were included. Primary outcomes were anastomotic leakage and anastomotic stricture. Mean differences (MDs) with 95 % confidence intervals (CIs) were calculated for continuous variables. Odds ratios (ORs) with 95 % CIs were calculated for dichotomous variables. Interstudy heterogeneity was assessed using the chi-squared test and was quantified using the I² statistic. Results One randomized control trial and five retrospective cohort studies, comprising 633 cases (229 SA cases and 404 HA cases), were included. No significant differences were observed in anastomotic leakage (6.5 % vs. 7.4 %; OR, 0.93; 95 % CI, 0.37–2.34; p = 0.88), anastomotic stricture (4.1 % vs. 9.3 %; OR, 0.54; 95 % CI, 0.19–1.51; p = 0.24), ileus (7.1 % vs. 9.3 %, OR, 2.35; 95 % CI, 0.15–37.51; p = 0.54), anastomosis-related complications (9.5 % vs. 10.9 %, OR, 0.98; 95 % CI, 0.52–1.86; p = 0.96; I2 = 39 %), and time until full-feeding (MD = -3.57 days; 95 % CI, -11.36 to 4.23; p = 0.37) between SA and HA. Operative time was significantly shorter in SA than in HA in children aged < 1 year (MD = -20.36 min; 95 % CI, -26.13 to -14.59). Conclusions SA required shorter operative time and was comparable to HA in the overall complication rate. Although the evidence was insufficient, SA could be an option for intestinal anastomosis in children.

Serum lactae level as an indicator for leakage in pediatric intestinal anastmosis

Background Its quite well know that high levels of serum lactic acid correlates with poor general condition and poor surgical outcome. Postoperative elevated serum lactate during the first 24h is associated with morbidity and even mortality in patients undergoing elective abdominal surgeries. In this study we need to compare the effect of fluctuation in serum lactate levels pre and postoperative on particularly instestinal anastmosis healing between elective vs emergency patients. Objective This study is designed to identify if high pre-operative lactate levels and post-operative lactate clearance are correlated with high risk of intestinal anatstmotic leakage in pediatrics. Patients and Methods This study was prospective observational study; conducted at Ain Shams University Hospital, Pediatrics surgery department and approved by the Ethical Research Committee at our hospital. We enrolled all patients (aged ≤ 14 years old) who were candidates for intestinal surgical anastomoses either elective or emergency. The patients included in our study were admitted post-operative at our department either in the intermediate or intensive care units accordingly. All patients with medical history of chronic kidney disease, liver failure, ICU admission or major surgery within the month prior to our study were excluded from our study. Results We enrolled 26 patients in our study who underwent intestinal anastomosis at our Pediatrics Surgery Department during the past six months. We had 7 female patients (26.9%) and 19 male patients (73.1%). The youngest was two-day old and the oldest was 14 years old. We had leakage incidence 38.5% of the studied patients. The cut-off lactate level for incidence of leakage is &gt; 1.2 mmol/L for the 0h (Baseline reading), &gt;2 mmol/L for the 6h, &gt;1.4mmol/L for the 12h, &gt;1.1mmol/L for the 18h, &gt;1.3mmol/L for the 24h. The highest sensitivity and specificity are for the reading at 24h that had the highest sum of both sensitivity(90%) and specificity (93.3%) and area under curve (AUC) 0.860. All patients with elevated lactate &gt; 1.4 mmol/L at 12 h had leakage (100% sensitivity) but with only 66.7% specificity. Conclusion This study shows that lactate levels during the first 24 hours postoperatively have a predictive value for postoperative intestinal anastomotic leakage after a laparotomy surgery. Serum lactate levels obtained 24 hours postoperatively had the best predictive value to discriminate between patients with and without anastomotic leakage. Although not explanatory by its design, our study demonstrates that elevated postoperative lactate is an ominous sign that should to be addressed by the intensivist. However, further studies are required to indicate which strategies aimed at resolving hyperlactatemia improve postoperative outcomes.