Anastomotic Troubleshooting

Anastomotic leak remains a critical and feared complication in colorectal surgery. The development of a leak can be catastrophic for a patient, resulting in overall increased morbidity and mortality. To help mitigate this risk, there are several ways to assess and potentially validate the integrity of a new anastomosis to give the patient the best chance of avoiding this postoperative complication. A majority of anastomoses will appear intact with no obvious sign of anastomotic dehiscence on gross examination. However, each anastomosis should be interrogated before the conclusion of an operation. The most common method to assess for an anastomotic leak is the air leak test (ALT). The ALT is a safe intraoperative method utilized to test the integrity of left-sided colon and rectal anastomoses and most importantly allows the ability to repair a failed test before concluding the operation. Additional troubleshooting is sometimes needed due to technical difficulties with the circular stapler. Problems, such as incomplete doughnuts and stapler misfiring, do occur and each surgeon should be prepared to address them.

Tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage

Background To investigate whether tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage has better short-term outcomes than non-intubated approach with chest tube drainage. Methods Data were collected retrospectively from January 2017 and December 2019. Tubeless group included 55 patients with pulmonary nodules underwent tubeless uniportal thoracoscopic wedge resection, 211 patients underwent non-intubated uniportal thoracoscopic wedge resection with chest tube drainage were included in drainage group. Peri-operative outcomes between two groups were compared. Results After 1:1 matching, 110 patients remained for analysis, baseline demographic and clinical variables were comparable between the two groups. Mean incision size was 3 cm in both group. Mean operative time was 59.3 min in tubeless group and 52.8 min in drainage group. The detectable mean lowest SpO2 and mean peak EtCO2 during operation was acceptable in both groups. Conversion to intubated ventilation or thoracotomy was not required. No patient failed the air leak test and did not undergo a tubeless procedure. Mean postoperative hospital stay was 1.5 days in tubeless group and 2.5 days in drainage group. Residual pneumothorax or subcutaneous emphysema was not frequent and mild in tubeless group. Side effects were rare and mild, including cough and hemoptysis. No re-intervention or readmission occurred. The postoperative VAS score was significantly lower in tubeless group. Conclusions Tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage is feasible and safe for selected patients with peripheral pulmonary nodules, it might reduce post-operation pain and lead to faster recovery.

Experimental Study of Mechanical Integrity Testing in Stapled Large Bowel: Methylene Blue Leak Test Is Not Inferior to Air Leak Test

<b><i>Background/Objectives:</i></b> Anastomotic leakage remains the most devastating postoperative complication in colorectal surgery. The mechanical integrity of the newly formed colorectal anastomosis can be evaluated by visual inspection intraoperatively; both air leak and liquid leak tests are also used to evaluate the integrity of stapled colorectal anastomoses. It is not clear whether double-stapled anastomoses are more prone to leaks than single-stapled anastomoses. The aim of our study was to compare the methylene blue and the air leak test in the experimental setting of single-stapled and double-stapled porcine bowels. <b><i>Methods:</i></b> Twenty-four distal colons were excised from slaughtered pigs without delay. The proximal bowel end was closed with a linear stapler using blue cartridges. The bowels were randomly divided into single-stapled or double-stapled groups. Air leak and methylene blue leak tests were performed. A digital pressure monitor with a gradual pressure increase function was used to both gradually increase pressure within the bowel and to determine the pressure at which the stapler line disintegrated. <b><i>Results:</i></b> Air leakage occurred at a mean pressure of 51.62 (±16.60) mm Hg and methylene blue leakage occurred at 46.54 (±16.78) mm Hg (<i>p</i> = 0.31). The air and methylene blue leaks occurred at comparable pressures in single-stapled bowels and in double-stapled bowels (47.21 [±14.02] mm Hg vs. 50.96 [±19.15] mm Hg, <i>p</i> = 0.6). <b><i>Conclusions:</i></b> The methylene blue solution leak test is not inferior to the air leak test. There is no significant difference in bursting pressure between single-stapled and double-stapled anastomoses.

Tubeless Uniportal Thoracoscopic Wedge Resection with Modified Air Leak Test and Chest Tube Drainage

Background: To investigate whether tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage has better short-term outcomes than non-intubated approach with chest tube drainage.Methods: Data were collected retrospectively from January 2017 and December 2019. Tubeless group included 55 patients with pulmonary nodules underwent tubeless uniportal thoracoscopic wedge resection, 211 patients underwent non-intubated uniportal thoracoscopic wedge resection with chest tube drainage were included in drainage group. Peri-operative outcomes between two groups were compared. Results: After 1:1 matching, 110 patients remained for analysis, baseline demographic and clinical variables were comparable between the two groups. Mean incision size was 3 cm in both group. Mean operative time was 59.3 minutes in tubeless group and 52.8 minutes in drainage group. The detectable mean lowest SpO2 and mean peak EtCO2 during operation was acceptable in both groups. Conversion to intubated ventilation or thoracotomy was not required. No patient failed the air leak test and did not undergo a tubeless procedure. Mean postoperative hospital stay was 1.5 days in tubeless group and 2.5 days in drainage group. Residual pneumothorax or subcutaneous emphysema was not frequent and mild in tubeless group. Side effects were rare and mild, including cough and hemoptysis. No re-intervention or readmission occurred. The postoperative VAS score was significantly lower in tubeless group.Conclusions: Tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage is feasible and safe for selected patients with peripheral pulmonary nodules, it might reduce post-operation pain and lead to faster recovery.

Tubeless Uniportal Thoracoscopic Wedge Resection with Modified Air Leak Test and Chest Tube Drainage

Background: To investigate whether tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage has better short-term outcomes than non-intubated approach with chest tube drainage.Methods: Data were collected retrospectively from January 2017 and December 2019. Tubeless group included 55 patients with pulmonary nodules underwent tubeless uniportal thoracoscopic wedge resection, 211 patients underwent non-intubated uniportal thoracoscopic wedge resection with chest tube drainage were included in drainage group. Peri-operative outcomes between two groups were compared. Results: After 1:1 matching, 110 patients remained for analysis, baseline demographic and clinical variables were comparable between the two groups. Mean incision size was 3 cm in both group. Mean operative time was 59.3 minutes in tubeless group and 52.8 minutes in drainage group. The detectable mean lowest SpO2 and mean peak EtCO2 during operation was acceptable in both groups. Conversion to intubated ventilation or thoracotomy was not required. No patient failed the air leak test and did not undergo a tubeless procedure. Mean postoperative hospital stay was 1.5 days in tubeless group and 2.5 days in drainage group. Residual pneumothorax or subcutaneous emphysema was not frequent and mild in tubeless group. Side effects were rare and mild, including cough and hemoptysis. No re-intervention or readmission occurred. The postoperative VAS score was significantly lower in tubeless group.Conclusions: Tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage is feasible and safe for selected patients with peripheral pulmonary nodules, it might reduce post-operation pain and lead to faster recovery.

Tubeless Uniportal Thoracoscopic Wedge Resection with Modified Air Leak Test and Chest Tube Drainage

Background: To investigate whether tubeless uniportal thoracoscopic wedge resection has better short-term outcomes than non-intubated approach with chest tube drainage.Methods: Data were collected retrospectively from January 2017 and December 2019. Tubeless group included 55 patients with pulmonary nodules underwent tubeless uniportal thoracoscopic wedge resection, 211 patients underwent non-intubated uniportal thoracoscopic wedge resection with chest tube drainage were included in drainage group. Perioperative outcomes between two groups were compared. Results: After 1:1 matching, 110 patients remained for analysis, baseline demographic and clinical variables were comparable between the two groups. Mean incision size was 3 cm in both group. Mean operative time was 59.3 minutes in tubeless group and 52.8 minutes in drainage group. The detectable mean lowest SpO2 and mean peak EtCO2 during operation was acceptable in both groups. Conversion to intubated ventilation or thoracotomy was not required. No patient failed the air leak test and did not undergo a tubeless procedure. Mean postoperative hospital stay was 1.5 days in tubeless group and 2.5 days in drainage group. Residual pneumothorax or subcutaneous emphysema was not frequent and mild in tubeless group. The postoperative pain VAS score was pain score was significantly lower in tubeless group in post-operative day 1 and 3. Side effects were rare and mild, including cough and hemoptysis. No reintervention or readmission occurred.Conclusions: Tubeless uniportal thoracoscopic wedge resection with modified air leak test and chest tube drainage is feasible and safe for selected patients with peripheral pulmonary nodules, it might reduce post-operation pain and lead to faster recovery.