Air Leak Test Research Articles

How to reduce anastomotic leakage in colorectal surgery-report from German expert meeting.

Anastomotic leakage is one of the most worrisome complications in colorectal surgery. An expert meeting was organized to discuss and find a consensus on various aspects of the surgical management of colorectal disease with a possible impact on anastomotic leakage. A three-step Delphi-method was used to find consensus recommendations. Strong consensus was achieved for the use of mechanical bowel preparation and oral antibiotics prior to colorectal resections, the abundance of non-selective NSAIDs, the preoperative treatment of severe iron deficiency anemia, and for attempting to improve the patients' general performance in the case of frailty. Concerning technical aspects of rectal resection, there was a strong consensus in regard to routinely mobilizing the splenic flexure, to dividing the inferior mesenteric vein, and to using air leak tests to check anastomotic integrity. There was also a strong consensus on not to oversew the stapled anastomoses routinely, to use protective ileostomies for low rectal and intersphincteric, but not for high-rectal anastomoses. Furthermore, a consensus was reached in regard to using CT-scans with rectal contrast enema to evaluate suspected anastomotic leakage as well as measuring C-reactive protein routinely to monitor the postoperative course after colorectal resections. No consensus was found concerning the indication and technique for testing bowel perfusion, the routine use of endoscopy to check the integrity of the anastomosis, the placement of transanal drains for rectal anastomoses and the management of anastomotic leakage with peritonitis. Consensus could be found for several practice details in the perioperative management in colorectal surgery that might have an influence on anastomotic leakage.

Endoscopy Used as Provocative Testing in Bariatric Surgery: An Analysis of the Texas Public Use Data File

Background:Many bariatric surgeons test the anastomosis and staple lines with some sort of provocative test. This can take the form of an air leak test with a nasogastric tube with methylene blue dye or with an endoscopy. The State Department of Health Statistics in Texas tracks outcomes using the Texas Public Use Data File (PUDF).Methods:We queried the Texas Inpatient and Outpatient PUDFs for 2013 to 2017 to examine the number of bariatric surgeries with endoscopy performed at the same time. We used the International Classification of Diseases Clinical Modification Version 9 (ICD-9-CM) and ICD-10 procedure codes and Current Procedural Terminology for Sleeve Gastrectomy (SG) and laparoscopic Roux-en-Y gastric bypass (LRYGB) and endoscopy, and the ICD-9-CM and ICD-10 diagnosis codes for morbid obesity.Results:There were 74,075 SG reported in the Texas Inpatient and Outpatient PUDF for the years 2013–2017. Of the SG performed, 5,521 (7.4%) had an intraoperative endoscopy. For the 19,192 LRYGB reported, 1640 (8.6%) underwent LRYGB + endoscopy. This was broken down by SG only vs SG + endoscopy and LRYGB only vs LRYGB + endoscopy. Overall, SG + endoscopy had a significantly shorter length of stay (LOS) vs LRYGB + endoscopy at 1.74 d vs 2.34 d (P < .001) and a significantly less cost of $71,685 vs $91,093 (P < .001).Conclusions:A small percentage of SG and LRYGB patients underwent endoscopy for provocative testing over the study period. Provocative testing with endoscopy costs more for SG and LRYGB and was associated with a shorter LOS.

1856 Immediate Air-Tight Seal With a Padlock Clip Defect Closure System for Iatrogenic Colonic Perforation

INTRODUCTION: Iatrogenic colonic perforations are an infrequent complication of endoscopy that often require immediate surgical repair. However, endoscopic suturing devices or endoscopic clips are increasingly being utilized for closure. Through-the-scope clips can have high rates of failure and often require multiple clips per closure to achieve a similar level success to over-the-scope clips. Ovesco over-the-scope clips (OTSC®) have been studied in small prospective studies with 89% successful closures of acute iatrogenic gastrointestinal perforations without adverse events1. More recently, the Padlock Clip® defect closure system has emerged as a newer over-the-scope clip with case reports showing high levels of efficacy and safety in a variety of uses. We present a case of iatrogenic colonic perforation repaired with the Padlock Clip with a concurrent laparoscopic air-leak test confirming immediate complete closure. CASE DESCRIPTION/METHODS: A 64-year-old female with a history of severe diverticulosis presented for routine colonoscopy for polyp surveillance. The patient became significantly uncomfortable with water irrigation and a perforation was identified approximately 20cm from the anal verge, likely consistent with a perforated diverticulum. The procedure was aborted with subsequent imaging confirming a sigmoid colon perforation. In the operating room, a Padlock Clip defect closure device was endoscopically deployed with subsequent laparoscopic leak test confirming immediate air-tight seal. A diet was subsequently initiated without evidence of a leak. DISCUSSION: This case illustrates the efficacy of an alternative over-the-scope clip in closure of an acute colonic perforation. Compared to prior over-the-scope clips, the Padlock Clip is easier to deploy with potentially similar rates of efficacy and safety. The design of the Padlock Clip better facilitates two-person deployment as opposed to the Ovesco OTSC®. The deeper cap length makes acquisition of tissue easier and obviates the need for additional graspers. This patient demonstrates the Padlock Clip system as a viable option for the management acute iatrogenic colonic perforations. Reference: 1Voermans RP, Le moine O, Von renteln D, et al. Efficacy of endoscopic closure of acute perforations of the gastrointestinal tract. Clin Gastroenterol Hepatol. 2012;10(6):603-8.

Clinical Significance of Intraoperative Colonoscopy for Anastomotic Assessment in Rectal Cancer Surgery.

To clarify the usefulness of intraoperative colonoscopy (CS) for preventing postoperative anastomotic leakage and bleeding in rectal cancer surgery. The data of rectal cancer patients who underwent circular-stapled anastomosis from January 2008 to December 2016 were compared between 162 patients who received intraoperative CS (the CS group) and 23 patients who did not receive intraoperative CS (the non-CS group). Anastomotic leakage rate in the CS group (8.6%) was similar to that in the non-CS group (4.3%) (p=0.70). Postoperative anastomotic bleeding rate was also similar between the CS and non-CS groups (2.4% vs. 0%, p=0.50). Although a positive air leak test was observed in two patients in the CS group, no postoperative leakage developed by adding intraoperative treatment. Although intraoperative CS did not significantly reduce the incidence of postoperative anastomotic leakage or bleeding, it can be useful for certain cases.

Novel air leak test and step-by-step strategy for preventing the air leak in lung surgery.

Receiving sincere comments from experts in the field on technology that shows new direction and possibility can be a great foundation for further development. Three (1-3) editorials expressed their curiosities and concerns for our study (4) as follows.

A standardized use of intraoperative anastomotic testing in colorectal surgery in the new millennium: is technology taking over? A systematic review and network meta-analysis.

Anastomotic leakage (AL) remains the most challenging complication following colorectal resection. There are several tests that can be used to test anastomotic integrity intraoperatively including air leak testing (ALT) andintraoperative colonoscopy (IOC). Indocyanine green (ICG) can be used to visualise blood supply to the bowel used in the anastomosis. However, there is no consensus internationally regarding routine use and which technique is superior. The aim of this study was to determine which intraoperative anastomotoic leak test (IALT) was most effective in reducing AL. A systematic review and network meta-analysis were performed. An electronic systematic search was performed using Pubmed, CENTRAL, and Web of Science, of studies comparing ALT, IOC, and ICG. The inclusion criteria were as follows: (a) patients must have had colorectal surgery with formation of an anastomosis; (b) studies must have compared one or more IALTs; (c) and studies must have clear research methodology. Eleven articles totalling 3844 patients met the inclusion criteria and were included in this meta-analysis. Point estimation showed that the AL rate in the control group (no IALT) was significantly higher when compared to the ICG group (RR 0.44; Crl 0.14-0.87) and higher, but without reaching statistical significance, when compared to ALT (RR 0.53; Crl 0.21-1.30) and IOC (RR 0.49; Crl 0.10-1.80). Indirect comparison showed that the AL rate in the ICG group was lower, when compared to both ALT (RR 0.44; Crl 0.14-0.87) and IOC (RR 0.44; Crl 0.14-0.87). This study suggests that intraoperative testing fora good blood supply using ICG may reduce the AL rate following colorectal surgery.

Investigation of Influencing Factors on Air Leakage of Canadian Dwellings

Air leakage is one of the main influencing factors in buildings’ thermal performance. The adverse effects of poor air leakage include higher energy costs, consumption in space heating and cooling, poor thermal comfort, corrosion, and the growth of molds due to air leakage induced condensation. The main objective of this study is to investigate the characteristics of air leakages of Canadian homes related to construction methods, age, size and climatic zones. The air leakage test results of 226,000 dwellings in three provinces of Canada were analyzed. Statistical analysis was utilized to compare the mean of air leakage with respect to different factors. Generally, the air leakage decreased by 40% in the period from 1960 until 2018, which has shown a remarkable effect of new construction techniques on air leakage. Investigations also indicated that the average air leakage rate of homes constructed by using the onsite technique is approximately 25% to 60% higher than those prefabricated in modular or panels, varying with respect to the workmanship and construction quality control. This study concluded that the prefabricated construction techniques could decrease the air leakage rate significantly, which will have a remarkable effect on buildings’ thermal performance as well as home’s heating and cooling costs. The findings contribute to estimating the effects of influencing factors on air leakage, also it is useful in performance simulations, HAVC sizing and energy management. And recommend the use of the prefabricated in modular or panel’s construction method to achieve better and acceptable air leakage performance.

Routine use of ultrasonography in prediction of uncuffed endotracheal tube size in pediatric patients

Background and aimsEndotracheal intubation is a crucial skill in anesthesia. Uncuffed pediatric endotracheal tube (ETT) size can be calculated by various methods like age-based formula or by using ultrasound to measure minimal transverse subglottic diameter (MTSD). This study aimed to compare both age-based formula and ultrasound to assess the advantage of routine use of ultrasound to determine pediatric ETT size.Materials and methodsForty children of 2–10 years of age, ASA class ≤ II, Mallampati airway classes I and II, scheduled for surgery away from the head and neck, were included. Uncuffed ETT size for each child was calculated using age-based formula. After induction of balanced general anesthesia, an ultrasound was done to measure MTSD and an endotracheal tube was selected accordingly. After intubation, an air leak test was done and the ETT was accordingly changed (if needed).ResultsETT size by age-based formula strongly correlated with the size measured by ultrasound (Pearson correlation 0.913; P < 0.001). The percentage of the need to change the endotracheal tube according to the leak test was only 7.5%.ConclusionThe ETT size calculation was similar for both age-based formula and ultrasound. So, we could not justify the routine use of ultrasound for calculating ETT size for intubation in pediatric patients.

Selection of cuffed endotracheal tube for children with congenital heart disease based on an ultrasound-based linear regression formula.

It remains to be discovered whether a formula predicting the subglottic transverse diameter measured by ultrasound (SGDformula) for the selection of an appropriate endotracheal tube (ETT) for children without congenital heart disease (CHD) is useful for children with CHD. A formula for predicting SGD was established after assessing 60 children ≤ 8years without CHD and validated on 60 children with CHD. We selected the cuffed ETT size based on the SGD by ultrasound (SGDultra). Subsequently, the fit of the ETT cuff in 60 children with CHD was examined via air-leak test. The maximum allowed difference between the SGDformula and the ETT size that fit was 0.2mm. The agreement among and accuracy of SGDultra, SGDformula, and the ETT used in children was analyzed. For children without CHD, we adopted a linear formula, given by SGDformula (mm) = 0.4 × age + 5.3. For children with CHD, allometric formula was adopted, given by SGDformula (mm) = 5.4 × age0.18. A stronger agreement exists between SGDultra and ETT size compared to that between SGDformula and ETT size. And the mean bias (SGDformula-ETT size and SGDultra-ETT size) was 0.21mm (95% confidence interval, - 0.59 to 1.01mm) and 0.00mm (- 0.79 to 0.84mm). For the CHD group, the ultrasound-based method yielded a 78% success rate of ETT size choice, while the formula-based method permitted an appropriate ETT size in only 32% of subjects (P < 0.001). Our analysis showed that measuring the SGDultra was more accurate in predicting the correct OD of the ETT in children with CHD undergoing cardiovascular surgery, based on the correlation and agreement with ETT OD.

Intraoperative air leak test reduces the rate of postoperative anastomotic leak: analysis of 777 laparoscopic left-sided colon resections.

The evidence supporting the use of the air leak test (ALT) after laparoscopic left-sided colon resection (LLCR) to test the colorectal anastomosis (CA) integrity aiming at reducing the rate of postoperative CA leakage (CAL) is not conclusive. The aim of this study was to challenge the use of ALT after elective LLCR. It is a retrospective analysis of a prospectively collected database including all patients undergoing elective LLCR with primary CA and no proximal bowel diversion between January 1996 and June 2017. The decision to perform the ALT was based on the individual surgeon routine practice. A multivariate analysis was performed to identify independent risk factors for CAL. A total of 777 LLCR without proximal diversion were included in the analysis: the CA was tested in 398 patients (ALT group), while intraoperative ALT was not performed in 379 patients (No-ALT group). The two groups were similar in demographic characteristics, indication, and type of procedure. Intraoperative ALT was positive in 20 (5%) patients: a stoma was created in 14 (70%) patients, while 6 (30%) patients had a suture repair alone. Overall, postoperative CAL occurred in 32 patients (4.1%): the postoperative CAL rate was lower in ALT patients (2.5% vs. 5.8%, p = 0.025). A reoperation was needed in 87.5% of cases. No CAL occurred in the 20 patients with intraoperative positive ALT. Multivariate analysis showed that ASA score 3-4 (OR 5.39, 95% CI 2.53-11.51, p < 0.001) and male sex (OR 3.96, 95% CI 1.66-9.43, p = 0.002) were independent risk factors for postoperative CAL, while intraoperative ALT independently reduced the postoperative CAL rate (OR 0.40, 95% CI 0.18-0.88, p = 0.022). Intraoperative ALT allows to detect AL defects after LLCR that can be effectively managed intraoperatively, leading to a significant lower risk of postoperative CAL.

PS01.078: AN UNUSUAL PRESENTATION OF BOERHAAVE SYNDROME

Abstract Background Oesophageal perforations are rare but potentially lethal. Boerhaave syndrome classically results in a longitudinal oesophageal perforation at the left posterolateral distal oesophagus. We present an unusual case with cervical oesophageal mucosal perforation and submucosal dissection. Methods We review our patient—a 53 year old lady, Mdm S, who presented after 4 days of vomiting with sepsis and diabetic ketoacidosis. CT thorax scan showed extensive long segment circumferential mural thickening and oedema of the entire oesophagus, extensive pneumotosis of the proximal half, and a focal mucosal discontinuitiy of the cervical oesophagus. There were also pneumomediastinum, fat stranding in the superior mediastinum, and a right pleural effusion. Results Gastroscopy and surgical exploration of the right hemithorax and neck identified a 2cm linear cervical oesophageal mucosal defect. There was no muscular perforation; an air leak test did not demonstrate a transmural perforation. Copious lavage of the mediastinum and right thoracic cavity were performed and large bore drains were placed in the neck, right thoracic cavity and superior mediastinum. A venting gastrostomy and a feeding jejunostomy were also created. Mdm S’s recovery was complicated by a persistent right pneumothorax. An interval gastroscopy revealed a line of interrupted longitudinal oesphageal mucosal defects starting at 18cm to 31 cm from the incisors. The submucosal space had opened up for the same length, and the scope easily entered the submucosal plane, where a muscle wall defect was detected at 18cm from the incisors. Conclusion Cervical oesophagus is an unusual site of Boerhaave's perforation. While the initial perforation was not transmural, surgical lavage and drainage were essential for sepsis control. Subsequent recovery was achieved by following principles of fistula management- diversion of gastrointestinal contents, drainage of oesophageal leak to control sepsis, optimisation of nutrition via a feeding jejunostomy. Disclosure All authors have declared no conflicts of interest.

Magnifying endoscopy with narrow-band imaging to assist the linear stapler closure of the pharynx during total laryngectomy

ObjectiveThis study aimed to present a novel technique for stapler-assisted laryngectomy under direct visualization using a videoendoscope with narrow-band imaging (NBI-endoscopy). MethodsA case series of five consecutive patients were treated with stapler-assisted total laryngectomy from December 2014 to March 2016. The technique involved monitoring the stapler closure of laryngopharyngeal cavity under NBI-endoscopic vision, triple checking of neo-pharynx cavity by an endoscopic view inside and transillumination verification outside, air leakage test, and guiding the insertion of feeding tube under direct visualization. The main evaluation of this study was pharyngocutaneous fistula, surgical margin, and oral feeding time. ResultsAll the patients healed well without a pharyngocutaneous fistula. The mean of surgical time, oral feeding, and hospitalization time were 40 min, 6 days, and 8 days, respectively. ConclusionThis study demonstrated a technique simple to learn and associated with decreased complication rates, which could be safe and efficient for stapler-assisted laryngectomy.

Surgical skills in the prevention of anastomotic leakage after rectal neoplasm surgery

For colorectal surgeons, how to reduce anastomotic leakage after laparoscopic rectal cancer surgery remains to be challenging. We provide a brief discussion regarding the surgical skills required to prevent anastomotic leakage after rectal cancer surgery, such as the following: 1) Low ligation of inferior mesenteric vessel during laparoscopic total mesorectal excision can improve anastomotic tension and blood supply, thus reducing the risk of anastomotic leakage. While high ligation of inferior mesenteric artery results in poor blood supply and high tension in atastomotic site, thus increasing the risk of anastomotic leakage. 2) Protective enterostomy is recommended for patients with high risk of developing anastomotic leakage. 3) Use of abdominal/pelvic drains after colorectal anastomosis is recommended to decrease the incidence of anastomotic leakage, early detect anastomotic leakage, and conservativdy manage anastomotic leackage through drainage of pelvic effusion. 4) Laparoscopic reinforcing sutures should be used if anastomotic tension and blood supply are unsatisfactory, including continuous suture with 3-0 or 4-0 absorbable suture and 2-needle interrupted suture in the weak anastomosis. However, these sutures should be performed by experienced surgeons. For male patients with narrow pelvis and those with low rectal cancer, laparoscopic reinforcing sutures should be performed carefully due to the limited operative space. 5) Intraoperative air leak test is recommended to identify the anastomotic integrity for those with suspicious mechanically insufficient rectal anastomosis. 6) Experienced surgeon can reduce the incidence of anastomotic leakage after rectal cancer operation.

Reflection on the present study of anastomotic leakage after colorectal surgery

Anastomotic leakage is one of the most serious complications of colorectal surgery. Despite progress in available surgical techniques, the morbidity associated with anastomotic leakage remains high. In this review, we summarize the current clinical status of this complication, the problems it causes, and relevant research achievements. To date, a lack of consensus regarding the diagnosis of anastomotic leakage has resulted in varying rates of diagnosis across countries and regions worldwide. Accurately predicting the occurrence of anastomotic leakage using the established risk factors and preoperative scoring systems remains difficult. Many of the described preventive measures, including defunctioning stoma creation, positive air leak testing, and use of effective tissue adhesives, remain controversial; more evidence-based medical information is urgently needed. Delayed diagnoses of anastomotic leakage also remain common in clinical practice. To prevent catastrophic outcomes, such as reoperations or deaths, early diagnosis is critically important. Parameters local to the area of the anastomosis may facilitate early detection of leakage, but their effectiveness is subject to clinical validation. Lastly, the pathological etiology of anastomotic leakage remains to be determined, and its elucidation may inspire innovative interventions that solve this critical surgical complication.

Intraoperative endoscopy prevents technical defect related leaks in laparoscopic Roux-en-Y gastric bypass: A randomized control trial

BackgroundPostoperative anastomotic leaks, bleeding and stenosis are major causes of morbidity after laparoscopic Roux-en-Y gastric bypass (LRYGB). Retrospective studies suggest that intraoperative endoscopy reduces the incidence of these complications. MethodsWe conducted a prospective randomized controlled trial in a single institution between March 2013 and January 2016. Patients were assigned to one of two groups: LRYGB with Intraoperative Endoscopy (IOE) or LRYGB without IOE. Patient selection criteria were morbidly obese patients, 18 years or older who were candidates to LRYGB. The primary outcome was the frequency of technical defect related anastomotic leaks. Secondary outcomes were operative time, length of hospital stay, anastomotic related complications, reoperations and 30-day mortality. Results50 patients were randomly assigned in the IOE group and 50 in the control group. The IOE group had statistically significant lower rate of anastomotic leak (0 vs. 8%, p = .0412), and lower need for reoperation (0 vs. 8%, p = .0412). The IOE group had longer operative time (194.10 vs. 159 min, p < .001), and shorter mean length of hospital stay (2.44 vs. 3.46 days, p = .025). No differences were found in the rate of bleeding of the anastomosis, narrow anastomosis and 30-day mortality. ConclusionThis study specifically provides evidence that air leak test performed by intraoperative endoscopy is superior to simple visual inspection in preventing technical defect related leaks after laparoscopic Roux-en-Y gastric bypass.

Discoid Resection of Rectosigmoid Endometriotic Nodules

Study ObjectiveTo show various techniques to perform laparoscopic anterior discoid resection of rectosigmoid endometriotic nodules. DesignA step-by-step explanation of the techniques using video with narration (educational video). SettingSegmental bowel resection and reanastomosis are treatment options for larger rectosigmoid endometriotic nodules. However, laparoscopic anterior discoid resection of rectosigmoid endometriotic nodules is feasible and potentially less morbid in the appropriate candidate. Detailed knowledge of the avascular planes of the pelvis, particularly the pararectal and rectovaginal spaces, is crucial when approaching these nodules, which may initially present within an obliterated posterior cul-de-sac. Resection begins with determination of the nodule size followed by enucleation of the nodule itself. A 2-layer closure with barbed suture is then performed using a rectal probe as a template. Our institution previously demonstrated that barbed suture is safe to use in bowel repair and did not result in major complications [1]. An air leak test assesses the integrity of the repair and may be completed with air insufflation or with a methylene blue or povidone-iodine enema. With larger nodules, a V-shaped closure may be necessary. The patients provided consent to use images and videos of the procedure. Institutional review board approval was not required for this procedure. InterventionsLaparoscopic anterior discoid resection of a rectosigmoid endometriotic nodule. ConclusionLaparoscopic anterior discoid resection avoids the need for segmental bowel resection and reanastomosis. Barbed suture is a safe option for 2-layer bowel closure [1].

Intra-operative removal of chest tube in video-assisted thoracoscopic procedures

ObjectiveThoracic Surgery has witnessed a massive revolution in the last 25 years with the standardization of video-assisted thoracoscopic surgery as the best approach of the thoracic operations. Earlier, when thoracic surgery was done through the huge thoracotomy incisions and rib spreading retractors with their excruciating pain, the chest tube pain was masked, but using VATS, has caused surgeons seeking early removal of chest tubes. With advances of the instruments and stapling devices, the amount of air-leak was significantly reduced, diminishing the time needed for chest tube drainage. MethodsA prospective study, from May 2014 to December 2016, included 29 patients admitted to the service in Faculty of Medicine, Assiut University. Patients had different clinical presentations. Undergoing VATS procedures (uni-portal VATS in all except one), they were then divided into two groups: study group, those with intra-operative removal of chest tube, (16 patients) and control group (13 patients). Patients would undergo an air-leak test. ResultsThe two groups had a significant difference in the post-operative mean pain score (study group 4.9 & control group 7.8), and hospital stay (study group 1.4 & control group 4). Both groups were similar in occurrence of post-operative pneumothorax (study group 25% & control group 23.1%), with only 2 patients (12.5%) in the study group requiring re-insertion of chest tube. ConclusionsIntra-operative removal of chest tube during VATS procedures was a safe technique in well selected patients with an intra-operative successful air-leak test with radiological and clinical follow-up. This technique provided lesser post-operative pain with shorter hospital stay.

Low rectal resection without a diverting stoma

Background: A diverting stoma is a usual practice after low and ultralow rectal resections in a fear to minimize the morbidities related to anastomotic leak. We tried to explore not to use a prophylactic diverting stoma and to assess the rate of leak.&#x0D; Methods: Patients undergoing total proctocolectomy (18%)/ low anterior resection of rectum (LAR) (59%)/ ultralow LAR (18%) and intersphincteric LAR (5%) for colorectal adenocarcinoma were analyzed. In all the cases, total mesorectal excision (TME) approach was used. CT/ MRI was used for proper staging and clinically locally advanced tumors were subjected to neoadjuvant chemoradiation (23%). Anastomosis was performed using circular stapler for colorectal or ileorectal anastomosis (94%) and hand-sewn for coloanal anastomosis (6%). Integrity and adequate vascularity of anastomosis was checked using air leak test and excising epiploica at the region of anastomosis.&#x0D; Results: Seventeen patients with mean age of 52 years were analyzed. Mean distance of tumor from the anal verge was 7 cm. Open and Laparoscopic resections were done in 82% and 18%, respectively. Average height of anastomosis was 3.5 cm from the anal verge. Superficial surgical site infection, intraabdominal abscess requiring prolonged intravenous antibiotics and urinary retention were observed in 41%, 6%, and 6%, respectively. There was one anastomotic leak (6%), which led to post operative death of the patient.&#x0D; Conclusion: Low rectal resections may be carried out without a diverting stoma with an acceptable anastomotic leak rate. In a well-performed ileorectal/ colorectal/ coloanal anastomosis with a good vascularity at the site of anastomosis, routine use of diverting stoma may not be justified, though a randomized controlled trial with larger sample is needed.

Successful Management of a Positive Air Leak Test during Laparoscopic Colorectal Surgery

Background/Aims: Anastomotic leakage remains the most serious complications of colorectal surgery. To prevent colorectal anastomotic leakage (CAL), an air leak test (ALT) with intraoperative colonoscopy (IOCS) is performed to detect mechanically insufficient colorectal anastomoses. The approaches to an intraoperative anastomotic air leak (IOAL) have not been fully investigated. This study aimed to clarify the safe management of an IOAL in laparoscopic colorectal surgery. Methods: One hundred forty-eight consecutive patients who underwent laparoscopic resection with double-stapling technique (DST) anastomosis for left-sided colorectal cancer between April 2015 and June 2016 were included and retrospectively reviewed. Results: Intraoperative anastomotic ALT yielded positive results in 7 patients. In all 7 patients, reanastomoses were performed, and diverting stomas were constructed to protect the anastomosis in 2 patients whose reanastomosis sites were close to the anus. Three of the revised DST anastomoses showed air leakage on the repeat ALT; these sites underwent suturing repair and were confirmed to be airtight. None of the patients with a positive intraoperative ALT had postoperative CAL. The overall CAL rate was 1.4%. Conclusions: Combination management using DST revision, direct suturing repair, and a diverting stoma is recommended for intraoperative repair of anastomotic defects detected by IOCS.

Is it still necessary to leave a chest tube after video-assisted pulmonary wedge resection?

The controversy whether or not leaving a chest tube in the pleural cavity after pulmonary resection has been under debate. A chest tube could negatively influence the postoperative course and diminish the possible benefits of video-assisted thoracoscopic surgery (VATS). The aim of this study was to evaluate our protocol of omitting a chest tube in the pleural cavity after pulmonary wedge resection in a selected group of patients. Between September 2011 and November 2014, 49 pulmonary wedge resections by VATS without conversion were performed. A chest tube was omitted if there was no air leak after performing the air leak test and patients did not have bullous/emphysematous lesions or dense pleural adhesions. If patients did not meet these criteria, a chest tube was placed. Primary outcome was postoperative morbidity and the secondary outcome was hospital stay. We omitted a chest tube in 28 patients and left a chest tube in the pleural cavity in 21 patients after VATS pulmonary wedge resection. Three reinterventions were necessary postoperatively because of pneumothorax or hematopneumothorax, all in the group without a chest tube. Hospital stay was 1 day shorter in the group without chest tube placement. Omitting a chest tube can decrease hospital stay but we have to be vigilant regarding postoperative complications. Quick removal of the chest tube in the recovery room could be a good alternative to prevent unnecessary reinterventions and to play it real safe.