RESUMEN
Grade C pancreatic fistulas are associated with severe morbidity and a significant risk of mortality. High-risk pancreatic anastomoses can be predicted to allow best practice fistula mitigation techniques. In these high-risk glands, any deviation from a stable postoperative clinical course should prompt early computed tomography and aggressive, percutaneous drainage of the operative bed. If salvage surgery is necessary, drainage of the operative bed and/or external diversion of pancreatic juice via stenting while completion pancreatectomy should be avoided. Senior mentorship in the perioperative period offers an opportunity to decrease this complication even in early career surgeons.
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Fístula Pancreática , Humanos , Fístula Pancreática/etiología , Fístula Pancreática/prevención & control , Fístula Pancreática/diagnóstico , Pancreatectomía/métodos , Drenaje/métodos , Complicaciones Posoperatorias/etiología , Anastomosis Quirúrgica/métodosRESUMEN
BACKGROUND: Robotic three-dimensional magnified visual effects and field of view stabilization have enabled precise surgical operations. Intracorporeal anastomosis in right-sided colorectal cancer surgery is expected to shorten operation times, avoid paralytic ileus, and shorten wound lengths; however, there are few reports of intracorporeal anvil fixation for intestinal anastomosis in left-sided colorectal cancer surgery. Herein, we introduce a simple, novel procedure for using robotic purse-string suture (RPSS) in intracorporeal anastomosis with the double-stapling technique in rectal and sigmoid cancer surgery and report short-term outcomes. METHODS: From September 2022 to April 2024, 105 consecutive patients underwent robotic surgery with double-stapling technique anastomosis for rectal or sigmoid colon cancer at our institution. Their data were retrospectively analyzed. Intracorporeal anastomosis with the double-stapling technique using RPSS was performed in 26 patients (the RPSS group), while the double-stapling technique anastomosis with extracorporeal anvil fixation was performed in 79 patients (the EC group). A 1:1 propensity score-matched analysis was performed (matching criteria: sex, age, body mass index (BMI), tumor location and tumor size) using a caliper 0.3. In the RPSS group, after tumor-specific or total mesorectal excision, specimens were extracted from the umbilical wound with simultaneous anvil placement in the body cavity. The oral colonic stump was robotically excised and robotically circumferentially stitched with 3-0 Prolene in all layers. After anvil insertion into the stump, the bowel wall of the colon was completely sewn onto the central rod of the anvil. Reconstructions were anastomosed using the double-stapling technique. RESULTS: The matched cohort contained 23 patients in each group. The RPSS group had significantly less bleeding than the EC group (p = 0.038). Super-low anterior resection (SLAR) in the RPSS group had shorter total operative times than those in the EC group (p = 0.045). The RPSS group experienced no perioperative complications greater than Clavien-Dindo grade III or any anastomosis-related complications. CONCLUSIONS: The RPSS technique can be performed safely without any anastomosis-related complications and reduces the total operative times in SLAR and blood loss through total robotic surgery. This may be a useful modality for robotic colorectal surgery.
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Anastomosis Quirúrgica , Puntaje de Propensión , Procedimientos Quirúrgicos Robotizados , Técnicas de Sutura , Humanos , Procedimientos Quirúrgicos Robotizados/métodos , Masculino , Anastomosis Quirúrgica/métodos , Femenino , Anciano , Estudios Retrospectivos , Persona de Mediana Edad , Técnicas de Sutura/instrumentación , Grapado Quirúrgico/métodos , Neoplasias del Recto/cirugía , Neoplasias del Colon Sigmoide/cirugía , Colon Sigmoide/cirugíaRESUMEN
PURPOSE: Ureteroplasty using buccal or lingual mucosa graft Is feasible for complex proximal ureteral stricture (1, 2). Ileal ureter replacement is considered as the last resort for ureteral reconstruction. Totally intracorporeal robot-assisted ileal ureter replacement can be performed safely and effectively (3). In China, the KangDuo Surgical Robot 2000 Plus (KD-SR-2000 Plus) has been developed featuring two surgeon consoles and five robotic arms. This study aims to share our experience with totally intracorporeal robot-assisted bilateral ileal ureter replacement using KD-SR-2000 Plus. MATERIALS AND METHODS: A 59-year-old female patient underwent a complete intracorporeal robot-assisted bilateral ileal ureter replacement for the treatment of ureteral strictures using KD-SR-2000 Plus. The surgical procedure involved dissecting the proximal ends of the bilateral ureteral strictures, harvesting the ileal ureter, restoring intestinal continuity, and performing an anastomosis between the ileum and the ureteral end as well as the bladder. The data were prospectively collected and analyzed. RESULTS: The surgery was successfully completed with single docking without open conversion. The length of the harvested ileal ureter was 25 cm. The docking time, operation time and console time were 3.4 min., 271 min and 231 min respectively. The estimated blood loss was 50 mL. The postoperative hospitalization was 6 days. No perioperative complications occurred. CONCLUSIONS: It is technically feasible to perform totally intracorporeal robot-assisted bilateral ileal ureter replacement for the treatment of ureteral strictures using KD-SR-2000 Plus. A longer follow-up and a larger sample size are required to evaluate its safety and effectiveness.
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Íleon , Procedimientos Quirúrgicos Robotizados , Uréter , Obstrucción Ureteral , Humanos , Femenino , Persona de Mediana Edad , Procedimientos Quirúrgicos Robotizados/métodos , Uréter/cirugía , Íleon/cirugía , Resultado del Tratamiento , Obstrucción Ureteral/cirugía , Constricción Patológica/cirugía , Tempo Operativo , Anastomosis Quirúrgica/métodos , Procedimientos Quirúrgicos Urológicos/métodosRESUMEN
BACKGROUND: Vessel grafting is an important technique in head and neck free tissue transfer (FTT) reconstruction when a tension-free anastomosis is not otherwise feasible. To our knowledge, there are limited data regarding interposition artery grafts for arterial anastomoses in head and neck reconstruction. Here, we present a multi-institutional cohort of arterial interposition grafts for FTT reconstruction for head and neck defects. METHODS: A retrospective review was conducted at four tertiary care institutions for patients who underwent FTT reconstruction for head and neck defects which utilized an interposition artery graft for the arterial anastomosis. Charts were reviewed for type and length of artery grafts harvested, surgical indication, indication for artery graft, types of flaps harvested, and various preoperative characteristics (including history of radiation or previous FTT reconstruction surgery). Postoperative complications within postoperative day 30 were measured and reported. RESULTS: Nine patients met inclusion criteria. The lateral circumflex femoral artery (either transverse or descending branches) (n = 3) and facial artery (n = 3) were the most commonly harvested arteries. The scalp (n = 5) was the most common primary defect site. Seven grafts were harvested initially and in a planned fashion, while two were harvested as salvage techniques (either for flap salvage or vein graft failure). In planned grafts, arteries were the preferred interposition grafting method due to either size match preferences (n = 4) or similarities in wall thickness (n = 3) between graft and recipient artery. There were no reported cases of unplanned readmission, postoperative hematoma, fistula formation, wound infection, or donor site morbidities. Two patients required unplanned return to the operating room for flap compromise, both of which ultimately resulted in flap failure secondary to clot formation at both arterial and venous anastomoses. CONCLUSIONS: When arterial pedicle length is insufficient, interposition artery grafting is both a feasible and viable technique to achieve tension-free arterial anastomoses for select cases of highly complex head and neck free tissue reconstruction.
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Anastomosis Quirúrgica , Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello , Procedimientos de Cirugía Plástica , Humanos , Estudios Retrospectivos , Colgajos Tisulares Libres/irrigación sanguínea , Colgajos Tisulares Libres/trasplante , Procedimientos de Cirugía Plástica/métodos , Anastomosis Quirúrgica/métodos , Masculino , Persona de Mediana Edad , Femenino , Neoplasias de Cabeza y Cuello/cirugía , Anciano , Adulto , Arterias/trasplante , Resultado del Tratamiento , Injerto Vascular/métodosRESUMEN
BACKGROUND: The recipient vessel choice is very important when performing free-flap breast reconstructions. Usually, the concomitant vein of the recipient artery is anastomosed, and mismatches in the diameter are occasionally observed. We consider the thoracoepigastric vein (TEV) as a potential useful recipient vein. The use of the TEV is not a novel technique. It has been used by surgeons for free-flap anastomoses in the axillary region, but usually as an anastomotic site for the second vein. However, anatomical findings such as TEV diameter, its deficiency rate, and influence on mastectomy are not clear. In this study, computed tomography (CT) was performed to evaluate the use of the TEV as a recipient vein for breast reconstruction. METHODS: The medical records of patients who underwent breast reconstruction with free-flap transfer were retrospectively evaluated. In most cases, CT was performed using a tissue expander inserted after mastectomy. The TEV was considered suitable if its diameter on the mastectomy side was >1 mm and the vertical distance from the most distal slice level where the TEV could be seen at the third costal cartilage height of the parasternal region was <50 mm. RESULTS: Sixty-six sides of 33 patients were evaluated. The mean age of the patients was 49.3 ± 5.1 years. The TEV was used in five flaps. TEV diameters were not significantly different between the left and right sides (1.85 ± 0.53 vs. 1.82 ± 0.6, respectively, p = 0.836). On the mastectomy side, eight (25%) TEVs were injured, but only three (8.6%) were considered unavailable. On the healthy side, 96.4% TEVs were available. CONCLUSIONS: TEVs may be a good choice as vein anastomosis targets for breast reconstruction with a free flap because of their relatively large vessel diameter. TRIAL REGISTRATION: UMIN-CTR: R000061573.
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Colgajos Tisulares Libres , Mamoplastia , Mastectomía , Tomografía Computarizada por Rayos X , Humanos , Mamoplastia/métodos , Femenino , Persona de Mediana Edad , Colgajos Tisulares Libres/irrigación sanguínea , Colgajos Tisulares Libres/trasplante , Estudios Retrospectivos , Adulto , Tomografía Computarizada por Rayos X/métodos , Mastectomía/métodos , Anastomosis Quirúrgica/métodos , Venas/diagnóstico por imagen , Venas/cirugía , Venas/anatomía & histología , Neoplasias de la Mama/cirugíaRESUMEN
BACKGROUND: One anastomosis gastric bypass (OAGB) has gained prominence in the search for better results in bariatric surgery. However, its efficacy and safety compared to Roux-en-Y gastric bypass (RYGB) and sleeve gastrectomy (SG) remain ill-defined. AIMS: To compare the efficacy and safety of OAGB relative to RYGB and SG in the treatment of obesity. METHODS: We systematically searched PubMed, EMBASE, Cochrane Library, Lilacs, and Google Scholar databases for randomized controlled trials comparing OAGB with RYGB or SG in the surgical approach to obesity. We pooled outcomes for body mass index, percentage of excess weight loss, type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease. Statistical analyses were performed with R software (version 4.2.3). RESULTS: Data on 854 patients were extracted from 11 randomized controlled trials, of which 422 (49.4%) were submitted to OAGB with mean follow-up ranging from six months to five years. The meta-analysis revealed a significantly higher percentage of excess weight loss at 1-year follow-up and a significantly lower body mass index at 5-year follow-up in OAGB patients. Conversely, rates of type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease were not significantly different between groups. The overall quality of evidence was considered very low. CONCLUSIONS: Our results corroborate the comparable efficacy of OAGB in relation to RYGB and SG in the treatment of obesity, maintaining no significant differences in type-2 diabetes mellitus remission, complications, and gastroesophageal reflux disease rates.
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Derivación Gástrica , Ensayos Clínicos Controlados Aleatorios como Asunto , Humanos , Derivación Gástrica/métodos , Derivación Gástrica/efectos adversos , Resultado del Tratamiento , Obesidad/cirugía , Obesidad/complicaciones , Obesidad Mórbida/cirugía , Anastomosis Quirúrgica/métodosAsunto(s)
Anastomosis Quirúrgica , Endosonografía , Humanos , Masculino , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Constricción Patológica/cirugía , Constricción Patológica/etiología , Endosonografía/métodos , Estenosis Esofágica/cirugía , Estenosis Esofágica/etiología , Esófago/cirugía , Esófago/diagnóstico por imagen , Yeyunostomía/métodos , Yeyuno/cirugía , Ultrasonografía IntervencionalAsunto(s)
Anastomosis Quirúrgica , Neoplasias del Colon , Laparoscopía , Escisión del Ganglio Linfático , Procedimientos Quirúrgicos Robotizados , Humanos , Escisión del Ganglio Linfático/métodos , Neoplasias del Colon/cirugía , Neoplasias del Colon/patología , Procedimientos Quirúrgicos Robotizados/métodos , Anastomosis Quirúrgica/métodos , Laparoscopía/métodos , Colon Descendente/cirugía , Colectomía/métodos , Masculino , Anciano , Femenino , Persona de Mediana EdadRESUMEN
BACKGROUND: In free jejunum transfer, knowing the ischemic tolerance time of the jejunum is crucial. It helps determine the need for reharvesting if an unexpected situation prolongs the ischemic time. The current ischemic tolerance time in humans is unknown. We investigated the relationship between ischemic time and postoperative complications in head and neck cancer patients who underwent free jejunum transfer. METHODS: The study included 76 patients with available medical records out of 103 patients who underwent free jejunum transfer between 2009 and 2023. The association between the surgical procedure, including ischemic time, and patient's background, and flap engraftment, stenosis of the intestinal anastomosis, the swallowing function, and other complications was investigated. RESULTS: The ischemic time for jejunal flaps ranged from 1 h 24 min to 6 h, with a mean of 197 ± 55.5 min. In 72 patients, the jejunum was successfully engrafted, but vascular occlusion occurred in another four patients. In three of these patients, jejunal necrosis occurred, and there was no specific trend in ischemic time. Stenosis of the intestinal anastomosis occurred in 17 cases (22%), with ischemic time (≥3 h) and age (≥75 years) being significant factors for stenosis (ischemic time: 30% vs. 10%, p = 0.048, age: 50% vs. 15%, p < 0.01). No significant correlations were observed with other complications or the swallowing function. CONCLUSION: There was no specific trend between ischemic time and jejunal survival rate, indicating that an ischemic time within 6 h may not have affected engraftment. Although we have recently performed intestinal anastomosis prior to vascular anastomosis, the choice of surgical technique should be adapted to the patient's age and background.
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Colgajos Tisulares Libres , Neoplasias de Cabeza y Cuello , Isquemia , Yeyuno , Complicaciones Posoperatorias , Humanos , Yeyuno/trasplante , Yeyuno/cirugía , Yeyuno/irrigación sanguínea , Masculino , Femenino , Persona de Mediana Edad , Anciano , Colgajos Tisulares Libres/irrigación sanguínea , Colgajos Tisulares Libres/trasplante , Colgajos Tisulares Libres/efectos adversos , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Adulto , Isquemia/etiología , Estudios Retrospectivos , Neoplasias de Cabeza y Cuello/cirugía , Procedimientos de Cirugía Plástica/métodos , Procedimientos de Cirugía Plástica/efectos adversos , Anciano de 80 o más Años , Supervivencia de Injerto , Anastomosis Quirúrgica/métodos , Anastomosis Quirúrgica/efectos adversos , Factores de TiempoRESUMEN
Microsurgical varicocelectomy is the most commonly used method for the treatment of varicocele (VC) in recent years. However, it is technically demanding with the risk of damaging the normal anatomical structure of the spermatic cord, such as the cremaster muscle, testicular artery, and vas deferens during the pampiniform plexus ligation. Also, traditional varicocelectomy hinders the drainage of the stagnant venous blood of the affected testicle, resulting in a persistent scrotal appearance of varicose veins and slower remission of swelling sensation in postoperative patients with grade III VC. Therefore, we developed a retroperitoneal varicocelectomy with a microscopical spermatic venous-superficial vein of the abdominal wall bypass procedure. The spermatic vein was transected and ligated proximally through the retroperitoneal space. Then, the distal spermatic vein was freed and passed through the internal ring; under the skin of the groin, a microscopic vascular anastomosis was performed to build the bypass of the distal spermatic vein and proximal inferior epigastric vein. The high ligation facilitates the protection of the normal anatomy of the spermatic cord, and the venous bypass allows rapid testicular blood drainage, which can effectively improve the degree of varicocele, testicular pain, and even spermatogenic function. In conclusion, the present protocol describes a promising way to reconstruct the spermatic return through high retroperitoneal ligation of the spermatic vein and anastomosis of the spermatic vein-inferior epigastric vein, which resulted in faster and more obvious improvement in symptoms and better prognosis of grade III VC.
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Cordón Espermático , Varicocele , Venas , Masculino , Humanos , Varicocele/cirugía , Cordón Espermático/cirugía , Cordón Espermático/irrigación sanguínea , Venas/cirugía , Anastomosis Quirúrgica/métodos , Microcirugia/métodos , Ligadura/métodosRESUMEN
Soft-tissue sarcomas (STS) are rare solid tumors of mesenchymal cell origin and account for only 1% of adult malignancies. They tend to occur most commonly in the lower extremities. Reconstruction after sarcoma resection can be challenging, especially when important structures are involved and recurrences occur. Additionally, more attention is now being paid to reconstructing the lymphatic system to prevent lymphatic complications. In this case report, we presented the management of recurrent medial thigh sarcoma that necessitated multiple challenging reconstructions to provide valuable insights for lectures on similar cases. A 50-year-old male patient was diagnosed with an undifferentiated pleomorphic cell sarcoma (UPS) of the anteromedial thigh. After preoperative radiotherapy, a mass of 23 × 15 cm was removed, and reconstruction with a pedicled deep inferior epigastric artery perforator (p-DIEP) flap-based lymphatic flow through (LyFT) was performed. Six months later, the patient developed the first local recurrence with the presence of a distant metastasis. Following the tumor resection, the medial part of the DIEP flap was de-epithelized and buried in the defect for dead space obliteration. Another local recurrence arose 7 months after the second surgery. Therefore, a major debulking surgery involving the femoral neurovascular bundle was performed. The femoral artery was reconstructed with a synthetic graft, and the femoral vein with the great saphenous vein harvested from the contralateral thigh. A composite myocutaneous neurotized anterolateral thigh (ALT) flap from the contralateral thigh was used to obliterate the defect and restore the loss of function of the quadriceps femoris. Two lymphaticovenular anastomoses (LVAs) were performed at the ankle to reduce the risk of lymphatic sequelae. This case report highlights the importance of integrating various techniques to create a tailored approach that effectively addresses complex surgical requirements to avoid limb amputation and maintain functionality.
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Anastomosis Quirúrgica , Arterias Epigástricas , Colgajos Tisulares Libres , Recurrencia Local de Neoplasia , Colgajo Perforante , Procedimientos de Cirugía Plástica , Sarcoma , Neoplasias de los Tejidos Blandos , Muslo , Humanos , Masculino , Persona de Mediana Edad , Muslo/cirugía , Colgajo Perforante/irrigación sanguínea , Colgajos Tisulares Libres/trasplante , Colgajos Tisulares Libres/irrigación sanguínea , Arterias Epigástricas/trasplante , Neoplasias de los Tejidos Blandos/cirugía , Anastomosis Quirúrgica/métodos , Sarcoma/cirugía , Recurrencia Local de Neoplasia/cirugía , Procedimientos de Cirugía Plástica/métodos , Músculo CuádricepsRESUMEN
BACKGROUND: Robotic distal gastrectomy (RDG) with Billroth I (BI) reconstruction is predominantly performed due to its physiological congruence and simplicity. The Intracorporeal Triangular Anastomotic Technique (INTACT) aims to reduce ischemic areas compared to the conventional Delta-shaped anastomosis using the unique characteristics of robotic surgery to standardize procedures, thereby ensuring safe, simple, and reliable reconstruction. This study aims to investigate the efficacy of the INTACT in RDG with BI reconstruction, focusing on its robotic precision in minimizing ischemic zones and improving surgical reliability. SURGICAL TECHNIQUE: The posterior duodenal wall is dissected before reconstruction, and the hepatoduodenal ligament is severed to facilitate passive duodenal manipulation. A quarter-circumference incision is created centrally on the anterior wall of the duodenal stump to avoid excessive tension during anastomosis and to ensure an adequate anastomotic diameter. A small opening is established on the greater curvature of the remaining stomach, and the posterior walls of the stomach and duodenum are joined using a Linear stapler in the first fire. A V-shape is created, and two EndoWrist instruments (robotic first and fourth arms) are utilized to grip and extend the anastomosis diameter, completing the anastomosis with a shared hole closure using the Linear stapler. The robotic arms' features improve the physiological integrity and stability of the BI reconstruction. RESULTS: A total of 81 patients underwent RDG with INTACT from September 2020 to January 2024. The median age was 72 years (range: 31-91), with 49 males and 32 females. The median blood loss was 0 ml (range: 0-200 ml), and the median postoperative hospital stay was 8 days (range: 6-20 days). No cases required reanastomosis during surgery, and no postoperative anastomotic leakage, surgery-related reoperations, or anastomotic strictures were reported. CONCLUSION: INTACT in RDG can be safely performed. The characteristics of the EndoWrist instruments helped in stabilizing the technique, making it a viable option in robotic-assisted surgeries.
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Anastomosis Quirúrgica , Gastrectomía , Gastroenterostomía , Procedimientos Quirúrgicos Robotizados , Neoplasias Gástricas , Humanos , Procedimientos Quirúrgicos Robotizados/métodos , Gastrectomía/métodos , Masculino , Anastomosis Quirúrgica/métodos , Femenino , Persona de Mediana Edad , Anciano , Neoplasias Gástricas/cirugía , Gastroenterostomía/métodos , Seguridad del Paciente , Duodeno/cirugía , Adulto , Anciano de 80 o más AñosRESUMEN
BACKGROUND: The role of intraoperative near-infrared fluorescence angiography with indocyanine green in reducing anastomotic leakage (AL) has been demonstrated in colorectal surgery, however, its perfusion assessment mode, and efficacy in reducing anastomotic leakage after laparoscopic intersphincteric resection (LsISR) need to be further elucidated. AIM: Aim was to study near-infrared fluorescent angiography to help identify bowel ischemia to reduce AL after LsISR. MATERIAL AND METHODS: A retrospective case-matched study was conducted in one referral center. A total of 556 consecutive patients with ultra-low rectal cancer including 140 patients with fluorescence angiography of epiploic appendages (FAEA)were enrolled. Perfusion assessment by FAEA in the monochrome fluorescence mode. Patients were divided into two groups based on perfusion assessment by FAEA. The primary endpoint was the AL rate within 6 months, and the secondary endpoint was the structural sequelae of anastomotic leakage (SSAL). RESULTS: After matching, the study group (n = 109) and control group (n = 190) were well-balanced. The AL rate in the FAEA group was lower before (3.6% vs. 10.1%, P = 0.026) and after matching (3.7% vs. 10.5%, P = 0.036). Propensity scores matching analysis (OR 0.275, 95% CI 0.035-0.937, P 0.039), inverse probability of treatment weighting (OR 0.814, 95% CI 0.765-0.921, P 0.002), and regression analysis (OR 0.298, 95% CI 0.112-0.790, P = 0.015), showed that FAEA was an independent protector factor for AL. This technique can significantly shorten postoperative hospital stay [9 (6-13) vs. 10 (8-13), P = 0.024] and reduce the risk of SSAL (1.4% vs. 6.0%, P = 0.029). CONCLUSIONS: Perfusion assessment by FAEA can achieve better visualization in LsISR and reduce the incidence of AL, subsequently avoiding SSAL after LsISR.
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Fuga Anastomótica , Angiografía con Fluoresceína , Laparoscopía , Neoplasias del Recto , Humanos , Fuga Anastomótica/prevención & control , Fuga Anastomótica/etiología , Masculino , Femenino , Persona de Mediana Edad , Laparoscopía/métodos , Estudios Retrospectivos , Neoplasias del Recto/cirugía , Angiografía con Fluoresceína/métodos , Anciano , Verde de Indocianina , Estudios de Casos y Controles , Canal Anal/cirugía , Canal Anal/irrigación sanguínea , Anastomosis Quirúrgica/métodos , Anastomosis Quirúrgica/efectos adversosRESUMEN
BACKGROUND: Anastomotic leakage (AL) is the most frequent life-threating complication following colorectal surgery. Several attempts have been made to prevent AL. This prospective, randomized, multicentre trial aimed to evaluate the safety and efficacy of nebulised modified cyanoacrylate in preventing AL after rectal surgery. METHODS: Patients submitted to colorectal surgery for carcinoma of the high-medium rectum across five high-volume centres between June 2021 and January 2023 entered the study and were randomized into group A (anastomotic reinforcement with cyanoacrylate) and group B (no reinforcement) and followed up for 30 days. Anastomotic reinforcement was performed via nebulisation of 1 mL of a modified cyanoacrylate glue. Preoperative features and intraoperative and postoperative results were recorded and compared. The study was registered at ClinicalTrials.gov (ID number NCT03941938). RESULTS: Out of 152 patients, 133 (control group, n = 72; cyanoacrylate group, n = 61) completed the follow-up. ALs were detected in nine patients (12.5%) in the control group (four grade B and five grade C) and in four patients (6.6%), in the cyanoacrylate group (three grade B and one grade C); however, despite this trend, the differences were not statistically significant (p = 0.36). However, Clavien-Dindo complications grade > 2 were significantly higher in the control group (12.5% vs. 3.3%, p = 0.04). No adverse effects related to the glue application were reported. CONCLUSION: The role of modified cyanoacrylate application in AL prevention remains unclear. However its use to seal colorectal anastomoses is safe and could help to reduce severe postoperative complications.
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Anastomosis Quirúrgica , Fuga Anastomótica , Cianoacrilatos , Recto , Humanos , Fuga Anastomótica/prevención & control , Fuga Anastomótica/etiología , Femenino , Masculino , Estudios Prospectivos , Anciano , Persona de Mediana Edad , Cianoacrilatos/administración & dosificación , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Recto/cirugía , Adhesivos Tisulares/uso terapéutico , Técnicas de Sutura , Neoplasias del Recto/cirugía , Resultado del TratamientoAsunto(s)
Anastomosis Quirúrgica , Endosonografía , Humanos , Endosonografía/métodos , Constricción Patológica/cirugía , Constricción Patológica/etiología , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Ultrasonografía Intervencional , Masculino , Yeyunostomía/métodos , Yeyuno/cirugía , Femenino , Colestasis/cirugía , Colestasis/etiología , Colestasis/diagnóstico por imagen , Persona de Mediana Edad , AncianoRESUMEN
BACKGROUND: Systemic-to-pulmonary shunt is a palliative procedure used to decrease pulmonary blood flow in congenital heart diseases. Shunt stenosis or occlusion has been reported to be associated with mortality; therefore, the management of thrombotic complications remains a challenge for most congenital cardiovascular surgeons. Despite its importance, the optimal method for shunt anastomosis remains unclear. OBJECTIVE: The study investigates the clinical benefits of the punch-out technique over conventional methods in the anastomosis process of Systemic-to-pulmonary shunt, focusing on its potential to reduce shunt-related complications. METHODS: Anastomotic models were created by two different surgeons employing both traditional slit and innovative punch-out techniques. Computational tomography was performed to construct three-dimensional models for computational fluid dynamics (CFD) analysis. We assessed the flow pattern, helicity, magnitude of wall shear stress, and its gradient. RESULTS: The anastomotic flow area was larger in the model using the punch-out technique than in the slit model. In CFD simulation, we found that using the punch-out technique decreases the likelihood of establishing a high wall shear stress distribution around the anastomosis line in the model. CONCLUSION: The punch-out technique emerges as a promising method in SPS anastomosis, offering a reproducible and less skill-dependent alternative that potentially diminishes the risk of shunt occlusion, thereby enhancing patient outcomes.
Asunto(s)
Anastomosis Quirúrgica , Simulación por Computador , Hidrodinámica , Modelos Cardiovasculares , Humanos , Anastomosis Quirúrgica/métodos , Cardiopatías Congénitas/cirugía , Cardiopatías Congénitas/fisiopatología , Circulación Pulmonar , Estrés Mecánico , Velocidad del Flujo Sanguíneo , Imagenología Tridimensional/métodosRESUMEN
BACKGROUND: Anastomotic leakage is a severe postoperative complication in colorectal surgery and compromised bowel perfusion is considered a major contributing factor. Conventional methods to assess bowel perfusion have a low predictive value for anastomotic leakage. We therefore aimed to evaluate the efficacy of real-time assessment with near-infrared (NIR) fluorescence imaging with indocyanine green (ICG) in the prevention of anastomotic leakage. METHODS: This multicentre, randomised, controlled, phase 3 trial was done in eight hospitals in the Netherlands. We included adults (aged >18 years) who were scheduled for laparoscopic or robotic colorectal surgery (with planned primary anastomosis) for benign and malignant diseases. Preoperatively, patients were randomly assigned (1:1) to fluorescence-guided bowel anastomosis (FGBA) or conventional bowel anastomosis (CBA) by variable block randomisation (block sizes 4, 6, and 8) and stratified by site. The operating surgeon and investigators analysing the data were not masked to group assignment. Patients were unmasked after the surgical procedure or after study end. In the FGBA group, surgeons marked anastomosis levels per conventional perfusion assessment and then administered 5 mg of ICG by 2 mL intravenous bolus. They assessed bowel perfusion using NIR fluorescence imaging and adjusted (or kept) transection lines accordingly. Only conventional methods for bowel perfusion assessment were used in the CBA group. The primary outcome was the difference in the rate of clinically relevant anastomotic leakage (ie, requiring active therapeutic intervention but manageable without reoperation [grade B] or requiring reoperation [grade C], per the International Study Group of Rectal Cancer) between the FGBA group and the CBA group within 90 days post-surgery. The primary outcome and safety were assessed in the intention-to-treat population. This study was registered with ToetsingOnline.nl (NL7502) and ClinicalTrials.gov (NCT04712032) and is complete. FINDINGS: Between July 2, 2020, and Feb 21, 2023, 982 patients were enrolled, of whom 490 were assigned to FGBA and 492 were assigned to CBA. After excluding 51 patients, the intention-to-treat population comprised 931 (463 assigned FGBA and 468 assigned CBA). Patients had a median age of 68·0 years (IQR 59·0-75·0) and 485 (52%) were male and 446 (48%) were female. Ethnicity data were not available. The overall 90-day rate of clinically relevant anastomotic leakage was not significantly different between the FGBA group (32 [7%] of 463 patients) and the CBA group (42 [9%] of 468 patients; relative risk 0·77 [95% CI 0·50-1·20]; p=0·24). No adverse events related to ICG use were observed. 313 serious adverse events in 229 (25%) patients were at 90-day follow-up (159 serious adverse events in 113 [24%] patients in the FGBA group and 154 serious adverse events in 116 [25%] patients in the CBA group). 18 (2%) people died by 90 days (ten in the FGBA group and eight in the CBA group). INTERPRETATION: ICG NIR fluorescence imaging did not reduce 90-day anastomotic leakage rates in this trial across all types of colorectal surgeries. Further research should be done in subgroups, such as rectosigmoid resections, for which evidence suggests ICG NIR might be beneficial. FUNDING: Olympus Medical, Diagnostic Green, and Intuitive Foundation.