RESUMEN
Anastomotic leakage and subsequent pelvic sepsis are serious complications after surgery for pelvic malignancies, particularly challenging due to the large pelvic cavity dead space post-exenteration. We report a 47-year-old man treated for a severely infected pelvic hematoma and sepsis following anastomotic leakage after anterior pelvic exenteration. Post robot-assisted exenteration for locally advanced sigmoid colon cancer treated with neoadjuvant chemotherapy, a pelvic abscess from anastomotic dehiscence was identified. Initial CT-guided drainage and subsequent laparoscopic drainage were performed. On postoperative day 22, a bleeding left internal iliac pseudoaneurysm required embolization. Despite these efforts, the sepsis worsened due to an enlarged, infected hematoma. Endoscopic lavage, in collaboration with skilled endoscopists, successfully removed the hematoma, leading to an improved inflammatory response, and the patient was discharged. Endoscopic lavage proved to be the safest and most effective treatment for pelvic sepsis with an infected hematoma after various attempted interventions.
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Hematoma , Exenteración Pélvica , Sepsis , Humanos , Masculino , Persona de Mediana Edad , Exenteración Pélvica/efectos adversos , Hematoma/etiología , Hematoma/cirugía , Sepsis/etiología , Fuga Anastomótica/cirugía , Fuga Anastomótica/etiología , Fuga Anastomótica/terapia , Irrigación Terapéutica , Drenaje , Complicaciones Posoperatorias/etiologíaRESUMEN
BACKGROUND: One of the approaches to distal sigmoid colon cancer surgical treatment is segmental colonic resection with vascular preservation of left colic artery (LCA). D3 lymph node dissection may technically vary according to different vascular anatomy. This study aims to show the approaches to D3 lymph node dissection with LCA preservation for distal sigmoid colon cancer according to different patterns of inferior mesenteric artery (IMA) branching. METHODS: CT angiography with 3D reconstruction was routinely performed to identify the IMA branching pattern. Laparoscopic distal sigmoid colon resection with D3 lymph node dissection and left colic artery preservation in standardized fashion was performed in all cases. Data, including clinical, intraoperative, and short-term surgical outcomes, is presented as median numbers (Me) and interquartile range (IQR). RESULTS: Twenty-six patients with distal sigmoid colon cancer were treated with laparoscopic distal sigmoid colon resection. The approach to D3 lymph node dissection varied according to different anatomical variations. There was one conversion (3.8%) and one anastomotic leakage (3.8%) in patients with high BMI. At the same time, there was a high apical lymph node count (Me 3 (IQR 2-5), min-max 0-10) due to the skeletonization of the IMA. CONCLUSIONS: The technical aspects of D3 lymph node dissection with left colic artery preservation may vary in different types of LCA and sigmoid artery branching patterns regardless of the standardized anatomical landmarks. The anatomical features should be considered when performing vascular-sparing lymph node dissection.
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Colon Sigmoide , Laparoscopía , Escisión del Ganglio Linfático , Arteria Mesentérica Inferior , Neoplasias del Colon Sigmoide , Humanos , Escisión del Ganglio Linfático/métodos , Neoplasias del Colon Sigmoide/cirugía , Arteria Mesentérica Inferior/cirugía , Arteria Mesentérica Inferior/diagnóstico por imagen , Femenino , Masculino , Anciano , Laparoscopía/métodos , Persona de Mediana Edad , Colon Sigmoide/cirugía , Colon Sigmoide/irrigación sanguínea , Colectomía/métodos , Angiografía por Tomografía Computarizada , Tratamientos Conservadores del Órgano/métodos , Imagenología Tridimensional , Fuga Anastomótica/etiología , Fuga Anastomótica/prevención & control , Resultado del Tratamiento , Colon/irrigación sanguínea , Colon/cirugíaRESUMEN
BACKGROUND: The aim of this study is to investigate the impact of arginine on immune function and postoperative complications in colorectal cancer (CRC) patients. METHODS: We conducted a comprehensive search to identify eligible RCTs in various databases, such as PubMed, Cochrane Library, EMBASE, Web of Science, MEDLINE, China National Knowledge Infrastructure (CNKI), Wanfang, VIP Medicine Information System (VIP), and Chinese Biomedical Database (CBM). This study aimed to examine IgA, IgG, and IgM levels as well as CD4+ and CD8+ counts as well as the CD4+/CD8+ ratio. Anastomotic leaking, length of stay (LOS), and surgical site infection (SSI) were included as secondary outcomes. Stata (StataCorp, version 14.0) was utilized for data analysis. To ensure the results were reliable, we used meta-regression, sensitivity analysis, and publication bias analysis. RESULTS: A total of 24 publications (including 1883 patients) out of 681 that were retrieved fulfilled the inclusion criteria. The arginine group showed notable improvements in humoral immunity, with gains in IgA (SMD=0.45, 95% CI: 0.30-0.60), IgG (SMD=0.80, 95% CI: 0.64-0.96), and IgM (SMD=0.66, 95% CI: 0.39-0.93). With regards to cellular immunity, the arginine group exhibited a substantial increase in the CD4+ T cell count (SMD = 1.03, 95% CI: 0.67-1.38) compared to the control group. However, the CD4+/CD8+ ratio decreased significantly (SMD=1.37, 95% CI: 0.88-1.86) in the same arginine group, indicating a change in the balance between these two cell types. Additionally, the CD8+ T cell count showed a notable decrease (SMD=-0.70, 95% CI: -1.09 to -0.32) in the arginine group when compared to the control group. Anastomotic leakage was also considerably lower in the arginine group (SMD=-0.05, 95% CI: -0.08 to -0.02), the rate of SSIs was lower (RR = -0.02, 95% CI: -0.05-0), and the length of time patients spent in the hospital was shorter (SMD=-0.15, 95% CI: -0.38 to -0.08). CONCLUSIONS: After radiation treatment for CRC, arginine improves immune function and decreases the risk of infection problems. TRIAL REGISTRATION: Registration with PROSPERO for this meta-analysis is number CRD42024520509.
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Arginina , Neoplasias Colorrectales , Complicaciones Posoperatorias , Humanos , Neoplasias Colorrectales/cirugía , Neoplasias Colorrectales/inmunología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/inmunología , Inmunoglobulina A/sangre , Tiempo de Internación/estadística & datos numéricos , Infección de la Herida Quirúrgica/inmunología , Relación CD4-CD8 , Inmunidad Humoral , Fuga Anastomótica/etiologíaRESUMEN
BACKGROUND: Anastomotic leakage following colorectal surgery remains a significant complication despite advances in surgical techniques. Recent findings on serosal injury repair in coelomic cavities, such as the peritoneum, challenge the current understanding of the cellular origins and mechanisms underlying intestinal anastomotic healing. Understanding the contribution of each layer of the intestinal wall during anastomotic healing is needed to find new therapeutic strategies to prevent anastomotic leakage. The aim of this experimental study was to investigate the role of the serosal layer of the intestinal wall in anastomotic healing. MATERIALS AND METHODS: Comprehensive histologic analysis of human and murine anastomoses was performed to elucidate histologic changes in the different intestinal layers during anastomotic healing. In vivo staining of the extracellular matrix (ECM) in the serosal layer was performed using a fluorophore-conjugated N-hydroxysuccinimide-ester before anastomosis surgery in a murine model. RESULTS: Histological examination of both human and murine anastomoses revealed that closure of the serosal layer occurred first during the healing process. In vivo serosal ECM staining demonstrated that a significant portion of the newly formed ECM within the anastomosis was indeed deposited onto the serosal layer. Furthermore, mesenchymal cells within the anastomotic scar were positive for mesothelial cell markers, podoplanin and Wilms tumour protein. CONCLUSIONS: In this experimental study, the results suggest that serosal scar formation is an important mechanism for anastomotic integrity in intestinal anastomoses. Mesothelial cells may significantly contribute to scar formation during anastomotic healing through epithelial-to-mesenchymal transition, potentially suggesting a novel therapeutic target to prevent anastomotic leakage by enhancing physiological healing processes.
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Anastomosis Quirúrgica , Fuga Anastomótica , Membrana Serosa , Cicatrización de Heridas , Animales , Anastomosis Quirúrgica/efectos adversos , Humanos , Ratones , Cicatrización de Heridas/fisiología , Fuga Anastomótica/prevención & control , Fuga Anastomótica/etiología , Membrana Serosa/patología , Masculino , Matriz Extracelular/metabolismo , Femenino , Ratones Endogámicos C57BL , Colon/cirugía , Colon/patologíaRESUMEN
Bariatric surgery is a safe and effective treatment option for patients with obesity and obesity-related comorbidities, with Roux-en-Y gastric bypass and sleeve gastrectomy being the two most common procedures. Despite the success of these interventions, adverse events are not uncommon. Endoscopic management has become first-line therapy when complications occur, and the armamentarium of devices and techniques continues to grow. This article focuses on the management of fistulas, leaks, and ulcers and also focuses on the etiology and endoscopic management strategy of each complication.
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Fuga Anastomótica , Cirugía Bariátrica , Complicaciones Posoperatorias , Humanos , Cirugía Bariátrica/efectos adversos , Cirugía Bariátrica/métodos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/cirugía , Fuga Anastomótica/cirugía , Fuga Anastomótica/etiología , Endoscopía Gastrointestinal/métodos , Obesidad Mórbida/cirugía , Obesidad Mórbida/complicaciones , Fístula Gástrica/etiología , Fístula Gástrica/cirugía , Úlcera/etiología , Úlcera/cirugía , Derivación Gástrica/efectos adversos , Derivación Gástrica/métodosRESUMEN
BACKGROUND: Esophageal cancer is currently one of the high-risk malignant tumors worldwide, posing a serious threat to human health. This study aimed to analyse the causes of postoperative mortality and intrathoracic anastomotic leakage(IAL) after esophagectomy. METHODS: A retrospective analysis was conducted on 172 patients with esophageal cancer resection and focused on the preoperative and postoperative indicators. Cox regression analysis was performed to identify factors affected IAL and evaluated the potential factors on postoperative mortality. The Kaplan-Meier curve was applied to evaluate the effect of leakage on postoperative mortality after propensity score matching. RESULTS: Univariable and multivariable Cox regression analysis showed that infection and high BMI were significant risk factors for IAL, patients with BMI over 24 kg/m2 in IAL group was two times higher than that of the group without IAL (95% CI = 1.01-6.38; P = 0.048). When patients were infected, the hazard ratios(HRs) of anastomotic leakage was twice that of patients without infection (95% CI = 1.22-4.70; P = 0.011). On the other hand, IAL was a significant cause of postoperative mortality, the 40-day postoperative mortality rate in the leakage group was significantly higher than the non leakage group (28.95% in leakage group vs. 7.46% in non leakage group, P<0.01). After propensity score matching, IAL still significantly affected postoperative mortality. The total length of hospital stay of the leakage group was inevitably longer than that of the non leakage group (22.19 ± 10.79 vs. 15.27 ± 8.59). CONCLUSION: IAL was a significant cause of death in patients underwent esophageal cancer resection. Patients with high BMI over 24 kg/m2 and infection may be more prone to developing IAL after esophagectomy. IAL inevitably prolonged the length of hospital stay and increased postoperative mortality.
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Fuga Anastomótica , Neoplasias Esofágicas , Esofagectomía , Humanos , Fuga Anastomótica/epidemiología , Fuga Anastomótica/etiología , Fuga Anastomótica/mortalidad , Neoplasias Esofágicas/cirugía , Neoplasias Esofágicas/mortalidad , Masculino , Femenino , Esofagectomía/efectos adversos , Estudios Retrospectivos , Persona de Mediana Edad , Factores de Riesgo , Anciano , Puntaje de Propensión , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/mortalidadRESUMEN
CASE PRESENTATION: A 70-year-old man was diagnosed with mid-thoracic esophageal squamous cell carcinoma (distance from incisors, 27-30 cm) because of progressive dysphagia and underwent thoracic laparoscopic esophagectomy at a local hospital. He was transferred from the ICU 4 days after surgery; however, a large amount of purulent fluid exuded from the neck incision after oral drinking, which was consistent with cervical anastomotic leakage. Later, the patient experienced difficulty breathing and expelling sputum; he was then transferred back to the ICU for treatment. A CT scan showed massive fluid collection in the mediastinum and left pleural cavity. Thoracentesis yielded yellowish fluid, and the patient's general condition gradually improved after placement of a closed chest drainage system. The patient's cervical anastomotic fistula persisted and did not heal, and he was subsequently transferred to our medical center with the closed chest drainage system left in place.
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Neoplasias Esofágicas , Tomografía Computarizada por Rayos X , Humanos , Masculino , Anciano , Neoplasias Esofágicas/cirugía , Neoplasias Esofágicas/diagnóstico , Drenaje/métodos , Esofagectomía/métodos , Fuga Anastomótica/diagnóstico , Fuga Anastomótica/cirugía , Toracocentesis/métodos , Carcinoma de Células Escamosas de Esófago/cirugía , Carcinoma de Células Escamosas de Esófago/diagnósticoRESUMEN
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
INTRODUCTION: Anastomotic stenosis (AS) is a common complication after colorectal resection. However, the predisposing factors for stricture formation are not fully understood. Previous studies have shown anastomotic leakage (AL) to be a risk factor for the occurrence of AS. Therefore, we aim to investigate the impact of anastomotic leakage characteristics on the occurrence of anastomotic stenosis after colorectal resection. METHODS: Consecutive patients with AL following elective, sphincter preserving, colorectal resection, with or without diversion ostomy, between January 2009 and March 2023 were identified from a prospectively collected database. The characteristics of the anastomotic leakage, patient baseline and operative characteristics as well as the postoperative outcomes were analyzed using univariate and multivariate logistic regression to identify factors associated with the occurrence of post-leakage AS. RESULTS: A total of 129 patients developed AL and met the inclusion criteria. Among these, 28 (21.7%) patients were diagnosed with post-leakage AS. There was a significantly higher frequency of patients with neoadjuvant radiotherapy (18% vs 3%; p = .026) and hand-sewn anastomoses (39% vs 17%; p = .011) within the AS group. Furthermore, the extent of the anastomotic defect was significantly higher in the AS group compared with the non-AS group (50%, IQR 27-71 vs. 20%, IQR 9-40, p = 0.011). Similar findings were observed between the study groups regarding age, sex, BMI, ASA score, medical comorbidities, diagnosis, surgical procedure, surgical approach (open vs. minimally invasive), and anastomotic fashioning (side-to-end vs. end-to-end). On multivariate analysis, the extent of the anastomotic defect (OR 1.01; 95% CI 1.00-1.03; p = 0.034) and hand-sewn anastomoses (OR 2.68; 95% CI 1.01-6.98; p = 0.043) were confirmed as independent risk factors for post-leakage AS. No correlation could be observed between the occurrence of post-leakage AS and the ISREC grading of AL, the anastomotic height or the management of AL. Time to ostomy reversal was significantly longer in the AS group (202d, IQR 169-275 vs. 318d IQR 192-416, p = 0.014). CONCLUSION: The extent of the anastomotic defect and hand-sewn anastomoses were confirmed as independent risk factors for the occurrence of post-leakage AS. No correlation could be observed between the ISREC grading of AL, the anastomotic height or AL management, and the occurrence of post-leakage AS.
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Anastomosis Quirúrgica , Fuga Anastomótica , Humanos , Fuga Anastomótica/etiología , Femenino , Masculino , Persona de Mediana Edad , Estudios Retrospectivos , Constricción Patológica/etiología , Anciano , Factores de Riesgo , Anastomosis Quirúrgica/efectos adversos , Neoplasias Colorrectales/cirugíaRESUMEN
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 TratamientoRESUMEN
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.
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Anastomosis Quirúrgica , Fuga Anastomótica , Verde de Indocianina , Humanos , Verde de Indocianina/administración & dosificación , Fuga Anastomótica/prevención & control , Fuga Anastomótica/etiología , Femenino , Masculino , Persona de Mediana Edad , Anciano , Anastomosis Quirúrgica/efectos adversos , Anastomosis Quirúrgica/métodos , Colorantes/administración & dosificación , Imagen Óptica/métodos , Laparoscopía/métodos , Laparoscopía/efectos adversos , Procedimientos Quirúrgicos Robotizados/efectos adversos , Procedimientos Quirúrgicos Robotizados/métodos , Imagen de Perfusión/métodos , Cirugía Colorrectal/efectos adversos , Cirugía Colorrectal/métodos , Países Bajos/epidemiologíaRESUMEN
Background: Celiac axis stenosis can potentially lead to insufficient blood supply to vital organs, such as the liver, spleen, pancreas, and stomach. This condition result in the development of collateral circulation between the superior mesenteric artery and the hepatic artery. However, these collateral circulations are often disrupted during pancreaticoduodenectomy (PD), which may increase the risk of postoperative complications. Methods: A retrospective analysis was conducted on patients who underwent laparoscopic pancreaticoduodenectomy (LPD) from April 2015 to April 2023. Celiac trunk stenosis is classified according to the degree of stenosis: no stenosis (<30%), grade A (30%-<50%), grade B (50%-≤80%), and grade C (>80%). The incidence of postoperative complications was evaluated, and both univariate and multivariate risk analyses were conducted. Results: A total of 997 patients were included in the study, with mild celiac axis stenosis present in 23 (2.3%) patients, moderate stenosis in 18 (1.8%) patients, and severe stenosis in 10 (1.0%) patients. Independent risk factors for the development of bile leakage, as identified by both univariate and multivariate analyses, included body mass index (BMI) (HR = 1.108, 95% CI = 1.008-1.218, P = .033), intra-abdominal infection (HR = 2.607, 95% CI = 1.308-5.196, P = .006), postoperative hemorrhage (HR = 4.510, 95% CI = 2.048-9.930, P = <0.001), and celiac axis stenosis (50%-≤80%, HR = 4.235, 95% CI = 1.153-15.558, P = .030), and (>80%, HR = 4.728, 95% CI = .882-25.341, P = .047). Celiac axis stenosis, however, was not determined to be an independent risk factor for pancreatic fistula (P > 0.05). Additionally, the presence of an aberrant hepatic artery did not significantly increase the risk of postoperative complications when compared with celiac axis stenosis alone. Conclusion: Severe celiac axis stenosis is an independent risk factor for postoperative bile leakage following LPD.
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Arteria Celíaca , Laparoscopía , Pancreaticoduodenectomía , Complicaciones Posoperatorias , Humanos , Estudios Retrospectivos , Pancreaticoduodenectomía/efectos adversos , Masculino , Femenino , Persona de Mediana Edad , Factores de Riesgo , Laparoscopía/efectos adversos , Anciano , Constricción Patológica/etiología , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/epidemiología , Adulto , Fuga Anastomótica/etiología , Fuga Anastomótica/epidemiología , BilisAsunto(s)
Fístula Esofágica , Esofagectomía , Stents , Humanos , Esofagectomía/efectos adversos , Stents/efectos adversos , Masculino , Fístula Esofágica/etiología , Fístula Esofágica/cirugía , Fístula Esofágica/terapia , Neoplasias Esofágicas/cirugía , Anastomosis Quirúrgica/efectos adversos , Fuga Anastomótica/cirugía , Fuga Anastomótica/etiología , Fuga Anastomótica/terapia , Persona de Mediana Edad , Esofagoscopía/métodosRESUMEN
BACKGROUND: Second primary esophageal cancer often develops in patients with head and neck cancer, and esophagectomy in patients with a history of total pharyngolaryngectomy (TPL) is challenging. However, the clinical outcomes of these patients have yet to be examined in a multicenter setting. METHODS: We evaluated the surgical outcomes of a nationwide cohort of 62 patients who underwent esophagectomy for esophageal cancer with a history of TPL. RESULTS: Ivor-Lewis and McKeown esophagectomies were performed in 32 (51.6%) and 30 (48.4%) patients, respectively. Postoperatively, 23 patients (37.1%) developed severe complications, and 7 patients (11.3%) required reoperation within 30 days. Pneumonia and anastomotic leakage occurred in 13 (21.0%) and 16 (25.8%) patients, respectively. Anastomotic leakage occurred more frequently in the McKeown group than in the Ivor-Lewis group (46.7% vs. 6.2%, P < 0.001). The adjusted odds ratio for anastomotic leakage in the McKeown group was 9.64 (95% confidence intervals (CI), 2.11-70.82, P = 0.008). Meanwhile, the 5-year overall survival rates were comparable between the groups (41.8% for Ivor-Lewis and 42.7% for McKeown), and the adjusted hazard ratio of overall survival was 1.44 (95% CI, 0.64-3.29; P = 0.381; Ivor-Lewis as the reference). CONCLUSIONS: In our cohort, anastomotic leakage occurred more frequently after McKeown than Ivor-Lewis esophagectomy, and almost half of patients in the McKeown group experienced leakage. Ivor-Lewis esophagectomy is preferred for decreasing anastomotic leakage when oncologically and technically feasible.
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Fuga Anastomótica , Neoplasias Esofágicas , Esofagectomía , Laringectomía , Faringectomía , Humanos , Masculino , Esofagectomía/efectos adversos , Esofagectomía/métodos , Femenino , Neoplasias Esofágicas/cirugía , Estudios Retrospectivos , Laringectomía/efectos adversos , Laringectomía/métodos , Anciano , Persona de Mediana Edad , Japón/epidemiología , Faringectomía/métodos , Faringectomía/efectos adversos , Fuga Anastomótica/epidemiología , Fuga Anastomótica/etiología , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiología , Neoplasias Primarias Secundarias/epidemiología , Reoperación/estadística & datos numéricos , Resultado del Tratamiento , Neumonía/epidemiología , Neumonía/etiología , Pueblos del Este de AsiaRESUMEN
PURPOSE: Leaks after sleeve gastrectomy remain a deadly complication significantly affecting outcomes and medical costs. The aim of the present review is to provide an updated decalogue on leak prevention. METHODS: Risk factors of leakage after LSG were examined based on an extensive review of literature (in period time 2016-2024) and summary of evidence was provided using Oxford levels of evidence scale. RESULTS: Pathogenesis of leakage after LSG still remain related to ischemic and mechanical factors and, therefore, no new evidence has been reported. Conversely, some technical aspect of the procedure has changed: bougie size, antrum resection, staple line reinforcement, and intraoperative leak testing. CONCLUSIONS: Bougie size 36 F is effective and safe achieving similar leakage rate compared to larger bougie sizes (EL:2) 2024 UPDATE; There is no significant difference in the leak rate between restrictive (< 6 cm) and conservative (6 cm) antrum resection (EL: 1) 2024 UPDATE; Surgical experience and case volume affect the leak rate more consistently than every kind of SLR (EL: 2) 2024 UPDATE; Intraoperative leak test after LSG represents a decision based on surgeon preference in absence of standardization (endoscopy, bubble test, methylene blue, indocyanine green.) and strong detection/prevention rate (EL: 3) 2024 UPDATE.
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Fuga Anastomótica , Gastrectomía , Laparoscopía , Humanos , Gastrectomía/efectos adversos , Gastrectomía/métodos , Laparoscopía/efectos adversos , Fuga Anastomótica/prevención & control , Fuga Anastomótica/etiología , Factores de Riesgo , Obesidad Mórbida/cirugíaRESUMEN
AIM: In terms of early-term mortality, there may be variability in terms of factors belonging to age groups. While some risk factors apply to all patients undergoing colorectal cancer surgery, some factors may come to the fore in terms of age. There have been very few studies on factors that increase the risk of early-term mortality, especially for geriatric patients. It was aimed to compare factors influencing prognosis and mortality within the first 30 postoperative days between geriatric patients and those <65 years of age, and to identify factors that increase the risk of anastomotic leakage and early-term mortality, particularly in geriatric patients. METHODS: Clinical, laboratory, and pathology findings from 341 patients (186 geriatric) who underwent surgery for colorectal cancer between January 2016 and December 2019 were collected and analyzed. In terms of categorical variables, comparisons between groups were made with Pearson's Chi Square test and Fisher's Exact Test. Risk coefficients of variables in terms of anastomotic leakage and early-term mortality were determined by logistic regression analysis. The results were evaluated within the 95% Confidence interval, and p < 0.05 values were considered significant. RESULTS: Anastomotic leakage was detected in 7% of patients, and 6.2% of the patients died within the first 30 postoperative days. The 30-day postoperative mortality rate was significantly higher in geriatric patients with hypertension (p = 0.003), those undergoing emergency surgery (p = 0.007), those with stage 4 tumors (p < 0.001), those with ostomy-related complications (p = 0.042), those who developed intraabdominal abscess or peritonitis (p < 0.001), those with respiratory failure (p = 0.009), and those with perforation (p = 0.001). In patients <65 years of age, groups stratified by these variables did not differ significantly in terms of early-term mortality rate (p > 0.05 for each). CONCLUSIONS: These findings show that lack of bowel preparation and development of intraabdominal abscess/peritonitis significantly increase early-term mortality rates in both <65 and geriatric patients. Additionally, hypertension, emergency surgery, advanced tumor stage, development of ostomy-related complications, respiratory failure, and perforation significantly increase early-term mortality solely in geriatric patients.
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Fuga Anastomótica , Neoplasias Colorrectales , Humanos , Fuga Anastomótica/etiología , Fuga Anastomótica/epidemiología , Fuga Anastomótica/mortalidad , Anciano , Neoplasias Colorrectales/cirugía , Neoplasias Colorrectales/mortalidad , Masculino , Femenino , Factores de Riesgo , Persona de Mediana Edad , Factores de Edad , Anciano de 80 o más Años , Estudios Retrospectivos , Factores de Tiempo , Complicaciones Posoperatorias/mortalidad , Complicaciones Posoperatorias/epidemiología , Pronóstico , Hipertensión/complicaciones , Peritonitis/mortalidad , Peritonitis/etiología , Absceso Abdominal/etiología , Absceso Abdominal/mortalidadRESUMEN
Introduction: Failure of low colorectal anastomosis remains challenging in surgical oncology, necessitating the exploration of new methods and improvements in existing preventive measures. Materials and Methods: This prospective study was conducted in two stages: intraluminal pressure in the colon was monitored in 32 patients by manometry and sonography over a 5-day postoperative period; 213 patients who underwent anterior resection of the rectum were analyzed, of whom 126 and 87 underwent diverting stoma (DS) and transanal intubation (TAI), respectively. Results: The effectiveness of the recommended technique for applying and removing transanal intubation (TAI) to prevent pneumo hydro strike (≥15 kPa) on the anastomosis line was analyzed in 87 patients and compared with imposed DS. TAI showed better borderline statistical significance (p = 0.051). The incidence of repeat surgery for anastomotic failure (AL) was seven (5.55%) and four (4.59%) in the DS and TAI groups, respectively. The distance of the anastomosis from the dentate line <60 mm was associated with a higher risk of AL occurrence (odds ratio (OR), 1.012; 95% confidence interval (CI), 1.007-1.017; p < 0.001; area under the curve (AUC) = 0.82). DS is recommended for men, as the risk of AL is significantly lower among women (OR, 0.41; 95% CI, 0.16-1.04; p = 0.062; AUC, 0.61; 95% CI, 0.54-0.67). Conclusions: Although TAI is advantageous over DS for preventing AL, surgeons select the method for the preventive approach based on the preoperative and intraoperative results.
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Anastomosis Quirúrgica , Recto , Humanos , Masculino , Femenino , Estudios Prospectivos , Persona de Mediana Edad , Anastomosis Quirúrgica/efectos adversos , Anciano , Recto/cirugía , Canal Anal/cirugía , Fuga Anastomótica/prevención & control , Fuga Anastomótica/etiología , Colon/cirugía , Adulto , Manometría , Neoplasias Colorrectales/cirugía , ReoperaciónRESUMEN
AIM: Surgeon personality is a factor influencing rectal anastomotic decision-making. However, it is unclear how or why this may be the case, or what aspects of personality are involved. The aim of this study was to investigate the views of colorectal surgeons on how their individual personality may influence variation in anastomotic decision-making. METHOD: Purposive sampling was used to invite certified UK-based colorectal surgeons to participate, with individual interviews used for data collection. Participants were recruited until ongoing data review indicated no new codes were generated (i.e. data sufficiency). Data were analysed thematically following Braun and Clarke's six-step framework. RESULTS: Seventeen colorectal surgeons (eight female, nine male) participated. Two key themes relating to personality and decision-making were identified: (1) surgeon development and training and (2) patient-surgeon interactions, each with relevant subthemes. Surgeons described how their personality may influence patients' postoperative outcomes (e.g. decision-making, team working and communication) and potential mechanisms for how their personality may influence operative risk-taking. Following anastomotic leakage, surgeons described a disproportionate sense of guilt and responsibility. There appears to be a significant transition in responsibility from trainee to newly appointed consultant, which may be part of the 'hidden curriculum' of surgical training. CONCLUSION: Colorectal surgeons have described their perceptions of how personality traits may impact variation in decision-making and patient outcomes for the first time. Early career surgeons felt ill-prepared for the level of guilt experienced when managing complications. Surgeons appear open to personality assessment if this was through an educational lens, with the aim of improving decision-making following complications and overall performance.
Asunto(s)
Anastomosis Quirúrgica , Actitud del Personal de Salud , Toma de Decisiones Clínicas , Cirugía Colorrectal , Personalidad , Investigación Cualitativa , Cirujanos , Humanos , Cirujanos/psicología , Femenino , Masculino , Anastomosis Quirúrgica/psicología , Cirugía Colorrectal/psicología , Relaciones Médico-Paciente , Adulto , Recto/cirugía , Reino Unido , Persona de Mediana Edad , Fuga Anastomótica/psicología , Toma de Decisiones , PercepciónRESUMEN
Laparoscopic total mesorectal excision is the main surgical approach for treating rectal cancer, but there is still no clear consensus on the issue of low ligation of the inferior mesenteric artery during the procedure. Robotic surgery has been shown to have certain advantages over laparoscopic surgery in multiple studies, but further research is needed to better understand the outcomes of robotic surgery in the context of low ligation procedures. In this study, we included 1590 patients with mid-low rectal cancer. Among them, 942 patients underwent low ligation surgery (LL), divided into 138 in the robotic group and 804 in the laparoscopic group. The high ligation surgery (HL) group consisted of 648 patients. The results of LL vs HL showed that the LL group had faster bowel movement recovery (P = 0.003), lower anastomotic leak rate (P = 0.032), and lower International Prostate Symptom Score (IPSS) at 6 months postoperatively (P < 0.001). The results of Rob-LL vs Lap-LL showed that the Rob-LL group had longer operative time (P < 0.001), less blood loss (P = 0.001), more lymph nodes retrieved (P = 0.045), and lower Wexner score at 2 weeks postoperatively (P = 0.029). The concept of low ligation of the inferior mesenteric artery is a promising surgical approach that can accelerate the patient's functional recovery. When combined with robotic technology, it may offer more benefits than laparoscopic techniques.