Subacute Meckel’s diverticulum perforation

Meckel’s diverticulum is the most common intestinal congenital defect, its prevalence is 0.2%–4.0% and it occurs more commonly in children younger than 2-year old with intestinal bleeding and abdominal pain. Perforation in the elderly is very rare with no more than 35 articles reported worldwide. Here we report the case of a 62-year-old man who was admitted to hospital with a history of acute abdominal pain with a 20-day onset. The patient was treated with laparotomy and 30 cm ileal resection was performed for an 8×5 cm perforated ileum tumour at 50 from ileocecal valve with a side-to-side mechanical anastomosis for reconstruction. Having morbidity Clavien-Dindo scale I in postsurgical and good outcome in 6-month follow-up. Meckel’s diverticulum is an infrequent pathology in paediatric and even rarer in adult population, however, it is always important to keep in mind how to act when is seen either as a finding or as a complication.

Ileo-colic intra-corporeal anastomosis during robotic right colectomy: a systematic literature review and meta-analysis of different techniques

Purpose Robotic assistance could increase the rate of ileo-colic intra-corporeal anastomosis (ICA) during robotic right colectomy (RRC). However, although robotic ICA can be accomplished with several different technical variants, it is not clear whether some of these technical details should be preferred. An evaluation of the possible advantage of one respect to another would be useful. Methods We conducted a systematic review of literature on technical details of robotic ileo-colic ICA, from which we performed a meta-analysis of clinical outcomes. The extracted data allowed a comparative analysis regarding the outcome of overall complication (OC), bleeding rate (BR) and leakage rate (LR), between (1) mechanical anastomosis with robotic stapler, versus laparoscopic stapler, versus totally hand-sewn anastomosis and (2) closure of enterocolotomy with manual double layer, versus single layer, versus stapled. Results A total of 30 studies including 2066 patients were selected. Globally, the side-to-side, isoperistaltic anastomosis, realized with laparoscopic staplers, and double-layer closure for enterocolotomy, is the most common technique used. According to the meta-analysis, the use of robotic stapler was significantly associated with a reduction of the BR with respect to mechanical anastomosis with laparoscopic stapler or totally hand-sewn anastomosis. None of the other technical aspects significantly influenced the outcomes. Conclusions ICA fashioning during RRC can be accomplished with several technical variants without evidence of a clear superiority of anyone of these techniques. Although the use of robotic staplers could be associated with some benefits, further studies are necessary to draw conclusions.

Comparison of Hand-sewn and Modified Mechanical Anastomosis in Esophageal Cancer Patients Undergoing Transhiatal Esophagectomy: An Iranian Retrospective Cohort Study

Background: There are controversies over the efficacy of mechanical stapler when compared with the hand-sewn (HS) technique in patients who underwent esophagogastric anastomosis in terms of efficacy and post-operative advantages. The purpose of the present study is to compare the clinical outcomes of manual and a modified mechanical stapled (MMS) anastomosis (double stapled technique) during esophagectomy for esophageal cancer.Methods: A retrospective cohort study was conducted on 409 patient’s medical records who underwent transhiatal esophagectomy for esophageal cancer between March 2010 and March 2016. All patients were operated using HS technique or MMS technique. All cases were visited in two weeks, four, eight and twelve months after surgery and were evaluated in terms of postoperative complications including anastomotic leakage, regurgitation, anastomotic stricture, dysphagia and need for anastomotic dilatation.Results: 259 (63.3%) patients were operated using HS technique and 150 patients (36.7%) were operated by MMS technique. The mean operative time was 211.45± 82.25 min for the MMS anastomosis group, whereas for the manual group it was 251.42±52.81 min, respectively (P = 0.023). Postoperatively, 38 (14.67%) anastomotic leakage were detected in the HS group compared to 8 (5.33%) the MMS group (P= 0.002). The results showed lesser anastomotic stricture in patients who underwent MMS anastomosis (P= 0.004). However, during the one-year follow-up period, patients with HS anastomosis required more anastomotic dilatation (P= 0.021).Conclusions: Using a MMS anastomosis may reduce operation time and lead to lower rates of anastomotic leak, decrease anastomotic stricture and anastomotic dilatation.

SSI Following Construction of Colorectal Anastomoses and C-Reactive Protein as Marker for Infectious Complications

Introduction. Surgical site infection (SSI) incidence amounts to as much as 30% in patients after colorectal surgeries. Infectious complications after colorectal surgeries are characterised by the prevalence of deep forms of SSI with an unclear clinical presentation and difficulties in a timely diagnosis. An important aspect here is finding the earliest marker of the developing infectious complications and establishing its threshold value.Materials and methods. This is a prospective study of outcomes of colon resection and construction of colon anastomoses in 135 patients. Patients were split in two groups depending on the method of anastomosis construction. The C-reactive protein level was recorded prior to surgery and on days 3, 5, and 7 postop.Results and discussion. SSI was diagnosed in 32 patients (23.7%). Comparing the SSI incidence in different groups the authors established a statistically significant difference in favour of mechanical anastomosis; 9 patients (15.2%) against 23 patients (30.3%), р=0,0164. Statistically significant differences in CRP levels have been established between patients with SSI and patients without SSI at all the times the samples were taken postop. At the level of CRP higher than 100.5 mg/l (0.95 confidence range lower limit) the incidence of SSI increases significantly.Conclusion. Mechanical anastomosis conclusively reduces the incidence of SSI in the postop period by 15.1%. The CRP level of higher than 100.5 mg/l from day 3 postop can be considered a reliable predictor for the development of SSI.

P133 INTRATORATHIC ANASTOMOSIS IN IVOR-LEWIS ESOFAGUECTOMY: TECHNICAL DESCRIPTION AND RESULTS

Aim Description of the technique of intrathoracic anastomosis in Ivor-Lewis esophagectomy in prone position with minimally invasive approach (MIE) by manual tobacco-bag suture and anastomosis with circular stapler and its results. Background & Methods Retrospective descriptive analysis of the intrathoracic anastomosis technique in prone of the cases performed in our Health Care Center by thoracoscopic and laparoscopic approach in Ivor-Lewis esophagectomy between April 2017 and December 2018. Patients who required conversion to thoracotomy due to pleural adhesions were excluded Results The median age of the 18 patients was 59 years (54-67 years). In the 18 analyzed (17 adenocarcinomas of 1/3 lower or gastro-esophageal junction and 1 benign stenosis post-RT) 12 were performed with mechanical anastomosis CEA 25, 2 with CEA 28 and 4 with Orvyl CEA 25. No leakage occurred during the postoperative period, performing in 16 a TEGD at 4-5º DPO. Three patients underwent feeding jejunostomy. In the postoperative period, 2 patients presented with ARDS, 2 with pneumonia, 2 with pleural effusion, and 1 with AF. In the follow-up performed until May 2019 1 patient presented stenosis of the anastomosis that was treated by endoscopic dilation. No leakage of the anastomosis has been recorded. The postoperative mortality (<30 days) was 0% Conclusion Compared with other technical variations, even with another type of anastomosis, the circular mechanical anastomosis, making the tobacco bag around the head by manual suture and reinforcing it by Endoloop is a safe and reproducible technique with a 0% leakage rate and stenosis of 5.88%. According to the literature, the rate of anastomotic leakage in the thoracoscopic approach is between 0-20% and that of anastomotic stenosis is 0-27.5%, without finding significant differences between the different types of anastomosis. It has been demonstrated in numerous series that the thoracoscopic approach is oncologically equal to or better than the approach by thoracotomy because it allows a better dissection with resection of a greater number of nodes and that provides benefits such as less postoperative pain, better patient ventilation, better ergonomics for the surgeon and better vision of the operative field. However, we believe that this new approach should not change the usual technique of performing the anastomosis or the indication of the Ivor-Lewis esophagectomy. Randomized studies with a larger number of cases are necessary to determine which anastomosis technique is safest and reproducible in MIE surgery of esophageal cancer.

Gracilis Muscle Flap for Recurrent Rectovaginal Fistula: a Case Report

We present the case of a 48-year-old patient with a recurrent rectovaginal fistula, who we treated surgically by transposing the gracilis muscle. The patient with a history of ulcerative colitis underwent colorectal resection with mechanical anastomosis and diverting ileostomy for rectal cancer. She was subsequently treated by radiation and chemotherapy. Six weeks later, the ileostomy was removed, but afterwards the patient developed a recto-vaginal fistula. A new diverting ileostomy was performed. After eight months, a transvaginal surgical procedure was performed, and the diverting ileostomy was closed after four months. Two years after the last surgery, the patient performed an MRI scan, which revealed the relapse of the rectovaginal fistula. This time the patient was reoperated using a flap of the gracilis muscle interposed between the rectum and the vagina, but the patient refused any diverting stoma. The rectovaginal fistula relapsed again after thirteen days. Fortunately, after six months of intensive systemic and local treatment with aminosalicilic-5-acid, the fistula closed by itself. Our conclusion is that with a well-managed medical treatment, the gracilis flap, because of its good vascular supply, could be successfully used to treat rectovaginal fistulas even in patients with ulcerative colitis who underwent rectal surgery and radiation therapy for cancer.

Successful treatment of a patient with Turcot syndrome

We report a case of successful treatment of a 15-year-old female patient (body mass index 16) diagnosed with Turcot syndrome (familial adenomatous polyposis of the colon) combined with multiple primary malignant tumors, including anaplastic astrocytoma (received combination therapy in 2007), metachronous cecal cancer (underwent subtotal colectomy and 12 courses of polychemotherapy in 2016–2017), and metachronous stage III pT3N1M0 rectal cancer at 8 cm. The patient underwent laparoscopic low resection with extirpation of the ileosigmoid anastomosis, creation of a reservoir-rectal anastomosis, and preventive ileostomy. The patient had minimal intraoperative blood loss and uneventful postoperative period (with an accelerated rehabilitation protocol). She was discharged from a hospital on day 9. Considering previous treatment episodes and the disease stage, we also included into the treatment regimen adjuvant FOLFOX polychemotherapy in a reduced dose for 6 months. During one-year follow up, there was no evidence of disease progression. Later, the patient underwent ileostomy closure with forming a side-to-side mechanical anastomosis. The patient is fully rehabilitated in term of her social activity.

PS01.132: RISK FACTORS OF ANASTOMOTIC LEAKAGE AFTER ESOPHAGECTOMY WITH GASTRIC TUBE RECONSTRUCTION FOR THORACIC ESOPHAGEAL CANCER

Background Anastomotic leakage is a major complication after esophagectomy. Recent studies reported that anastomotic leakage is associated with poor prognosis. We aimed to identify the risk factors of anastomotic leakage after esophagectomy for thoracic esophageal cancer. Methods We analyzed retrospectively consecutive patients who underwent esophagectomy with reconstruction using gastric tube by cervical anastomosis for thoracic esophageal cancer between January 2009 and December 2017. In the reconstruction, end-to side mechanical anastomosis with circular stapler through the posterior mediastinal route was preferred until 2014, and end-to end hand-sewn anastomosis through the retrosternal route was preferred from 2015. As inflammation-based and/or nutritional markers, prognostic nutritional index (PNI), modified Glasgow Prognostic Score (mGPS), Controlling Nutritional Status (CONUT) score, and neutrophil lymphocyte ratio (NLR) were investigated. Receiver operator characteristic curve analyses were performed to set the cut-off value of continuous variables. Risk factors predicting anastomotic leakage were analyzed using logistic regression model. Results A total of 170 patients (144 males and 26 females) were evaluated. Median age was 65 years (59 − 70). Anastomotic leakage was observed in 21 patients (12.3%). A mechanical anastomosis with circular stapler (P = 0.047) and longer operative time (≧560 minutes) (P = 0.015) were identified as risk factors of anastomotic leakage in univariate analysis. Multivariate analysis including variables with P < 0.1 on univariate analyses identified lower PNI (< 45) (P = 0.044, OR 2.78, 95% CI: 1.02 − 7.56) and mechanical anastomosis with a circular stapler (P = 0.036, OR 3.30, 95% CI: 1.07 − 10.09) as independent risk factors. Conclusion Our findings suggested that preoperative lower PNI and mechanical anastomosis were independent risk factors of anastomotic leakage after esophagectomy. Further studies aimed at preoperative nutritional intervention and anastomotic technique are warranted. Disclosure All authors have declared no conflicts of interest.

PS01.213: COMPARISON OF MANUAL VERSUS MECHANICAL INTRA-THORACIC ESOPHAGO-GASTRIC ANASTOMOSIS IN RADICAL 2-STAGE MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER

Background While in open esophagectomy a plethora of studies comparing outcomes of mechanical (circular or linear stapler) versus hand-sewn intra-thoracic anastomosis have been published, little evidence exists regarding 2-stage minimally invasive esophagectomy; In the majority of published studies the mechanical anastomosis is favored. Construction of the intra-thoracic esophago-gastric anastomosis in minimally invasive esophagectomy is the procedure's rate limiting step. We aim to present our results of hand-sewn versus mechanical anastomosis in 2-stage minimally invasive esophagectomy. Methods Data of 113 consecutive patients over a 20-month period that underwent 2-stage minimally invasive esophagectomy for cancer in our institution were analyzed. Inclusion criteria included only 2-stage and only minimally invasive esophagectomies for cancer. 43 cases underwent fully minimally invasive esophagectomy and 70 had laparoscopic-assisted hybrid esophagectomy. A fully hand-sewn anastomosis with 3/0 v-lock barbed suture was formed in 38% of cases and a mechanical anastomosis with a 25mm or 28mm circular stapler was formed in 62% of cases. Comparison between anastomotic techniques was assessed through Chi-Square and Log-Rank analysis. Results Median age was 68(IQR,47–82) in manual anastomosis group and 65(IQR,31–81) in circular stapler group. Of the manual anastomosis group, 74% received neo-adjuvant treatment versus 20% of the mechanical anastomosis group. In the manual anastomosis group n = 3(6.97%) developed a leak; of these, n = 2 were stented and n = 1 was subclinical requiring no intervention. There was one sepsis-related death; 30-day mortality was 2.3%. In the mechanical anastomosis group n = 2(2,8%) developed anastomotic leak (one combined with tracheo-esophageal fistula) and both were stented and eventually resulted in mortality. 30-day mortality was 2.8%. No conduit necrosis was noticed. Anastomotic strictures requiring dilatation were seen in n = 4(9.3%) in the manual anastomosis group versus n = 5(7.1%) in the mechanical anastomosis group. No statistically significant difference was found between the groups in terms of leak (P = 0.312), stricture (P = 0.698) and mortality rate (P > 0.005). Median length of stay was 11 days (7–70) in the manual anastomosis group and 12 days (7–51) in mechanical anastomosis group. Conclusion Outcomes between manual and mechanical intra-thoracic anastomosis in minimally invasive esophagectomy show no difference within our study group. Both are equally safe and efficient, with surgeon's preference taking priority. Disclosure All authors have declared no conflicts of interest.