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.

Intussusception after reconstruction following gastrectomy for gastric cancer

Background Gastric cancer is the most prevalent tumor in Chinese men, and surgery is currently the most important treatment. Billroth II and Roux-en-Y are the anastomosis methods used for reconstruction after gastrectomy. Jejunal intussusception is a rare complication after gastric surgery. Main Body Intussusception after gastric surgery occurs mostly at the gastrojejunostomy site for Billroth II reconstruction, and the Y-anastomosis site for Roux-en-Y reconstruction. Many studies have reported that postoperative intussusception appears at the anastomosis after bariatric surgery, while a few have reported intussusception at the anastomosis and its distal end after radical gastrectomy. Conclusion A review was carried out to analyze intussusception after radical gastrectomy with roux-en-y anastomosis during the current situation. And the relevant mechanisms, diagnosis, treatment methods, etc. are described, hoping to provide better guidance for clinicians

Hemodynamic Principles in Free Tissue Transfer: Vascular Changes at the Anastomosis Site

Purpose: Various factors such as blood velocity, turbulent flow,and intimal injury are the most basic elements in free tissue transfers. However, how blood flow is reestablished, maintained, and changed after vascular anastomosis has rarely been studied.Methods: A 54-year-old male sustained an unreplantable severe crushing injury to his right hand. The middle finger was transferred to the thumb as an ectopic replantation using an anastomosis between the radial and digital arteries. However, secondary reconstruction for the first web space defect was inevitable and an anteromedial thigh free flap procedure was performed 2 months later using the previously anastomosed vessels. During the procedures, we noted morphologic changes in the microvessels and tried to explain those phenomena by applying the principles of hemodynamics.Results: Due to the discrepancy in vascular size between the radial and digital arteries, the velocity of the blood flow in the post-anastomotic site, which was the digital artery, must have been increased by Poiseuille’s law. Supposing that the velocity through the post-anastomotic site of the digital artery was increased, the pressure exerted by that flow decreased, resulting in more shrinkage of the vessel lumen of the digital artery by Bernoulli’s principle. Pascal’s law could also be applied in confined spaces with a static flow; where there is a constant pressure, as the radius of the post-anastomotic digital artery diminishes, the tension within the digital artery’s wall also simultaneously decreases. By Laplace’s law, the post-anastomotic digital artery’s wall thickens as less tension is exerted on the wall.Conclusion: Understanding these simple flow mechanics will enable microsurgeons to better avoid the risk factors causing thrombosis, which is related to flap failure.

Successful treatment of remnant gastric cancer with afferent loop syndrome managed by percutaneous transhepatic cholangial drainage followed by elective gastrectomy: a case report

Background There are only few reported cases of remnant gastric cancer with concomitant afferent loop syndrome. Emergency surgery is the standard treatment strategy for this disease. However, some afferent loop syndrome cases, especially those with complete obstruction, can lead to a septic state, which makes performing emergency surgery risky. We describe a case of remnant gastric cancer with complete afferent loop obstruction, which was successfully managed by radical surgery following percutaneous transhepatic cholangial drainage of the afferent loop. Case presentation A 71-year-old man presented with nausea and abdominal discomfort. When he was 27 years old, he had undergone distal gastrectomy for a benign gastric ulcer, with gastrojejunostomy (Billroth II reconstruction). Abdominal computed tomography revealed thickening of the anastomosis site and significant dilation of the afferent loop. Gastrointestinal fiberscopy revealed advanced remnant gastric cancer at the anastomosis site, and the stoma of the afferent loop was completely obstructed. We diagnosed the patient with remnant gastric cancer with afferent loop syndrome. Percutaneous transhepatic cholangial drainage was performed twice before surgery to decompress the afferent loop. This provided more time for the patient to recover. Radical surgery of total remnant gastrectomy and Roux-en-Y reconstruction were performed electively. There were no severe postoperative complications. The patient died 8 months following the operation owing to peritoneal dissemination recurrence. Conclusion We encountered a case of remnant gastric cancer with afferent loop obstruction, which was successfully managed by radical surgery following decompression of the afferent loop by percutaneous transhepatic cholangial drainage. Percutaneous transhepatic cholangial drainage effectively managed the afferent loop syndrome, resulting in the safe performance of elective surgery.

Hemodynamic Analysis on the Anastomosis Angle in Arteriovenous Graft Using Multiphase Blood Model

Numerical analysis was performed for the effect of the venous anastomosis angle in a forearm arteriovenous graft for hemodialysis using a multiphase blood model. The geometry of the blood vessel was generated based on the patient-computed tomography data. The anastomosis angles were set at 15°, 30°, and 45°. The hematocrit was set at 34%, 45%, and 58%. The larger anastomosis angle, high wall shear stress area >11 Pa, increases to the side of the vein wall away from the anastomosis site. Further, the relatively low wall shear stress area, <3 Pa, occurs near the anastomosis site in larger anastomosis angles. Therefore, the effect of high wall shear stress has advantages in the vicinity of the anastomosis, as the anastomosis angle is larger, but disadvantages as the distance from the anastomosis increases. Moreover, patients with low hematocrit are advantageous for WSS area.

Large anastomotic leak: endoscopic treatment using combined fibrin glue and polyglycolic acid (PGA) sheets

Anastomotic leak after gastrectomy is a major complication and various endoscopic methods have been suggested. However, the treatment of large-sized leaks remains a challenge. Here, we present a case of a large anastomotic leak successfully treated endoscopically using a combination of fibrin glue and polyglycolic acid (PGA) sheets. A 68-year-old man who underwent laparoscopic total gastrectomy and oesophagojejunal anastomosis presented with abdominal pain and fever. In the endoscopic examination, two fistulas were observed at the anastomosis site. One was small (0.6 cm) while the other measured 2.5 cm. For the large leak, endoscopic treatment using endoclip and detachable snare was attempted, but failed. Subsequently, fibrin glue was injected into the large fistula through an endoscope. After 28 days, the size of the fistula was reduced and PGA sheets were inserted into the remaining fistula. After about 4 weeks, leaks were observed to be completely healed.

Comparison of two end-to-end continuous sutures for intestinal anastomoses in dogs.

Background: Single-layer appositional closures are preferred to inverting or everting patterns, as submucosal apposition has been shown to promote primary healing of the intestinal wall, whereas inverted or everted closures require second-intention healing and can increase the risk of luminal stenosis or anastomosis site leakage. There are different suture patterns available, but relatively few studies comparing these aspects have been published.The aim of this study was to compare two suture techniques for end-to-end anastomosis of the canine intestine (jejunum and colon): handsewn intestinal anastomosis by appositional simple continuous suture and inverting Cushing suture. The objectives of this study were to investigate 1.) whether the type of suture influences the specific effort to which the anastomosis site is submitted to, 2.) whether the anastomosis technique influences the diameter of the intestinal lumen and 3.) survival and complication rates in canine clinical cases undergoing end-to-end anastomoses. Results: The equilibrium angle for implanting the sutures in an anastomosis is 35°, aspect completely fulfilled by the simple continuous suture. The efforts to which sutures are submitted to in anastomoses are minimal for the Cushing suture. The difference in size of the anastomoses’ lumen between simple continuous suture and the Cushing suture are minimal, without being statistically relevant. The differences between the lumen of the anastomoses performed using PDS and those performed using PGA are not statistically relevant. The retrospective analysis of the outcome for 676 dogs (clinical cases) that underwent intestinal resection and anastomosis reveals that the dehiscence rate was 1.48%, out of which 1.18% following simple continuous anastomoses, and 0.3% following Cushing anastomoses. Narrowing of the intestinal lumen due to anastomotic healing was not registered.Conclusions: Use of the Cushing suture should be considered for performing an end-to-end intestinal anastomosis, although more studies are required to determine if there are any clinically significant differences between the sutures investigated in this study.