Description of a novel robotic early post-prostatectomy anastomotic repair technique and institutional outcomes

Objective:A vesicourethral anastomotic leak(VUAL)is a known complication following robotic-assisted radical prostatectomy.The natural history of a VUAL has been well described and is frequently managed with prolonged catheterization.With increasing emphasis on patient reported outcomes,catheter duration and VUAL are associated with significant short-term quality of life impairment.We aimed to present a case series of our robotic early post-prostatectomy anastomotic repair technique,defined as revision within 6 weeks from index surgery.Methods:A single institution prospective database identified eleven patients with a VUAL from July 2016 to October 2022 who underwent robotic early post-prostatectomy anastomotic repair by a single surgeon.Patients were diagnosed with a VUAL on pre-operative CT urogram or CT/fluoroscopic cystogram.The primary outcome was resolution of the anastomotic leak,defined as no contrast extravasation on post-operative cystography.Secondary outcomes included post-repair catheter duration and continence on the last follow-up defined as pad(s)per day.Results:The mean time to intervention after robotic-assisted radical prostatectomy was 21 days.Eight of the eleven(72.7%)patients had no evidence of extravasation on postrepair cystogram.The range from intervention to first cystogram was 7e20 days.The median catheter duration for those with successful intervention was 10 days.The median catheter duration for those with the leak on initial post-operative cystogram was 20 days.At a mean follow-up time of 25 months,eight(72.7%)patients reported using no pads per day,and three(27.3%)patients reported one pad per day.Conclusion:Management of a VUAL has traditionally relied on prolonged catheter drainage and the tincture of time.As the role of robotic reconstruction has been shown to be a viable modality for management of bladder neck contracture,it is important to reconsider prior dogmas of urologic care.Our case series suggests that an early repair is safe and has a high success rate.Early robotic intervention gives providers an additional tool in aiding patient recovery.

Clinical diagnostic advances in intestinal anastomotic techniques:Hand suturing,stapling,and compression devices

The development of intestinal anastomosis techniques,including hand suturing,stapling,and compression anastomoses,has been a significant advancement in surgical practice.These methods aim to prevent leakage and minimize tissue fibrosis,which can lead to stricture formation.The healing process involves various phases:hemostasis and inflammation,proliferation,and remodeling.Mechanical staplers and sutures can cause inflammation and fibrosis due to the release of profibrotic chemokines.Compression anastomosis devices,including those made of nickel-titanium alloy,offer a minimally invasive option for various surgical challenges and have shown safety and efficacy.However,despite advancements,anastomotic techniques are evaluated based on leakage risk,with complications being a primary concern.Newer devices like Magnamosis use magnetic rings for compression anastomosis,demonstrating greater strength and patency compared to stapling.Magnetic technology is also being explored for other medical treatments.While there are promising results,particularly in animal models,the realworld application in humans is limited,and further research is needed to assess their safety and practicality.

Recanalization of anastomotic occlusion following rectal cancer surgery using a rendezvous endoscopic technique with transillumination:A case report

BACKGROUND Colorectal anastomotic occlusion is a serious complication of colorectal cancer surgery.Although several treatment strategies have been proposed,the mana-gement of anastomotic occlusion remains challenging.In this report,we present a case of anastomotic occlusion recanalization performed using a novel technique involving two endoscopes,one for radial incision and the other serving as a guide light.This novel technique offers significant advantages in terms of operational feasibility,reduced invasiveness,rapid recovery,and shortened hospital stay.CASE SUMMARY A 37-year-old man underwent low anterior resection and prophylactic double-lumen ileostomy for rectal cancer in June,2023.Two months later,complete anastomotic occlusion was observed on colonoscopy.Therefore,we developed a novel atresia recanalization technique.Two endoscopes were placed,one through the colonic anastomosis and the other through the anus.A radial incision was successfully made from the colonic side,guided by the light of the endoscope from the anal side.Atresia recanal-ization was performed within 20 minutes.Three weeks after recanalization,colonoscopy revealed that the diameter of the colorectal anastomosis was approximately 16 mm and the patient therefore underwent stoma reversal in September.During the follow-up period of approximately one year,the patient remained well and no stenosis or obstruction symptoms were observed.CONCLUSION Endoscopic atresia recanalization of colorectal anastomotic occlusion assisted by an opposing light source is safe and effective.

Construction and validation of a risk-prediction model for anastomotic leakage after radical gastrectomy: A cohort study in China

Objectives:Anastomotic leakage(AL)stands out as a prevalent and severe complication following gastric cancer surgery.It frequently precipitates additional serious complications,significantly influencing the overall survival time of patients.This study aims to enhance the risk-assessment strategy for AL following gastrectomy for gastric cancer.Methods:This study included a derivation cohort and validation cohort.The derivation cohort included patients who underwent radical gastrectomy at Sir Run Run Shaw Hospital,Zhejiang University School of Medicine,from January 1,2015 to December 31,2020.An evidence-based predictor questionnaire was crafted through extensive literature review and panel discussions.Based on the questionnaire,inpatient data were collected to form a model-derivation cohort.This cohort underwent both univariate and multivariate analyses to identify factors associated with AL events,and a logistic regression model with stepwise regression was developed.A 5-fold cross-validation ensured model reliability.The validation cohort included patients from August 1,2021 to December 31,2021 at the same hospital.Using the same imputation method,we organized the validation-queue data.We then employed the risk-prediction model constructed in the earlier phase of the study to predict the risk of AL in the subjects included in the validation queue.We compared the predictions with the actual occurrence,and evaluated the external validation performance of the model using model-evaluation indicators such as the area under the receiver operating characteristic curve(AUROC),Brier score,and calibration curve.Results:The derivation cohort included 1377 patients,and the validation cohort included 131 patients.The independent predictors of AL after radical gastrectomy included age65 y,preoperative albumin<35 g/L,resection extent,operative time240 min,and intraoperative blood loss90 mL.The predictive model exhibited a solid AUROC of 0.750(95%CI:0.694e0.806;p<0.001)with a Brier score of 0.049.The 5-fold cross-validation confirmed these findings with a calibrated C-index of 0.749 and an average Brier score of 0.052.External validation showed an AUROC of 0.723(95%CI:0.564e0.882;p?0.006)and a Brier score of 0.055,confirming reliability in different clinical settings.Conclusions:We successfully developed a risk-prediction model for AL following radical gastrectomy.This tool will aid healthcare professionals in anticipating AL,potentially reducing unnecessary interventions.

Therapy for benign rectal anastomotic stricture after surgery for colorectal cancer:A systematic review

Objective:To evaluate various treatment methods for benign rectal anastomotic stricture(AS)following surgery for colorectal cancer.Method:A systematic review of the literature was conducted,focusing on studies that reported outcomes of different treatment modalities for benign AS.The PubMed,Embase,Scopus,China National Knowledge Infrastructure,and Cochrane Library databases were searched from January 2000 to December 2023.The inclusion criteria were studies involving human subjects,published in English,and reporting on therapeutic outcomes for benign AS.Results:A total of 19 papers identified a range of therapeutic strategies,including nonoperative anastomotic dilation,endoscopic balloon dilation(EBD),transanal minimally invasive surgery(TAMIS),selfexpandable metal stents(SEMS),endoscopic incision(EI)and newer techniques such as prostate resection instrumentation.Nonoperative anastomotic dilation can serve as an initial treatment for lower AS.EI demonstrated promise in cases where EBD was ineffective,providing an alternative method for managing AS.TAMIS and SEMS showed higher efficacy in refractory cases,with TAMIS being particularly effective for severe fibrotic or completely closed AS.The use of rigid instrumentation with an electric knife for transanal incisions demonstrated precision but lacked the flexibility needed for complex procedures.Conclusion:While traditional methods such as nonoperative anastomotic dilation and EBD remain firstline treatments for benign AS,advanced techniques such as EI,TAMIS,and SEMS offer promising alternatives,particularly in refractory cases.The choice of treatment should be tailored to individual patient conditions,with consideration for the technical expertise required and the potential for complications.

Serum nutritional predictive biomarkers and risk assessment for anastomotic leakage after laparoscopic surgery in rectal cancer patients

BACKGROUND Anastomotic leakage(AL)is one of the severest complications after laparoscopic surgery for middle/low rectal cancer,significantly impacting patient outcomes.Identifying reliable predictive factors for AL remains a clinical challenge.Serum nutritional biomarkers have been implicated in surgical outcomes but are un-derexplored as predictive tools for AL in this setting.Our study hypothesizes that preoperative serum levels of prealbumin(PA),albumin(ALB),and transferrin(TRF),along with surgical factors,can accurately predict AL risk.AIM To determine the predictive value of preoperative serum nutritional biomarkers for rectal cancer AL following laparoscopic surgery.METHODS In the retrospective cohort study carried out at a tertiary cancer center,we examined 560 individuals who underwent laparoscopic procedures for rectal cancer from 2018 to 2022.Preoperative serum levels of PA,ALB,and TRF were measured.We employed multivariate logistic regression to determine the independent risk factors for AL,and a predictive model was constructed and evaluated using receiver operating characteristic curve analysis.RESULTS AL occurred in 11.96%of cases,affecting 67 out of 560 patients.Multivariate analysis identified PA,ALB,and TRF as the independent risk factor,each with an odds ratio of 2.621[95%confidence interval(CI):1.582-3.812,P=0.012],3.982(95%CI:1.927-4.887,P=0.024),and 2.109(95%CI:1.162-2.981,P=0.031),respectively.Tumor location(<7 cm from anal verge)and intraoperative bleeding≥300 mL also increased AL risk.The predictive model demonstrated an excellent accuracy,achieving an area under the receiver operating characteristic curve of 0.942,a sensitivity of 0.844,and a specificity of 0.922,demonstrating an excellent ability to discriminate.CONCLUSION Preoperative serum nutritional biomarkers,combined with surgical factors,reliably predict anastomotic leakage risk after rectal cancer surgery,highlighting their importance in preoperative assessment.

Peritoneal fluid indocyanine green test for diagnosis of gut leakage in anastomotic leakage rats and colorectal surgery patients

BACKGROUND Application of indocyanine green(ICG)fluorescence has led to new developments in gastrointestinal surgery.However,little is known about the use of ICG for the diagnosis of postoperative gut leakage(GL).In addition,there is a lack of rapid and intuitive methods to definitively diagnose postoperative GL.AIM To investigate the effect of ICG in the diagnosis of anastomotic leakage in a surgical rat GL model and evaluate its diagnostic value in colorectal surgery patients.METHODS Sixteen rats were divided into two groups:GL group(n=8)and sham group(n=8).Approximately 0.5 mL of ICG(2.5 mg/mL)was intravenously injected postoperatively.The peritoneal fluid was collected for the fluorescence test at 24 and 48 h.Six patients with rectal cancer who had undergone laparoscopic rectal cancer resection plus enterostomies were injected with 10 mL of ICG(2.5 mg/mL)on postoperative day 1.Their ostomy fluids were collected 24 h after ICG injection to identify the possibility of the ICG excreting from the peripheral veins to the enterostomy stoma.Participants who had undergone colectomy or rectal cancer resection were enrolled in the diagnostic test.The peritoneal fluids from drainage were collected 24 h after ICG injection.The ICG fluorescence test was conducted using OptoMedic endoscopy along with a near-infrared fluorescent imaging system.RESULTS The peritoneal fluids from the GL group showed ICG-dependent green fluorescence in contrast to the sham group.Six samples of ostomy fluids showed green fluorescence,indicating the possibility of ICG excreting from the peripheral veins to the enterostomy stoma in patients.The peritoneal fluid ICG test exhibited a sensitivity of 100%and a specificity of 83.3%for the diagnosis of GL.The positive predictive value was 71.4%,while the negative predictive value was 100%.The likelihood ratios were 6.0 for a positive test result and 0 for a negative result.CONCLUSION The postoperative ICG test in a drainage tube is a valuable and simple technique for the diagnosis of GL.Hence,it should be employed in clinical settings in patients with suspected GL.

Novel magnetic compression technique for the treatment of postoperative anastomotic stenosis in rectal cancer:A case report

BACKGROUND The treatment of postoperative anastomotic stenosis after excision of rectal cancer is challenging.Endoscopic balloon dilation and radial incision are not effective in all patients.We present a new endoscopy-assisted magnetic compression technique(MCT)for the treatment of rectal anastomotic stenosis.We successfully applied this MCT to a patient who developed an anastomotic stricture after radical resection of rectal cancer.A 50-year-old man had undergone laparoscopic radical rectal cancer surgery at a local hospital 5 months ago.A colonoscopy performed 2 months ago indicated that the rectal anastomosis was narrow due to which ileostomy closure could not be performed.The patient came to the Magnetic Surgery Clinic of the First Affiliated Hospital of Xi'an Jiaotong University after learning that we had successfully treated patients with colorectal stenosis using MCT.We performed endoscopy-assisted magnetic compression surgery for rectal stenosis.The magnets were removed 16 d later.A follow-up colonoscopy performed after 4 months showed good anastomotic patency,following which,ileostomy closure surgery was performed.CONCLUSION MCT is a simple,non-invasive technique for the treatment of anastomotic stricture after radical resection of rectal cancer.The technique can be widely used in clinical settings.

Preoperative neutrophil-to-lymphocyte ratio predicts symptomatic anastomotic leakage in elderly colon cancer patients: Multicenter propensity score-matched analysis

BACKGROUND The neutrophil-to-lymphocyte ratio(NLR),a composite inflammatory biomarker,is associated with the prognosis in patients with colorectal tumors.However,whether the NLR can be used as a predictor of symptomatic postoperative ana-stomotic leakage(AL)in elderly patients with colon cancer is unclear.AIM To assess the role of the NLR in predicting the occurrence of symptomatic AL after surgery in elderly patients with colon cancer.METHODS Data from elderly colon cancer patients who underwent elective radical colectomy with anastomosis at three centers between 2018 and 2022 were retrospectively analyzed.Receiver operating characteristic curve analysis was performed to determine the best predictive cutoff value for the NLR.Twenty-two covariates were matched using a 1:1 propensity score matching method,and univariate and multivariate logistic regression analyses were used to determine risk factors for the development of postoperative AL.RESULTS Of the 577 patients included,36(6.2%)had symptomatic AL.The optimal cutoff value of the NLR for predicting AL was 2.66.After propensity score matching,the incidence of AL was significantly greater in the≥2.66 NLR subgroup than in the<2.66 NLR subgroup(11.5%vs 2.5%;P=0.012).Univariate logistic regression analysis revealed statistically significant correlations between blood transfusion intraoperatively and within 2 d postoper-atively,preoperative albumin concentration,preoperative prognostic nutritional index,and preoperative NLR and AL occurrence(P<0.05);multivariate logistic regression analysis revealed that an NLR≥2.66[odds ratio(OR)=5.51;95%confidence interval(CI):1.50-20.26;P=0.010]and blood transfusion intraoperatively and within 2 d postoperatively(OR=2.52;95%CI:0.88-7.25;P=0.049)were risk factors for the occurrence of symptomatic AL.CONCLUSION A preoperative NLR≥2.66 and blood transfusion intraoperatively and within 2 d postoperatively are associated with a higher incidence of postoperative symptomatic AL in elderly patients with colon cancer.The preoperative NLR has predictive value for postoperative symptomatic AL after elective surgery in elderly patients with colon cancer.

Characteristics of gut microbiota in anastomotic leakage patients in cold zones post-colorectal cancer surgery: A high-throughput sequencing and propensity-score matching study

Objective:The study aimed to explore the association between gut microbiota and anastomotic leakage(AL)after surgery in colorectal cancer(CRC)patients from a frigid zone,based on high-throughput sequencing.Methods:A total of 98 CRC patients admitted to the Second Affiliated Hospital of Harbin Medical University from July 2018 to February 2019,who met the inclusion criteria,were included.Among these,10 patients were diagnosed as AL.After propensity-score matching of baseline characteristics,10 patients from the anastomotic leakage group(AG)and 10 patients from the normal group(NG)were finally included in this study.Fecal samples were collected,and total DNA was extracted for high-throughput sequencing and bioinformatic analysis.Results:Alpha diversity analysis showed no significant difference between the two groups,while beta diversity analysis revealed significant differences in principal components.Differential microbiota were classified as Proteobacteria at the phylum level(P=0.021).At the genus level,the abundances of Streptococcus(P=0.045),Citrobacter(P=0.008)and Klebsiella(P=0.002)were significantly different between the two groups.LEfSe analysis indicated that these genera contributed most to the differences between the groups.Conclusion:The characteristics of the gut microbiota in the AG and NG were significantly different,and these differences might be associated with AL in CRC patients from frigid zones.

Surgeon Perspectives on Anastomotic Leaks and FluidAI’s StreamTM Platform: Integrating Qualitative Insights for Technological Innovation

Purpose: This article investigates the critical importance of integrating surgeons’ direct input into the development of innovative technologies that address gaps in surgical care, including those aimed at reducing anastomotic leaks (AL), a major complication in gastrointestinal surgery. While traditional quantitative research methods are prevalent, they often overlook the invaluable insights of the surgeons who manage these complications firsthand. Subjects and Methods: This study employs a qualitative approach, utilizing semi-structured interviews with 40 surgeons from various specialties, including general, bariatric, colorectal, trauma, hepato-biliary, and thoracic surgery. The interviews were designed to probe the needs of surgeons, challenges currently faced, and gaps in clinical practice, research, and technology for detection and/or management of AL. The data were analyzed using thematic analysis, which revealed significant gaps in current technologies for early detection and prevention of leaks. Results: Surgeons expressed strong interest in FluidAI’s Stream™ Platform, a non-invasive medical device designed to monitor postoperative drainage fluid in real-time, providing continuous data on AL risk. The ability of this platform to offer early prediction through pH and electrical conductivity analysis was particularly appealing to participants, who emphasized the importance of timely interventions in improving patient outcomes. The study’s findings highlight not only the clinical challenges but also the emotional toll that AL takes on surgeons, underlining the need for innovations that are both data-driven and humanistic. Conclusion: By centering surgeons’ perspectives, this research advocates for a human-centered approach to technological advancement, ensuring that new tools are both clinically effective and aligned with the real-world needs of surgical practitioners.

Evaluation of the Quality of Micturition in Patients Who Underwent Anastomotic Urethroplasty at the Yaounde Central Hospital, Cameroon

Introduction: Radiological investigation which is the gold standard to perform following anastomotic urethroplasty in order to evaluate the quality of micturition is costly. In our context, due to financial limitations, reconstructive urologists prefer to use the uroflowmetry in order to assess the micturition post-surgery. Therefore, the objective of the study was to assess the quality of micturition using the uroflowmetry after anastomotic urethroplasty. Methodology: We conducted an 11-year retrospective review (1st January 2006-31st December 2017) and a cross-sectional descriptive observational study for a period of 8 months (November 2017-June 2018) at the Urology and Andrology Department of the Yaounde Central Hospital (YCH) of patients who were diagnosed with urethral stenosis and underwent an anastomotic urethroplasty at the YCH. We excluded patients who had incomplete files, patients lost to follow-up and did not do pre-operative uroflowmetry. Quality of micturition was evaluated using a uroflowmetry. Data was analyzed using EPI info 7.0. Parametric variables were reported as means and standard deviations and percentages and counts were used to report categorical variables. Results: We had a sample of 60 patients. The mean age was 42 ± 5 years with extremes ranging from 20 to 76 years. Twenty-seven (27) patients, or 45%, had no post-operative complications, and those who did had a urinary tract infection (26.70%). In our series, we had 82% excellent results (patient satisfied with his urination with bell-shaped urinary stream and urinary flow greater than or equal to 15 ml/sec);15% good results (patient with moderate dysuria with average urinary stream and urinary flow between 10 and 14.9 ml/sec) and 3% poor results (severe dysuria with urinary flow less than 10 ml/sec, urinary retention or urinary incontinence). Based on these results we can say that the success rate in our series was 97%. 96.70% of patients were satisfied against 3.3% who were not. Conclusion: Anastomotic urethroplasty is the gold standard for the treatment of short urethral strictures. The results are good in the immediate and long term post-operative period. The use of the uroflowmetry as a screening tool for evaluating the quality of micturition after urethroplasty is effective.

Risk factors for anastomotic fistula development after radical colon cancer surgery and their impact on prognosis

BACKGROUND Colon cancer is a common malignant tumor in the gastrointestinal tract that is typically treated surgically.However,postradical surgery is prone to complic-ations such as anastomotic fistulas.AIM To investigate the risk factors for postoperative anastomotic fistulas and their impact on the prognosis of patients with colon cancer.METHODS We conducted a retrospective analysis of 488 patients with colon cancer who underwent radical surgery.This study was performed between April 2016 and April 2019 at a tertiary hospital in Wuxi,Jiangsu Province,China.A t-test was used to compare laboratory indicators between patients with and those without postoperative anastomotic fistulas.Multiple logistic regression analysis was performed to identify independent risk factors for postoperative anastomotic fistulas.The Functional Assessment of Cancer Therapy-Colorectal Cancer was also used to assess postoperative recovery.RESULTS Binary logistic regression analysis revealed that age[odds ratio(OR)=1.043,P=0.015],tumor,node,metastasis stage(OR=2.337,P=0.041),and surgical procedure were independent risk factors for postoperative anastomotic fistulas.Multiple linear regression analysis showed that the development of postoperative anastomotic fistula(P=0.000),advanced age(P=0.003),and the presence of diabetes mellitus(P=0.015),among other factors,independently affected CONCLUSION Postoperative anastomotic fistulas significantly affect prognosis and survival rates.Therefore,focusing on the clinical characteristics and risk factors and immediately implementing individualized preventive measures are important to minimize their occurrence.

Establishment and application of three predictive models of anastomotic leakage after rectal cancer sphincter-preserving surgery

BACKGROUND Anastomotic leakage(AL)occurs frequently after sphincter-preserving surgery for rectal cancer and has a significant mortality rate.There are many factors that influence the incidence of AL,and each patient’s unique circumstances add to this diversity.The early identification and prediction of AL after sphincter-preserving surgery are of great significance for the application of clinically targeted preventive measures.Developing an AL predictive model coincides with the aim of personalised healthcare,enhances clinical management techniques,and advances the medical industry along a more precise and intelligent path.AIM To develop nomogram,decision tree,and random forest prediction models for AL following sphincter-preserving surgery for rectal cancer and to evaluate the predictive efficacy of the three models.METHODS The clinical information of 497 patients with rectal cancer who underwent sphincter-preserving surgery at Jincheng People’s Hospital of Shanxi Province between January 2017 and September 2022 was analyzed in this study.Patients were divided into two groups:AL and no AL.Using univariate and multivariate analyses,we identified factors influencing postoperative AL.These factors were used to establish nomogram,decision tree,and random forest models.The sensitivity,specificity,recall,accuracy,and area under the receiver operating characteristic curve(AUC)were compared between the three models.RESULTS AL occurred in 10.26%of the 497 patients with rectal cancer.The nomogram model had an AUC of 0.922,sensitivity of 0.745,specificity of 0.966,accuracy of 0.936,recall of 0.987,and accuracy of 0.946.The above indices in the decision tree model were 0.919,0.833,0.862,0.951,0.994,and 0.955,respectively and in the random forest model were 1.000,1.000,1.000,0.951,0.994,and 0.955,respectively.The DeLong test revealed that the AUC value of the decision-tree model was lower than that of the random forest model(P<0.05).CONCLUSION The random forest model may be used to identify patients at high risk of AL after sphincter-preserving surgery for rectal cancer owing to its strong predictive effect and stability.

Impact of anastomotic leakage on long-term prognosis after colorectal cancer surgery

Colorectal cancer(CRC)is one of the most common malignancies in the world.Despite significant improvements in surgical technique,postoperative complications still occur in a fair percentage of patients undergoing colorectal surgery.The most feared complication is anastomotic leakage.It negatively affects shortterm prognosis,with increased post-operative morbidity and mortality,higher hospitalization time and costs.Moreover,it may require further surgery with the creation of a permanent or temporary stoma.While there is no doubt about the negative impact of anastomotic dehiscence on the short-term prognosis of patients operated on for CRC,still under discussion is its impact on the long-term prognosis.Some authors have described an association between leakage and reduced overall survival,disease-free survival,and increased recurrence,while other Authors have found no real impact of dehiscence on long term prognosis.The purpose of this paper is to review all the literature about the impact of anastomotic dehiscence on long-term prognosis after CRC surgery.The main risk factors of leakage and early detection markers are also summarized.

Efficacy of transanal drainage tube in preventing anastomotic leakage after surgery for rectal cancer: A meta-analysis

BACKGROUND Anastomotic leakage(AL)following rectal cancer surgery is an important cause of mortality and recurrence.Although transanal drainage tubes(TDTs)are expected to reduce the rate of AL,their preventive effects are controversial.AIM To reveal the effect of TDT in patients with symptomatic AL after rectal cancer surgery.METHODS A systematic literature search was performed using the PubMed,Embase,and Cochrane Library databases.We included randomized controlled trials(RCTs)and prospective cohort studies(PCSs)in which patients were assigned to two groups depending on the use or non-use of TDT and in which AL was evaluated.The results of the studies were synthesized using the Mantel-Haenszel randomeffects model,and a two-tailed P value>0.05 was considered statistically significant.RESULTS Three RCTs and two PCSs were included in this study.Symptomatic AL was examined in all 1417 patients(712 with TDT),and TDTs did not reduce the symptomatic AL rate.In a subgroup analysis of 955 patients without a diverting stoma,TDT reduced the symptomatic AL rate(odds ratio=0.50,95%confidence interval:0.29–0.86,P=0.012).CONCLUSION TDT may not reduce AL overall among patients undergoing rectal cancer surgery.However,patients without a diverting stoma may benefit from TDT placement.

Management of low colorectal anastomotic leak:Preserving the anastomosis

Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy(Hartmann's procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.

Biliary complications in liver transplantation: Impact of anastomotic technique and ischemic time on short- and long-term outcome

AIM: To elucidate the impact of various donor recipient and transplant factors on the development of biliary complications after liver transplantation.METHODS: We retrospectively reviewed 200 patients of our newly established liver transplantation(LT) program, who received full size liver graft. Biliary reconstruction was performed by side-to-side(SS), end-to-end(EE) anastomosis or hepeaticojejunostomy(HJ). Biliary complications(BC), anastomotic stenosis, bile leak, papillary stenosis, biliary drain complication, ischemic type biliary lesion(ITBL) were evaluated by studying patient records, corresponding radiologic imaging and reports of interventional procedures [e.g., endoscopic retrograde cholangiopancreatography(ERCP)]. Laboratory results included alanine aminotransferase(ALT), gammaglutamyltransferase and direct/indirect bilirubin with focus on the first and fifth postoperative day, six weeks after LT. The routinely employed external bile drain was examined by a routine cholangiography on the fifth postoperative day and six weeks after transplantation as a standard procedure, but also whenever clinically indicated. If necessary, interventional(e.g., ERCP) or surgical therapy was performed. In case of biliary complication, patients were selected, assigned to different complication-groups and subsequently reviewed in detail. To evaluate the patients outcome, we focussed on appearance of postoperative/post-interventional cholangitis, need for rehospitalisation, retransplantation, ITBL or death caused by BC.RESULTS: A total of 200 patients [age: 56(19-72), alcoholic cirrhosis: n = 64(32%), hepatocellular carcinoma: n = 40(20%), acute liver failure: n = 23(11.5%), cryptogenic cirrhosis: n = 22(11%), hepatitis B virus /hepatitis C virus cirrhosis: n = 13(6.5%), primary sclerosing cholangitis: n = 13(6.5%), others: n = 25(12.5%) were included. The median follow-up was 27 mo until June 2015. The overall biliary complication rate was 37.5%(n = 75) with anastomotic strictures(AS): n = 38(19%), bile leak(BL): n = 12(6%), biliary drain complication: n = 12(6%); papillary stenosis(PS): n = 7(3.5%), ITBL: n = 6(3%). Clinically relevant were only 19%(n = 38). We established a comprehensive classification for AS with four grades according to clinical relevance. The reconstruction techniques [SS: n = 164, EE: n = 18, HJ: n = 18] showed no significant impact on the development of BCs in general(all n < 0.05), whereas in the HJ group significantly less AS were found(P = 0.031). The length of donor intensive care unit stay over 6 d had a significant influence on BC development(P = 0.007, HR = 2.85; 95%CI: 1.33-6.08) in the binary logistic regression model, whereas other reviewed variables had not [warm ischemic time > 45 min(P = 0.543), cold ischemic time > 10 h(P = 0.114), ALT init > 1500 U/L(P = 0.631), bilirubin init > 5 mg/d L(P = 0.595), donor age > 65(P = 0.244), donor sex(P = 0.068), rescue organ(P = 0.971)]. 13%(n = 10) of BCs had no therapeutic consequences, 36%(n = 27) resulted in repeated lab control, 40%(n = 30) received ERCP and 11%(n = 8) surgical therapy. Fifteen(7.5%) patients developed cholangitis [AS(n = 6), ITBL(n = 5), PS(n = 3), biliary lesion BL(n = 1)]. One patient developed ITBL twelve months after LT and subsequently needed retransplantation. Rehospitalisation rate was 10.5 %(n = 21) [AS(n = 11), ITBL(n = 5), PS(n = 3), BL(n = 1)] with intervention or reinterventional therapy as main reasons. Retransplantation was performed in 5(2.5%) patients [ITBL(n = 1), acute liver injury(ALI) by organ rejection(n = 3), ALI by occlusion of hepatic artery(n = 1)]. In total 21(10.5%) patients died within the follow-up period. Out of these, one patient with AS developed severe fatal chologenic sepsis after ERCP.CONCLUSION: In our data biliary reconstruction technique and ischemic times seem to have little impact on the development of BCs.

Preoperative bowel preparation does not favor the management of colorectal anastomotic leak

BACKGROUND Controversy exists regarding the impact of preoperative bowel preparation on patients undergoing colorectal surgery. This is due to previous research studies,which fail to demonstrate protective effects of mechanical bowel preparation against postoperative complications. However, in recent studies, combination therapy with oral antibiotics(OAB) and mechanical bowel preparation seems to be beneficial for patients undergoing an elective colorectal operation.AIM To determine the association between preoperative bowel preparation and postoperative anastomotic leak management(surgical vs non-surgical).METHODS Patients with anastomotic leak after colorectal surgery were identified from the 2013 and 2014 Colectomy Targeted American College of Surgeons National Surgical Quality Improvement Program(ACS-NSQIP) database and were employed for analysis. Every patient was assigned to one of three following groups based on the type of preoperative bowel preparation: first groupmechanical bowel preparation in combination with OAB, second groupmechanical bowel preparation alone, and third group-no preparation.RESULTS A total of 652 patients had anastomotic leak after a colectomy from January 1,2013 through December 31, 2014. Baseline characteristics were assessed and found that there were no statistically significant differences between the three groups in terms of age, gender, race, American Society of Anesthesiologists score,and other preoperative characteristics. A χ~2 test of homogeneity was conducted and there was no statistically/clinically significant difference between the three categories of bowel preparation in terms of reoperation.CONCLUSION The implementation of mechanical bowel preparation and antibiotic use in patients who are going to undergo a colon resection does not influence the treatment of any possible anastomotic leakage.

Differences in examination results of small anastomotic fistula after radical gastrectomy with afterward treatments:A case report

BACKGROUND Gastrografin swallow,methylthioninium chloride test,and computed tomography(CT)are the main methods for postoperative anastomotic fistula detection.Correct selection and application of examinations and therapies are significant for the early diagnosis and treatment of small anastomotic fistulas after radical gastrectomy,which are conducive to postoperative recovery.CASE SUMMARY A 44-year-old woman underwent radical total gastrectomy for laparoscopic gastric cancer.The patient developed a fever after surgery.The methylthioninium chloride test and early CT suggested no anastomotic fistula,but gastrografin swallow and late CT showed the opposite result.The fistula was successfully closed using an endoscopic clip.The methylthioninium chloride test,gastrografin,and CT performed on different postoperative dates for small esophagojejunostomy fistulas are different.The size of the anastomotic fistula is an important factor for the success of endoscopic treatment.CONCLUSION The advantages and limitations of the diagnosis of different examinations of small esophagojejunostomy fistulas are noteworthy.The size of the leakage of the anastomosis is an important basis for selecting the repair method.