Anastomosis Failure Research Articles

ANALYSIS OF POSTOPERATIVE COMPLICATIONS IN THE TREATMENT OF PATIENTS WITH LUNG CANCER

Summary. The aim of the study. Based on the analysis of the nature and course of postoperative complications in the treatment of patients with lung cancer, to improve the results of surgical treatment of this category of patients.
 Materials and methods. The results of the analysis of postoperative complications of 363 patients with lung cancer who were treated in the oncological department of the thoracic cavity of the clinic of the Communal Non-Commercial Enterprise «Regional Center of Oncology» in Kharkiv for the period from 2017 to 2021 are presented. There were 234 men (64.6 %) , women - 128 (35.4 %), the age of patients ranged from 43 to 84 years, the average age was (59.8±2.4 years). All patients underwent radical surgery for primary lung cancer. Lobectomies were performed most often. In this volume, 296 patients were operated on, which was 81.5 %. Pneumonectomy was performed on 51 patients, which was 14.1 %. Anatomical segmentectomy was performed in 16 patients (4.4 %). Postoperative complications and factors causing them were analyzed.
 Research results and their discussion. The main complications typical for the postoperative period of lung cancer patients are highlighted. Complications in the postoperative period occurred in 10.5 % of patients. Complications related to failure of bronchus stump sutures and tracheobronchial tree anastomoses occurred in 8 patients (2.2 %). In two patients, this led to the development of pleural empyema and death.Thanks to early diagnosis, 4 patients underwent rethoracotomy, bronchus stump suturing, resection or final pneumonectomy.
 Cardiovascular complications (acute myocardial infarction, acute cardiovascular failure, stroke, pulmonary embolism) were found in 5 patients (1.4 %). 3 patients died of stroke, acute myocardial infarction and acute cardiovascular failure. Two patients survived, and one of them was diagnosed with Pulmonary embolism (PE), COVID-19 and bilateral pneumonia.
 Postoperative mortality was 2.5 % (9 patients died). Two patients (0.6 %) died from failure of the bronchus stump sutures, which led to empyema of the pleura. Two patients (0.6 %) died from the consequences of intrapleural bleeding. Another 2 (0.6 %) patients died of acute myocardial infarction. One patient each (0.3 %) died of stroke, postoperative pneumonia, and pericux abscess, which led to empyema of the pleura.
 Conclusions. The surgical method of treating patients with lung cancer remains the main one despite the number of postoperative complications, the majority of which are «non-surgical». Analysis of the nature and course of postoperative complications in the treatment of patients with lung cancer, and the improvement of the method of determining functional operability, made it possible to reduce the frequency of complications and form a concept for improving the results of surgical treatment of this category of patients.

RISK FACTORS OF POSTOPERATIVE COMPLICATIONS DEVELOPMENT IN PATIENTS WITH RECTAL CANCER

Rectal cancer remains one of the most pressing problems today. Despite the development of technologies that can stage the disease and the use of modern treatment protocols, there is no continuous linear improvement in patient survival. The various concepts proposed for the treatment of colorectal cancer do not lead to a statistically significant improvement in overall survival. This may be due to the variability of the concepts of rectal cancer treatment, including the choice of a short or long course of neoadjuvant therapy, a standard regimen or total neoadjuvant therapy, surgery or "watch and wait" tactics. The likelihood of developing surgical complications, especially in cases of neoadjuvant treatment, also remains high, despite the development of minimally invasive accesses and the use of suturing devices, which in turn can lead to poor survival, local recurrence, and disability in patients. Understanding different concepts and strategies for treating patients with rectal cancer, systematically assessing various risk factors for postoperative complications, and modifying them individually can improve not only local outcomes but also overall survival of rectal cancer patients. Several studies have shown that the use of neoadjuvant chemotherapy in patients with rectal cancer significantly increases the risk of postoperative complications, although it reduces the likelihood of local and long-term recurrence. Therefore, given that neoadjuvant therapy is usually a mandatory step in treatment, further research should be conducted on the effects of different doses and regimens, and there is an urgent need to study other modified risk factors for postoperative complications, including BMI, stapler use, size stitching circular apparatus and others. Only in-depth study and accumulation of more data will allow you to more effectively choose the right treatment tactics that will increase life expectancy and reduce the disability of patients with rectal cancer. Thus, despite the great advances in understanding the treatment of rectal cancer, the application of the concept of combination therapy and the development of technical equipment, there are still several controversial issues that require detailed study. In particular, this applies to neoadjuvant chemotherapy, and a detailed study of the timing and different courses of radiation therapy, to ensure maximum effectiveness and reduce the risk of complications. This can be achieved only with the use of an individualized approach to the treatment of patients. The aim of the study is to assess the impact of various risk factors for postoperative complications, including anastomotic failure in patients receiving neoadjuvant chemotherapy. A research and analysis of PubMED publications for 2015-2022 has been made, which provided data on the use of neoadjuvant therapy in patients with rectal cancer and assessed risk factors for postoperative complications. The search queries included "rectal cancer", "anastomosis failure", "neoadjuvant therapy", "risk factors", and "survival of rectal cancer patients". Analysis of treatment and postoperative surgical complications in patients with adenocarcinoma of the rectum stage I-III in the Precarpatian clinical oncological centre during 2019-2022 was performed.

S1906 A Rare Cause of Delayed Life-Threatening Hemorrhage in a Patient With Pancreas Transplant

Introduction: Complications of vascular anastomosis usually occur early after pancreas transplant (PTx) and carry a substantial risk of graft loss and mortality. Hemorrhage may result from arterial anastomosis failure, but more commonly from superior mesenteric or splenic vessel ligation. We present a challenging case of GI hemorrhage from a pseudoaneurysm (PA) in the implanted vascular Y graft 7 years after PTx. Case Description/Methods: A 45-year-old male 7 years post simultaneous pancreas-kidney transplant presented with painless rectal bleeding. EGD and Colonoscopy showed blood throughout the duodenum and colon, but the source could not be localized. Push enteroscopy showed blood extending into the proximal jejunum, and no active bleeding source could be identified. CT angiogram showed active extravasation into a small bowel loop near the PTx. Mesenteric angiography with IR revealed active extravasation into jejunum from a PA which had developed off the SMA Y graft anastomosis, eroding into the adjacent duodenal stump. Successful coil embolization was performed. 2 days later, he developed rectal bleeding requiring massive transfusion. Tagged RBC scan and CT angiography could not localize the bleeding source. Emergent mesenteric angiography showed contrast leakage into the anastomotic stump beyond the previously placed coil (Figure A). A covered stent was placed into the right external iliac artery arresting the bleeding into the SMA anastomotic stump (Figure B). Bleeding and shock resolved, and he was discharged with transplant surgery follow-up. Discussion: Pseudoaneurysms, AV fistulae, arterial dissection and stenosis represent rare vascular complications of PTx. PAs, if early, may be the result of surgical technique, infection, severe pancreatitis, or allograft biopsy. Arterial anastomotic PAs can be asymptomatic or present with symptoms signaling impending rupture such as abdominal pain, pulsatile mass, or endocrine failure. Endoscopic localization and management of bleeding from Y graft PAs are challenging due to altered anatomy and brisk bleeding. Multidisciplinary management is essential and often involves endovascular hemostasis with IR, possibly with surgical exploration. Stent placement is usually preferred over embolization due to the ability to deploy with precision while maintaining end-organ perfusion. Although guidelines are lacking, it would be reasonable to consider periodic Doppler US to screen for post-operative PAs for early detection and preventative endovascular treatment.Figure 1.: A. Pre-stent mesenteric angiogram with contrast leaking through coil into SMA anastomotic stump; B. Post stent mesenteric angiogram with no contrast leaking into the SMA anastomotic stump.

ULTRASOUND DIAGNOSIS OF COMPLICATIONS IN THE EARLY POSTOPERATIVE PERIOD IN PATIENTS AFTER IMPOSITION OF COLON ANASTHOMOSIS

Purpose of the study. Investigate the possibility of using ultrasound in the early postoperative period to identify complications in patients after the imposition of colon anastomoses.
 Methods. 183 patients who underwent surgery with the imposition of primary continuous two-line СA on the left parts of the colon were treated. With suspicion of anastomosis failure from this group examined 75 (40.9%) patients, which are divided into 2 groups, depending on the inability of СA: 1 group - 32 patients with recorded failure of СA - median age of patients - 65 (57; 75) years, group 2 (control) - 43 patients, without inability to anastomosis, (median age of patients - 63.5 (58.5; 70.5) years.
 Results. The most reliable ultrasound signs of CA failure were the presence of gas outside the intestinal lumen, which was observed in 9 (28.1%) patients of group 1 on the 3rd day and 5 (15.6%) - on the 7th day after surgery, and also the presence of fluid formation in the area of CA in 6 (18.8%) and 12 (37.5%) patients, respectively. Both of these ultrasound signs were absent in patients of group 2. Restoration of intestinal peristalsis in the area of CA at its capacity was also significantly more frequent and earlier, which was found in 14 (32.5%) patients of group 2 on the 3rd and in 29 (67.4%) patients on the 7th day after surgery, respectively, while in the inability of СA this sign on the 3rd day, was not observed in patients of group 1, and on the 7th was registered only in 7 (21.9%; χ2 = 31.2; P < 0.05) patients. Thus, ultrasound signs of СA failure on day 3 were found in 15 (46.8%) patients of group 1, 8 (53.4%) of whom were treated conservatively, 7 (46.6%) patients required changes in treatment tactics. These patients underwent 2 relaparotomies for peritonitis, 3 removal of colostomy from the mini-access, 2 puncture drainage of fluid accumulation under ultrasound control. On the 7th day in 4 (53.1%) patients, 13 (76.5%) of whom were treated conservatively, 4 (23.5%) patients required changes in treatment tactics, respectively. These patients underwent 3 removal of colostomy from mini access, 1 puncture drainage of fluid accumulation under ultrasound control.
 Conclusion. Early diagnosis of complications allowed to change the tactics and scope of intensive care to prevent further complications. Ultrasound patients in the early postoperative period allows to detect signs of failure of СA in 46.8% of patients on the 3rd day and is the basis for correction of treatment tactics in 46.6% of these patients and 53.1% of patients on the 7th day, which led to change the tactics of treatment in 23.5% of them, respectively. Timely diagnosis of early signs of anastomosis failure allows to predict the further course of the disease, which reduces the number of complications and the severity of their course.

Super-microsurgery technique for lymphaticovenular anastomosis

BackgroundIn super-microsurgery, such as lymphaticovenular anastomosis (LVA), the diameter of the target vessel can be small and difficult to manage, and the basic surgical technique of microsurgery, such as inserting a forceps into the lumen and applying countertraction, can be difficult. In addition, it can be difficult to confirm the success or failure of the postoperative anastomosis, unlike with normal free-flap transfer, or to learn the technique by reviewing the results. MethodsWe have described a safe, quick, and accurate technique for LVA based on our experience performing several hundred such cases at our institution. ResultsBefore LVA, the location of the significant lymphatic vessels and veins proximal to the lymphatic vessels should be marked using indocyanine green fluorescence angiography and a vein viewer to help determine the skin incision site. We used super-microsurgical titanium needles and surgical scissors and an end-to-end anastomosis. The lymphatic vessels should be dissected as far as possible from the skin incision to the center, and the veins should be dissected as far as possible from the periphery. First, a stay suture should be applied to the upper and lower ends of the anastomosis at 180°. Next, the anterior wall should be sutured. In some cases, countertraction can be applied by inserting the tip of a forceps into the vascular vessel. However, because its insertion could damage the lymphatic vessel wall, it would be more appropriate to perform the anastomosis using the involved stitch technique. After anastomosis of the anterior wall, the vessel should be inverted and the posterior wall anastomosed using the same technique. ConclusionsWe have reported the key points necessary to perform LVA quickly and accurately and the precautions necessary to maintain long-term patency. This sophisticated LVA technique can be applied to improve the outcomes for patients with lymphedema.

Hand-Sewn Versus Stapled Small Bowel Anastomoses in Patients With Secondary Mesenteric Ischemia

IntroductionAlthough stapled anastomoses have been widely evaluated in the context of the elective surgery, few reports compared manual with stapled anastomoses in patients undergoing emergency surgery. The aim of this study is to compare the outcome of hand-sewn end-to-end anastomoses with stapled side-to-side and stapled end-to-side anastomoses in patients undergoing small bowel resection for acute mesenteric ischemia secondary to intestinal obstruction. MethodsFrom January 2015 to June 2021 all the hemodynamically stable patients undergoing emergency surgery with small bowel resection for intestinal obstruction were enrolled in this study. According to surgical technique in performing anastomosis, the patients were divided into three groups: group 1: hand-sewn end-to-end anastomosis, group 2: stapled end-to-side anastomosis, and group 3: stapled side-to-side anastomosis. ResultsAlthough the anastomosis failure rate was higher in group 3, it was not significantly different between the three groups (P = 0.78: chi-square test). Likewise, no significant differences in the median hospital stay were found between the patients’ groups (P = 0.87: Kruskal-Wallis test). The median operating time was similar in patients undergoing stapled anastomoses and was significantly higher in patients undergoing hand-sewn anastomoses (P = 0.0009: Kruskal-Wallis test). ConclusionsIn patients undergoing emergency small bowel resection for complicated intestinal obstruction, a similar outcome in terms of dehiscence rate and hospital stay can be achieved performing stapled or hand-sewn anastomoses, even if restoring the intestinal continuity with stapled technique is associated with lower operating time.

Restoration of Bile Outflow in Case of Damage to Hepaticocholedochus and Failure of the Biliary Anastomosis After Laparoscopic Cholecystectomy

The aspect of injuring bile ducts during laparoscopic cholecystectomy is still of current concern. Causes of this complication include insufficient experience of surgical team, poor knowledge of topographic anatomy of subhepatic space, particularly when perivesical inflammatory infiltrate presents, inadequate approach conversion and so on. Most of patients with bile duct injuries undergo repeated operation in the same surgical unit where cholecystectomy was performed. In many cases, this results in a shortening of the segment of the common hepatic duct, which is favorable for restoration. Subsequent reconstructive surgery is usually performed in the worse conditions with a high risk of complications such as failure of sutures, biliary fistula, anastomotic stricture, etc. Most specialists recommend to abstain from primary reconstruction of the biliary tree in hospitals with no proper experience in hepatobiliary surgery and to perform only the external drainage of subhepatic space with subsequent admission of patient to a specialized clinic. We report a case of a young woman who suffered an excision of hepaticocholedochus fragment during laparoscopic cholecystectomy. A primary reconstructive surgery (hepatico-hepaticoanastomosis) was performed in the same clinic and resulted in external fistula of the common hepatic duct. The subsequent operation (hepaticoejunostomy) was performed in a specialized department of the regional clinical hospital. The woman underwent right-sided hypochondrium laparotomy with debridement of postoperative scar tissues. The stumps of common bile duct were mobilized in compact inflammatory infiltrate. The operation ended with distal stump closure and hepaticoenteroanastomosis formation. The patient was discharged with recovery. Six months later, her condition was satisfactory, and she was engaged in occupational activity.

Pathology gradual assessment of colorectal anastomosis

Aim: to analyze the state of the colorectal anastomosis after laparoscopic and open resection of the sigmoid and rectum in patients with colorectal cancer and to develop a unified grading of pathological changes in the anastomosis during its laparoscopic and videorectoscopic assessment. Materials and methods. Results of the treatment of 79 patients who underwent resection of the rectum and sigmoid colon due to adenocarcinoma were analyzed. Patients were divided into two groups. The first group consisted of 34 (43.04 %) patients, whose treatment method was laparoscopic resection of the sigmoid and rectum (main group). The second group consisted of 45 (56.96 %) patients who underwent laparotomic resection. A stapler colorectal anastomosis was formed in both groups. The patients had II–III stages of the oncological disease without prior chemotherapy or radiotherapy in the anamnesis. During the operation visual assessment of the applied anastomosis was performed taking into account both external and internal characteristics. For external examination visual assessment of the anastomosed ends from the side of the serous membrane and a pneumohydrotest were used, for internal – an ordinary 10 mm laparoscope was inserted into the anus with CO2 insufflation at the level of 6 mm Hg and a visual assessment was carried out from the side of the mucosa. According to the received data, an original gradation of pathological changes in the colorectal anastomosis and recommendations for the prevention of its failure were developed. Results. The developed technique for assessing and gradation of pathological changes in colorectal anastomosis made it possible to identify and eliminate suturing defects in 19 (24.05 %) patients, to eliminate stitching defects, control bleeding, identify ischemic zones of the anastomotic ends and improve total results of the treatment. One patient had anastomotic failure on the third day after operation. This case required reoperation with removal of the anastomosis and formation of the terminal colostomy. There were no lethal cases in both groups. Usage of additional methods for assessing the anastomosis is time-consuming and important in detecting pathological changes in the colorectal anastomosis. Conclusions. The gradation of pathologic changes in the colorectal anastomosis should be comprehensive with an assessment of not only its external characteristics but also internal ones using videorectoscopy and allows to reduce the risks of colorectal anastomosis failure. The average number of points in the combination of laparoscopic and videorectoscopic evaluation is higher than in the laparoscopic one alone, but there is no statistical significance (U = 884.5; P = 0.071). This makes it possible to use the proposed grading system both in laparoscopy and in open surgery with the same results. There is no statistically significant difference in the number of detected anastomotic complications between open and laparoscopic resection of the sigmoid colon or the rectum (P = 0.137).

High-flow nasal oxygen therapy in patients after esophageal interventions: аdvantages and disadvantages

BACKGROUND: Pulmonary complications in patients who underwent esophagectomy with one-stage esophagoplasty are a frequent cause of death in the intensive care unit (ICU). However, the use of noninvasive ventilation (NIV) in these patients is not indicated because of the failure of esophagogastric anastomosis. Compared with NIV and standard oxygen therapy, high-flow oxygen therapy (HFOT) reduces the rate of transfer to mechanical ventilation (MV) in the case of acute respiratory failure.
 AIM: This study aimed to assess the clinical advantages and disadvantages of HFOT in patients with respiratory failure after esophagectomy.
 MATERIALS AND METHODS: Ninety patients with esophagectomy were examined. Two groups were formed by randomization: group 1 (n=45) with standard respiratory therapy, incentive spirometry, and nasal oxygen therapy with NIV sessions and low end-expiratory pressure (up to 6 mmHg) and group 2 (n=45) with HFOT. Therapy parameters were selected according to oxygenation (PaO2/FiО2) and saturation (SaО2) index values. Parameter changes, session duration, patients tolerance to respiratory therapy methods (from 1 to 10 points), dynamics of chest X-ray pattern, and duration of treatment in ICU were analyzed.
 RESULTS: The advantages of HFOT were the absence of discomfort during the session, possibility to decrease O2 flow required for an adequate level of oxygenation, high flow with controlled O2 fraction allowed to reach target values of oxygenation index, decreased frequency of patients transfer to MV, and time spent in ICU.
 CONCLUSIONS: The use of HFOT is justified as part of the complex respiratory therapy in patients with moderate respiratory failure. In patients with severe respiratory failure, HFOT is an alternative to other high-flow techniques and NIV. The choice between these methods should be individualized and depend on the patients condition and ventilation requirement.

SUTURING TECHNIQUE FOR ESOPHAGOGASTRIC AND GASTROENTEROANASTOMOSIS DURING OPERATIONS ON THE ESOPHAGUS AND STOMACH

Relevance: Esophageal cancer is in 4th place, and gastric cancer is in 3rd place in terms of cancer incidence in the West Kazakhstan region
 (WKR). In 2019-2021, an average of 80-120 patients had identified annually, of which 40-50 patients underwent surgical treatment.
 The study aimed to evaluate the effectiveness of the proposed improved method of suturing the anastomosis and enhancing the results of surgery by reducing postoperative complications in the form of anastomosis failure and reducing the time of the intra-operative period.
 Methods: In 2019-2021, 150 operations on the esophagus and stomach were performed in the Regional Oncological Dispensary of the West
 Kazakhstan Region (Uralsk, Kazakhstan) in the amount of Lewis operation – 76, Garlock operation – 29, extended gastrectomy – 45.
 According to the method of M.I. Davydov, the standard technique of suturing includes four stages and involves the imposition of 16 stitches.
 In the proposed version, an improved technique consisting of 3 steps is used without forming the second row of anterior lip anastomosis sutures.
 The results were evaluated according to the following criteria: a) the number of cases of anastomosis failure compared to the standard procedure; b) the duration of the intraoperative period.
 Results: Using an improved technique for applying esophagogastric and esophago-intestinal anastomosis has reduced the number of postoperative complications. So, from 2019-2021, postoperative complications decreased from 8.1% to 3.9%.
 Conclusion: The effectiveness and practicality of the proposed technique of applying esophagogastric and esophago-intestinal anastomosis
 during operations in patients with diseases of the esophagus and stomach have been proven.

SUTURING TECHNIQUE FOR ESOPHAGOGASTRIC AND GASTROENTEROANASTOMOSIS
 DURING OPERATIONS ON THE ESOPHAGUS AND STOMACH

Relevance: Esophageal cancer is in 4th place, and gastric cancer is in 3rd place in terms of cancer incidence in the West Kazakhstan region
 (WKR). In 2019-2021, an average of 80-120 patients had identified annually, of which 40-50 patients underwent surgical treatment.
 The study aimed to evaluate the effectiveness of the proposed improved method of suturing the anastomosis and enhancing the results of surgery by reducing postoperative complications in the form of anastomosis failure and reducing the time of the intra-operative period.
 Methods: In 2019-2021, 150 operations on the esophagus and stomach were performed in the Regional Oncological Dispensary of the West
 Kazakhstan Region (Uralsk, Kazakhstan) in the amount of Lewis operation – 76, Garlock operation – 29, extended gastrectomy – 45.
 According to the method of M.I. Davydov, the standard technique of suturing includes four stages and involves the imposition of 16 stitches.
 In the proposed version, an improved technique consisting of 3 steps is used without forming the second row of anterior lip anastomosis sutures.
 The results were evaluated according to the following criteria: a) the number of cases of anastomosis failure compared to the standard procedure; b) the duration of the intraoperative period.
 Results: Using an improved technique for applying esophagogastric and esophago-intestinal anastomosis has reduced the number of postoperative complications. So, from 2019-2021, postoperative complications decreased from 8.1% to 3.9%.
 Conclusion: The effectiveness and practicality of the proposed technique of applying esophagogastric and esophago-intestinal anastomosis
 during operations in patients with diseases of the esophagus and stomach have been proven.

The role of obstructive resection in the treatment of acute intestinal obstruction complicated by bowel necrosis

Methods of surgical intervention in acute intestinal obstruction with necrosis of the strangulated area of the intestine are the subject of ongoing discussions. There is no doubt that every patient with this disease should undergo emergency surgery. However, diagnosing necrosis of the strangulated area is not easy. For this reason, a number of authors recommend refraining from emergency surgery for all patients with intestinal obstruction during dynamic follow-up, which can last up to 14 days. Over the past century, the etiology of intestinal obstruction has shifted from strangulated hernia to postoperative adhesive disease, which has led to a paradigm shift in methodological approaches. In order to successfully manage acute intestinal obstruction with suspected strangulation, the clinician today must be able to distinguish between patients requiring urgent surgery and those who should receive conservative therapy.In this paper, we consider the surgical approach of delayed anastomosis formation on significant clinical material, including tactical approaches, timing and necessary conditions for anastomosis formation in patients with intestinal obstruction complicated by necrosis of the strangulated area.The complex of therapeutic measures in the treatment of patients with acute intestinal obstruction complicated by necrosis of the strangulated area of the intestine, intraoperative perforation of the intestine during separation of adhesions, both in conditions of peritonitis and without it, should include obstructive resection of the intestine in combination with the formation of an anastomosis in a delayed order, as well as or planned sanitation of the abdominal cavity. All this makes it possible to reduce the incidence of interintestinal anastomosis failure from 86.7 to 0.96% of cases, and postoperative mortality from 41.8 to 14.4%.

51. Microsurgical Breast Reconstruction Clinical Outcomes in the Covid-19 Era

Purpose: COVID19 has led to major disruptions in plastic surgery care. Microsurgical breast reconstruction has arguably been affected the most as the procedure is subject to COVID19 elective surgery bans and often competes for limited intensive care unit beds and nursing staff. Additionally, hypercoagulopathy and vasculitis are known manifestations of COVID19, which can increase risk for microsurgical vessel anastomosis failure. This study seeks to determine if the COVID19 pandemic has led to poorer clinical outcomes in microsurgical breast reconstruction due to limited healthcare resources or complications of COVID19 infection. Methods: A retrospective, multi-institutional study was conducted using the TriNetX research database, which includes de-identified patient records from 55 healthcare organizations across the United States. Clinical outcomes from microsurgical breast reconstruction patients who had any history of COVID19 infection and underwent surgery from 3/11/2020 to 7/31/2021 were compared with a historical control of microsurgical breast reconstruction patients who underwent surgery from 3/11/2018 to 7/31/2019. Results: 1309 patients had a history of COVID19 infection and underwent microsurgical breast reconstruction; 2195 patients were included in the historical control. COVID19 breast reconstruction patients were found to have a higher risk of reoperation within 30 days (OR1.57, p<0.01), vascular complications/flap failure (OR1.52, p=0.02), need for additional vascular procedures (OR1.74, p=0.02), wound dehiscence (OR1.34, p=0.01), and need for revision wound closures (OR2.22, p<0.01). No significant differences were found in venous thromboembolism/pulmonary embolism, infection, and hematoma/seroma between the two groups. Conclusion: Microsurgical breast reconstruction during COVID19 is at increased risk for complications. Surgeons should proceed with caution with these procedures.

X-ray Surgery for Iatrogenic Bile Duct Injury After Laparoscopic Cholecystectomy (Single Center Experience)

IM OF STUDY To show the possibilities of antegrade X-ray surgical techniques in the treatment of iatrogenic bile duct injuries after videolaparoscopic cholecystectomy.MATERIAL AND METHODS The study included 24 patients with “minor” and 20 patients with “major” (according to Strasberg) iatrogenic injuries of the extrahepatic biliary tract. Antegrade endobiliary intervention was performed in 26 patients, including the “bridge-procedure” variant preceding the reconstructive surgery. Endobiliary drains were maintained during the reconstructive surgery and in the early postoperative period to control the viability of the anastomosis.When a stricture of the biliodigestive anastomosis (BDA) was detected, balloon dilatation of the anastomotic area was performed. In the subgroup of “minor” injuries, external drainage of the subhepatic biloma in 18 people were supplemented with endoscopic papillotomy in 12 cases.RESULTS In all patients with “minor” injuries of the biliary tree, X-ray surgical techniques were effective. In 11 patients with “major” bile duct injuries, cholangiostomy drainage was gradually transformed into external-internal drainage. In 2 trauma cases of classes D and E temporary antegrade stenting of the duct injury area with a coated self-expanding endobiliary stent was performed. The follow-up period after removal of the antegrade frame drainage ranged from 8 months to 14 years. There were no stricture or failure of BDA.CONCLUSION Short-term external biliary drainage, including the use of rendezvous techniques, may be suffi cient to eliminate the failure of the cystic duct stump. Cholangiostomy drainage, temporary endobiliary stent allow preparing the patient for reconstructive intervention. Drainage marking of the damaged area facilitates the verifi cation of tubular structures in the reconstruction area. Preservation of drainage after reconstructive intervention is the prevention of failure of the biliodigestive anastomosis in the early postoperative period, the development of its stricture in the long term.

Redo surgery after low anterior resection for chronic pelvic sinus and anastomotic disruption. Could pull-through procedure with delayed anastomosis be a feasible alternative? Case reports and narrative review.

IntroductionA considerable step forward in low rectal cancer resection has been done in the last decades. Maintaining total mesorectal excision as the gold standard treatment, new techniques such as Trans-Anal Mini-Invasive Surgery (TAMIS) and Trans-Anal Total Mesorectal Excision (TATME), which have been added to improve skills in laparoscopic and robotic surgery, currently represent the advancement of this procedure. Despite improvements in surgical techniques, complications after low anterior resection for rectal cancer still remain a challenge. Drainage and colostomy are the main treatments used to overcome the problem caused by anastomosis failure, and most patients will never been restored. Different techniques of redo surgery could be proposed to deal complex cases, although remaining high risk procedures.Case presentationWe present two clinical cases with a late complication of the colorectal anastomosis: one with a late leakage of low colorectal anastomoses, treated with Hartman procedure, that developed a pelvic chronic sinus; the another one with complete anastomotic disruption after massive suture bleeding; both treated with delayed pull-through anastomosis, according to Turnbull-Cutait technique. We also made a review of relative literature, in order to back our therapeutic iters.DiscussionBoth the procedures were carried out satisfactorily, with restoration of intestinal continuity and good anastomotic result. It allows the resolutions of the chronic sepsis caused by the pelvic sinus and maintenance of intestinal continuity with a good Wexner incontinence score. Literary review demonstrated that this procedure still remains undervalued and not widely exploited.ConclusionDelayed pull-through coloanal anastomosis could be considered as a valid option, in order to preserve intestinal continuity in septic or complicated low colorectal anastomosis.

Analysis of treatment outcomes of patients with colorectal cancer in the COVID-19 pandemic

Introduction. The COVID-19 pandemic has made adjustments to the health care system. Among other things, it has led to shortened hospital stays. In the surgical treatment of patients with colorectal cancer (CRC), the possibility of reducing the bed-day is limited. The aim of the study was to evaluate the results of treatment of CRC patients during and before the pandemic new coronavirus infection. Material and methods. We analyzed the results of treatment of patients with CRC who were treated at the Oppel Hospital Surgery Clinic in 2015 and 2020. Group A included 58 patients treated in 2020, Group B included 44 patients treated in 2015. Patients with stage II disease predominated in both groups: in group A — 31 patients (53.4%), in group B — 19 (43.2%). Results. The average period of hospitalization in the patients of the group A was 12 days, in the group B — 16 days in the patients with uncomplicated postoperative period, in case of complications — 31 days. In group B 47.7% of surgical interventions were performed using laparoscopic techniques, in group A this index was 74.1%. In Group A complications in the early postoperative period were detected in 8 patients (13.8%). In group B complications were diagnosed in 10 patients (22.7%). The incidence of anastomosis failure tended to decrease in group A. In group B six patients (85.7%) who developed this complication required repeated surgical treatment, and in group A only two patients (50%). Discussion. The results demonstrate the effectiveness of the recommendations for perioperative management of patients with CRC and prevention of anastomosis failure. Conclusion. Based on the results obtained, we can say that the quality of surgical care for patients with CRC was avoided during the pandemic. The implementation of research recommendations in this area has helped to reduce the incidence of serious postoperative complications (anastomosis failure).

Features to Prevent Failed Hardware Colorectal Anastomoses in Laparoscopic Rectal Resections

The aim of research was to study proper results of laparoscopic anterior rectal resection using intraoperative measures to prevent failure of hardware colorectal anastomoses in patients with rectal tumor.Material and methods. Out of 68 patients included in the study, colorectal anastomotic leakage occurred clinically only in 2 cases (2.9%, class A and B) and required no further surgical interventions. When evaluating the risk of colorectal anastomosis failure in each specific case, it is necessary to consider pre- and intraoperative risk factors. Formation of colorectal anastomosis with one angular end of the rectal stump followed by immersion; additional strengthening of the anastomosis zone with interrupted serous-muscular sutures; adequate drainage of the pelvic cavity (the most effective - transperineal presacral) are intraoperative methods that reduce the risk of failed hardware colorectal anastomoses.Results. Out of 68 operated patients, colorectal anastomosis failure occurred clinically only in 2 cases (2.9%, class A and B) and did not require repeated surgical intervention. When assessing the risk of colorectal anastomosis failure in each specific case, it is necessary to take into account pre-and intraoperative risk factors. Formation of a colorectal anastomosis with one angular end of the rectal stump, followed by its immersion; additional strengthening of the anastomosis zone with nodular serous-muscular sutures; adequate drainage of the pelvic cavity (most effectively - trans-interventional presacral) - intraoperative methods that reduce the risk of failure of hardware colorectal anastomoses.Conclusion. Reasonable doubts in the intraoperative evaluation of the blood supply to the end section of the descending colon, viability of the colorectal anastomosis, presence of 3 or more risk factors, low position of anastomosis (less than 10 cm from the outer end of the anal canal) indicate the necessity to form preventive transversostomy.

ПРОФИЛАКТИКА НЕСОСТОЯТЕЛЬНОСТИ ШВОВ КИШЕЧНЫХ АНАСТОМОЗОВ

The failure of intestinal anastomotic suture is one of the urgent and dangerous problems in abdominal surgery. This problem not only complicates the course of the early postoperative period and increases financial costs, but it is also the main cause of deaths, the rate of which remains quite high with generalized peritonitis. The problem of the intestinal anastomotic leakage in the postoperative period forces researchers to develop various methods of preoperative preparation of patients, ways to strengthen the line of stitched ends of the intestine, new protocols for managing patients in the postoperative period. Despite the use of atraumatic and minimally invasive techniques as well as various stapling devices, and biopolymers of various compositions, the morbidity rate for ananastomotic leak remains quite high. The literature analysis demonstrates a tendency of preservation high rates of the suture failure of intestinal anastomosis. The actuality of this problem is especially clearly observed in case of emergency and urgent resection of the intestine against the background of acute intestinal obstruction, cancer intoxication and generalized peritonitis. The risk of anastomotic failure is believed to be caused by the age and general condition of a patient, the nature of the underlying disease, the presence of concomitant chronic diseases, the type of surgical operation, as well as the method and localization of the anastomosis being created. Despite the fact that there are a lot of sources devoted to the analysis of the causes of this problem, there is no consensus on the significance of risk factors and the effectiveness of the preventive methods used. In a number of publications there are contradictory data concerning the effectiveness of some preventive methods. Therefore, the solution of this problem requires new fundamental researches.

Frequency and risk factors of surgical complications in patients with locally advanced cervical esophageal cancer

Objective. Analyze the frequency and prognostic factors of complications in patients with locally advanced cervical esophageal cancer after pharyngolaryngoesophagectomy with simultaneous reconstruction of the defect.Material and methods. The retrospective study included patients with a verified locally advanced cervical esophageal cancer who were treated at the N. N. Petrov National Research Institute of Oncology in the period from 2009 to 2018, who underwent surgical treatment followed by chemoradiotherapy. The end point of the study was the frequency of postoperative complications.Results. Forty-eight patients were included in the study. All patients underwent laryngopharyngoesophagectomy with simultaneous reconstruction of the digestive tract. Forty-one patients (85.4 %) underwent the reconstructive stage using a narrow gastric stalk, and a wide gastric stalk and a small intestine graft were used in 5 (10.4 %) and 2 (4.2 %) patients, respectively. The average duration of the operation was 390 (337.5–525.0) minutes, the volume of blood loss was 300 (200–500) ml, and the average time of hospitalization and the patient’s stay in the intensive care unit was 21.5 (16.00–36.00) and 3 (1.000–6.75) days, respectively. Complications within 30 days after surgical treatment were observed in 54.1 % of patients, while anastomosis failure, fistula formation and pneumonia were observed in 22.9 %, 12.5 % and 18.8 % of cases, respectively. Factors slightly increasing the likelihood of pneumonia in the early postoperative period were: duration of surgery [OR = 1.0 (95 % CI: 1.00–1.01), p = 0.0131] and intraoperative blood loss [OR = 1.0 (95 % CI: 1.00–1.01), p = 0.0017].Conclusion. The overall complication rate after pharyngolaryngoesophagectomy with simultaneous repair of the defect by bioengineered graft was 54.1 %. Intraoperative blood loss and duration of surgery were associated with an increased risk of complications.

Crushed and crushed-avulsion finger replantation/revascularization: is it feasible?

ObjectivesTo evaluate the results of posttraumatic microvascular replantation/revascularization of crushed fingers and establish the prognostic factors that increase the success rate.BackgroundPosttraumatic digital amputations are one of the most common injuries in emergency room (ER) that face plastic surgeons with a wide range of options for management. Optimization of the results after digital microvascular surgeries represents a challenge, especially in crushed and crushed-avulsion cases.Patients and methodsA descriptive, retrospective study of 21 patients who underwent urgent replantation/revascularization digital surgery after crushed/crushed-avulsion injury in our center between January 2018 and March 2019. The data collected were classified into preoperative, intraoperative, postoperative, and follow-up data. The follow-up parameters were esthetic, sensory, and functional outcomes. The follow-up period extended to 1 year postoperative, every patient visited our outpatient clinic every 3 months for assessment of the results and data collection.ResultsDuring the period of the study, 21 patients of crushed fingers have been subjected to microvascular replantation/revascularization. The patients were 15 (71.4%) males and six (28.6%) females with mean age 27.7 years and their BMI ranged from 22 to 40. From 21 cases, there were 13 (61.9%) cases in which the injured finger totally survived, two (9.5%) cases show partial necrosis of the distal stump, and there were failure of anastomosis in six (28.6%) cases. Excellent esthetic outcomes were reported in 13 (86.5%) cases, while accepted or good outcomes were reported in five (33.3%) cases and poor results in only three (19.9%) cases (P = 0.013).ConclusionsWith taking great care to some important factors, the survival rate in crushed and crushed/avulsion is accepted with excellent long-term esthetic, functional, and sensory outcomes.