Comments on “Improved outcomes with cyanoacrylate glue for ileocolic anastomosis in right colectomy: a multicenter study”

Best of foregut: esophagus, stomach, and duodenum

PurposeAnastomotic leaks (AL) remain a major complication following right colectomy for colon cancer. This multicenter, prospective, observational study evaluated the efficacy of Glubran 2, a cyanoacrylate-based sealant, in reducing the incidence of AL by reinforcing ileocolic anastomoses.MethodsThe study enrolled 380 patients undergoing right colectomy for colon cancer across 7 Italian hospitals. Glubran 2 was applied to reinforce ileocolic anastomoses. The primary endpoint was a 50% reduction in AL incidence from a baseline of 6.18% within 10 days after surgery. Secondary endpoints included examining the correlation between AL and preexisting risk factors and determining the rate of anastomotic bleeding. Statistical analyses employed binomial tests and logistic regression.ResultsThe AL rate was reduced to 1.85% compared to the reference rate of 6.18% (P<0.01). Glubran 2 exhibited a protective effect even in patients with preexisting risk factors such as smoking, diabetes, or prior surgeries; none of these factors was significantly associated with AL (P>0.05). Surgical technique (P=0.687), anastomosis technique (P=0.998), and anastomosis type (P=0.998) did not influence AL rates. Operation time was similar across groups (P=0.613), and anastomotic bleeding occurred in 1.3% of cases, with no association with AL (P=0.989).ConclusionGlubran 2 was safely applied to ileocolic anastomoses, significantly reducing AL rates and potentially providing a protective effect even in patients with known risk factors. Its hemostatic and bacteriostatic properties support improved postoperative outcomes, highlighting its potential as an effective adjunct in colorectal surgery. Further studies are warranted to confirm these findings and explore broader applications.

Gastrointestinal bleeding

Mo1687 Efficacy of Anti-TNF on Severe Postoperative Endoscopic Recurrence in Crohn's Disease

Mo1688 Interobserver and Intraobserver Agreement of the Mayo Score of Endoscopic Activity in Ulcerative Colitis

There is little evidence to support choice of technique and configuration for stapled anastomoses after right hemicolectomy and ileocaecal resection. This study aimed to determine the relationship between stapling technique and anastomotic failure. Any unit performing gastrointestinal surgery was invited to contribute data on consecutive adult patients undergoing right hemicolectomy or ileocolic resection to this prospective, observational, international, multicentre study. Patients undergoing stapled, side-to-side ileocolic anastomoses were identified and multilevel, multivariable logistic regression analyses were performed to explore factors associated with anastomotic leak. One thousand three hundred and forty-seven patients were included from 200 centres in 32 countries. The overall anastomotic leak rate was 8.3%. Upon multivariate analysis there was no difference in leak rate with use of a cutting stapler for apical closure compared with a noncutting stapler (8.4% vs 8.0%, OR 0.91, 95% CI 0.54-1.53, P = 0.72). Oversewing of the apical staple line, whether in the cutting group (7.9% vs 9.7%, OR 0.87, 95% CI 0.52-1.46, P = 0.60) or noncutting group (8.9% vs 5.7%, OR 1.40, 95% CI 0.46-4.23, P = 0.55) also conferred no benefit in terms of reducing leak rates. Surgeons reporting to be general surgeons had a significantly higher leak rate than those reporting to be colorectal surgeons (12.1% vs 7.3%, OR 1.65, 95% CI 1.04-2.64, P = 0.04). This study did not identify any difference in anastomotic leak rates according to the type of stapling device used to close the apical aspect. In addition, oversewing of the anastomotic staple lines appears to confer no benefit in terms of reducing leak rates. Although general surgeons operated on patients with more high-risk characteristics than colorectal surgeons, a higher leak rate for general surgeons which remained after risk adjustment needs further exploration.

Cyanoacrylate adhesives serve multiple purposes and have increasingly been used in medical settings. Among pediatric emergencies, iatrogenic cyanoacrylate glue spillage into children's eyes is a common occurrence lacking standardized management recommendations. This retrospective multicenter study used the French national adverse event data from January 1, 1999, to July 1, 2023. Inclusion criteria included ocular cyanoacrylate glue exposure, closed eyelids, and age<15 years. Among 20 pediatric patients studied, primary symptoms post-eyelid opening included eyelid swelling (35%), superficial keratitis (20%), and conjunctivitis (20%). Severity assessments using the Poisoning Severity Score (PSS) showed an absence of severe eye lesions. Spontaneous eyelid detachment took an average of 8.5 days. Surgical interventions in three cases exhibited limited improvement and potential iatrogenicity. This study indicates a prevalent preference for conservative management approaches to iatrogenic cyanoacrylate glue spills in pediatric ocular cases in France. No severe complications were reported among observed cases.

In reply to: Comments on "Improved outcomes with cyanoacrylate glue for ileocolic anastomosis in right colectomy: a multicenter study”

Laparoscopic right hemicolectomy is a commonly performed procedure. Little is known on how to perform the enterotomy closure after stapled side-to-side intracorporeal anastomosis. A multicentric case-controlled study has been designed to compare different ways to fashion enterotomy closure: double layer versus single layer, sewn versus stapled, and robotic versus laparoscopic approach. Furthermore, additional characteristics including sutures' materials, interrupted versus running suture and the presence of deep corner suture has been investigated. We collected data for 1092 patients who underwent right hemicolectomy at ten centers. We analyzed 176 robotic against 916 laparoscopic anastomosis: no significant differences were found in terms of bleedings (p = 0.455) and anastomotic leak (p = 0.405). We collected data from 126 laparoscopic sewn single-layer versus 641 laparoscopic sewn double-layer anastomosis: a significant reduction was recorded in terms of leaks in double-layer group (p = 0.02). About double-layer characteristics, we found a significant reduction of bleedings (p = 0.008) and leaks (p = 0.017) with a running suture; similarly, a reduction of bleedings (p = 0.001) and leaks (p = 0.005) was observed with the usage of deep corner closure. The presence of a barbed suture thread seemed to significantly reduce both bleedings (p = 0.001) and leaks (p = 0.001). We found no significant differences in terms of bleedings (p = 0.245) and anastomotic leak (p = 0.660) comparing sewn versus stapled anastomosis. Fashioning a stapled ileocolic intracorporeal anastomosis, we can recommend the adoption of a double-layer enterotomy closure using a running barbed suture in the first layer. Totally, stapled closure and robotic assistance have to be considered a non-inferior alternative.

P694 Long-term monitoring of post-surgical recurrence in Crohn’s disease using a strategy based on the periodic determination of fecal calprotectin in patients without early postoperative recurrence

Ablation length, not modality type, determines healing outcomes in venous leg ulcers

Surgical resection rates remain high in Crohn's disease (CD). Reducing postoperative recurrence (POR) is challenging. Besides drug therapy, the surgical anastomosis technique may reduce POR. We aimed to compare the endoscopic POR rate after Kono-S vs standard ileocolic anastomosis. The study included all consecutive CD patients operated on for ileocolic resection with a Kono-S anastomosis between February 2020 and March 2022. These patients were prospectively followed, and colonoscopy was performed 6 to 12 months after surgery. Patients were compared with a historical cohort of patients operated on with a conventional anastomosis in the same center. The primary end point was endoscopic POR (Rutgeerts score ≥i2). Factors associated with POR were assessed by univariate and multivariable analyses. A total of 85 patients were included, 30 in the Kono-S group and 55 in the control group. At baseline, there was no significant difference between the 2 groups regarding CD characteristics or known POR risk factors, including previous exposure to biologics. At 6 to 12 months, endoscopic POR rate did not differ significantly between groups (56.7% in the Kono-S group vs 49.1% in the control group; P = .50), nor did endoscopic POR according to the modified Rutgeerts score ≥i2b (46.7% in the Kono-S group vs 40% in the control group; P = .55). Severe endoscopic POR rates were 23.3% and 18.2% in each group, respectively. Clinical recurrence rate was similar in both groups, and no recurrent surgery occurred. By multivariable analysis, the type of anastomosis was not associated with endoscopic POR (OR, 1.229; 95% CI, 0.461-3.274, P = .68); however, postoperative treatment with anti-TNF was (OR, 0.337; 95% CI, 0.131-0.865 P = .02). Kono-S anastomosis was not associated with a reduced rate of endoscopic POR. These results warrant confirmation in prospective, randomized, multicenter studies.

Crohn's disease is widely described in the Western literature, but it has not been widely observed in the Middle Eastern community. We diagnosed Crohn's disease in seven Arabs, three whom were Saudi Nationals. Their mean age was 32.4 years (range, 18-40 years) and duration of symptoms varied from three months to ten years. The site of the disease was ileocolic in five patients and colonic in two. Mass lesions in the abdomen were seen in three patients. Four cases were diagnosed from histological specimens obtained at laparotomy and resection and the other three were diagnosed from colonoscopic biopsy specimens. Extraintestinal manifestations were found in three patients. Surgery alone was the treatment in two patients, whereas the remaining required medical therapy, mainly steroids, with or without surgery. We conclude that Crohn's disease does occur in the Arab population, but with milder systemic effects.

Anastomotic leak (AL) is the most severe complication after laparoscopic right colectomy (RC), with historical median rates around 8%. Whether intracorporeal ileocolic anastomosis (ICA) offers advantages over extracorporeal anastomosis (ECA) under standardized, purely laparoscopic conditions remains uncertain. We aimed to compare AL rates and short-term postoperative outcomes between ICA and ECA in laparoscopic RC for colon cancer. Prospective multicenter cohort (TREND-compliant) across 11 hospitals (January 2019-June 2022). Adults with non-metastatic right colon cancer undergoing elective laparoscopic RC were included. Exposure (ICA vs ECA) was determined by each hospital's routine practice. AL, per predefined clinical, radiologic, or endoscopic criteria. conversion to open surgery, length of stay (LOS), complications (Clavien-Dindo), surgical site infection (SSI), and a composite of severe complications (COSC). Analyses used the full cohort; propensity score matching (PSM) was prespecified as a sensitivity analysis. A total of 438 patients were analyzed: 225 ICA and 213 ECA. AL occurred in 3/225 (1.33%) after ICA and 3/213 (1.41%) after ECA (p = 1.00; risk difference - 0.08 percentage points; 95% CI - 2.1 to 2.3). Conversion was lower with ICA (2.2% vs 7.5%; p = 0.013), while LOS was shorter with ICA (median 4days; p < 0.001). There were no significant differences in severe morbidity (Clavien-Dindo ≥ III: 5.8% ICA vs 3.8% ECA; p = 0.375), SSI (incisional or organ/space), COSC (6.7% ICA vs 4.2% ECA; p = 0.298), reoperation, or mortality. Findings were consistent in PSM analyses (213:213). In this prospective multicenter laparoscopic cohort, both intracorporeal and extracorporeal anastomosis achieved anastomotic-leak rates below 2%, with no superiority of one technique over the other regarding leak or severe morbidity. ICA was associated with lower conversion and shorter hospital stay. These results confirm the overall safety and feasibility of both approaches in experienced centers. NCT03918369.

BackgroundWhile laparoscopic approach for right hemicolectomy (LRH) is considered appropriate for the surgical treatment of both malignant and benign diseases of right colon, there is still debate about how to perform the ileo-colic anastomosis. The ColonDxItalianGroup (CoDIG) was designed as a cohort, observational, prospective, multi-center national study with the aims of evaluating the surgeons’ attitude regarding the intracorporeal (ICA) or extra-corporeal (ECA) anastomotic technique and the related surgical outcomes.MethodsOne hundred and twenty-five Surgical Units experienced in colorectal and advanced laparoscopic surgery were invited and 85 of them joined the study. Each center was asked not to change its surgical habits. Data about demographic characteristics, surgical technique and postoperative outcomes were collected through the official SICE website database. One thousand two hundred and twenty-five patients were enrolled between March 2018 and September 2018.ResultsICA was performed in 70.4% of cases, ECA in 29.6%. Isoperistaltic anastomosis was completed in 85.6%, stapled in 87.9%. Hand-sewn enterotomy closure was adopted in 86%. Postoperative complications were reported in 35.4% for ICA and 50.7% for ECA; no significant difference was found according to patients’ characteristics and technologies used. Median hospital stay was significantly shorter for ICA (7.3 vs. 9 POD). Postoperative pain in patients not prescribed opioids was significantly lower in ICA group.ConclusionsIn our survey, a side-to-side isoperistaltic stapled ICA with hand-sewn enterotomy closure is the most frequently adopted technique to perform ileo-colic anastomosis after any indications for elective LRH. According to literature, our study confirmed better short-term outcomes for ICA, with reduction of hospital stay and postoperative pain.Trial registrationClinical trial (Identifier: NCT03934151).