Anastomotic Stricture in End-to-End Anastomosis—Risk Factors in a Series of 261 Patients with Esophageal Atresia

Aim To assess the risk factors for anastomotic stricture (AS) in end-to-end anastomosis (EEA) in patients with esophageal atresia (EA). Methods With ethical consent, hospital records of 341 EA patients from 1980 to 2020 were reviewed. Patients with less than 3 months survival (n = 30) with Gross type E EA (n = 24) and with primary reconstruction (n = 21) were excluded. Outcome measures were revisional surgery for anastomotic stricture (RSAS) and number of dilatations required for anastomotic patency without RSAS. The factors that were tested for risk of RSAS or dilatations were distal tracheoesophageal fistula (TEF) at the carina in C-type EA (congenital TEF [CTEF]), type A/B EA, antireflux surgery (ARS), anastomotic leakage, recurrent TEF, and Spitz group and congenital heart disease. Main Results A total of 266 patients, Gross type A (n = 17), B (n = 3), C (n = 237), or D (n = 9) underwent EEA (early n = 240, delayed n = 26). Early anastomotic breakdown required secondary reconstruction in five patients. Of the remaining 261 patients, 17 (6.1%) had RSAS, whereas 244 patients with intact end to end required a median of five (interquartile range: 2–8) dilatations for anastomotic patency. Main risk factors for RSAS or (> 8) dilatations were CTEF, type A/B, ARS, and anastomotic leakage that increased the risk of RSAS or dilatations from 4.6- to 11-fold. Conclusion The risk of severe AS is associated with long-gap EA, significant gastroesophageal reflux, and anastomotic leakage.

Influence of the Microbiome on Anastomotic Leak

Despite advances in surgical technique and the expanded use of antibiotics, anastomotic leak remains a dreaded complication leading to increased hospital length of stay, morbidity, mortality, and cost. Data continues to grow addressing the importance of a functional and diverse colonic microbiome to ensure adequate healing. Individual pathogens, such as Enterococcus faecalis and Pseudomonas aeruginosa, have been implicated in the pathogenesis of anastomotic leak. Yet how these pathogens proliferate remains unclear. It is possible that decreased microbial diversity promotes a shift to a pathologic phenotype among the remaining microbiota which may lead to anastomotic breakdown. As the microbiome is highly influenced by diet, antibiotic use, the stress of surgery, and opioid use, these factors may be modifiable at various phases of the surgical process. A large amount of data remains unknown about the composition and behavior of the “normal” gut microbiome as compared with an altered community. Therefore, targeting the gut microbiome as a modifiable factor in anastomotic healing may represent a novel strategy for the prevention of anastomotic leak.

Bishop-Koop jejunostomy in an adult following proximal small bowel anastomotic breakdown

This case involves a proximal penetrating small bowel injury and the use of a Bishop-Koop anastomosis in a 33-year-old man. This case highlights the use of alternative methods used to prevent a proximal small bowel stoma in a rural setting. The Bishop-Koop anastomosis was originally designed for neonates in cases of intestinal anomalies such as atresia, volvulus and apple-peel syndrome. A literature search for the use of the Bishop-Koop anastomosis in adults, although scanty, is included in this article. We believe this article will benefit readers and that this method may be considered in breakdown of proximal small bowel injuries, to prevent a high-output stoma.

A Case of Small Bowel Obstruction and Enterocutaneous Fistulation Resulting from a Mesenteric Haematoma following Blunt Abdominal Trauma

A 23-year-old male with a history of previous abdominal surgery was involved in a road traffic accident. He was discharged after initial assessment but represented several days with small bowel obstruction secondary to a mesenteric haematoma. He underwent resection and recovered well but represented later on the day of discharge with a leaking surgical wound consistent with an enterocutaneous fistula. This was managed conservatively and closed spontaneously after ten days. This case serves to highlight that adhesions from previous surgery can tether the small bowel causing mesenteric injury following blunt-force trauma. It also demonstrates that postoperative ileus can result in an enterocutaneous fistula that has the appearance of an anastomotic breakdown but which resolves more rapidly.

Severe Hemoperitoneum after Patient Self-Induced Fecal Evacuation

An increasing incidence of rectal injuries following patient self-induced harmful acts, aimed to sexual or laxatives porpouses, is a fact reported in literature (El-Ashaal et al., 2008). We herein report a case of severe hemoperitoneum related to a middle and upper rectal third seromuscolar tear caused by a self-induced fecal evacuation by means of an arrow with a covered cork tip. An urgent intestinal diversion by means of a Hartmann's operation was performed. The clinical case is presented in relation to the literature debate, regarding the issue of primary repair or resection and anastomosis versus fecal diversion for penetrating rectal injuries (Fabian, 2002; Cleary et al., 2006; Office of the Surgeon General, 1943; Busic et al., 2002). In conclusion, the importance of avoiding an anastomotic breakdown in a patient undergoing a hemorrhagic shock is highlighted.