Anastomosis Research Articles

242.12: The Outcome of the Inferior Epigastric Artery as a Donor Vessel for Managing Accessory Renal Arteries in Renal Transplantation: A Systematic Review and Meta-Analysis

Background: Utilisation of renal allografts with multiple renal arteries (MRA) has always been considered a technical challenge during implantation of renal allografts. There is sparse literature comparing the implantation technique of MRA and allograft outcomes. The aim of this study was to perform systematic review and meta-analysis of literature comparing inferior epigastric artery (IEA) to other surgical anastomosis techniques in renal allografts with MRA. Methodology: The database MEDLINE was searched via PubMed, EMBASE, The Cochrane Library. Grey literature search was utilised including GoogleScholar. We appraised the studies using Keywords and MeSH were utilised, including: “epigastric artery” AND “kidney transplant”. The studies were appraised using Newcastle-Ottawa scale and meta-analysed using random-effects model. Results: A total of eight studies met the inclusion and exclusion criteria for analysis. Five studies were included in the quantitative analysis. Majority of the studies were poor (n=4) or fair (n=4). There were a total of n=846 patients in the studies, with n=161(19.0%) undergoing inferior epigastric artery anastomosis. Other anastomosis techniques consisted of: side-to-side with single anastomosis, long or modified carrell patch, end to side to main renal artery with single anastomosis. Nearly all of the renal allografts in the study population consisted of living donation kidney allografts. In meta-analysis: there was no statistical difference in urological complication rate between IEA versus other techniques, O.R. 0.82 (CI 0.21, 3.24). There was a trend towards lower delayed graft function (DGF) in IEA versus other anastomosis techniques but it did not reach statistical significance (O.R. 0.45, CI 0.10, 2.02). In qualitative analysis, vascular complications were largely reported in one paper, with 3 in IEA vs 6 in other anastomosis group. Long-term graft function was only reported in one paper, with 2 (9.5%) in IEA vs 47(16.2%) in other anastomosis group. Overall follow-up ranged from 12 months to 10 years, with none reporting long-term patient survival. Conclusion: Utilisation of recipient inferior epigastric artery for accessory polar vessels is an acceptable technique in renal transplantation. Whilst no short-term differences were shown in peri-procedural vascular or urological complication, there was a trend towards reduced delayed graft function. Long-term impact on graft function remains to be determined.

In-silico Analysis and Functional Characterization of Rhizoctonia solani Effector Proteins

Sheath blight is considered the second most prevalent disease in rice with no proper resistance genes identified for its resistance. Out of the 14 anastomosis groups in R. solani (AG1 to AG13 and AGBI), the AG1 group is mostly responsible for the infection in the rice. There are many effector proteins under this group, function as transcription factors. Many bioinformatics tools are available to determine the interaction between the promoter region and effector proteins. But in an attempt to use these effector proteins for molecular docking and simulation studies, criteria like In-silico analysis and validation of the proteins are to be analyzed. The reactivity and stability of these proteins were evaluated physicochemically, domain prediction, and secondary structure prediction using bioinformatics methods such as Protparam, Pfam, and SOPMA, respectively. These bioinformatics techniques were found to be remarkably suitable for characterizing the protein's function. Robetta an abinitio approach was used to predict the 3D structure, and the models were validated using the SAVESv6.0 (PROCHECK) server. The effector protein functional analysis and 3D structure predictions made using empirical data can shed light on the interaction studies for locating effector binding elements in the promoter regions of host genes.

1006 Supersized-Simulation vs Traditional Cardiothoracic Surgery Education: A Prospective, Randomised Controlled Trial

Abstract Aim Exposure to cardiothoracic surgery is limited during medical school in the United Kingdom. This study evaluated the effectiveness of a supersized simulation model (SSM) compared to traditional methods (TM) in developing coronary anastomosis surgical skills. Method This was a prospective, randomised controlled trial with a 1:1 allocation ratio. Undergraduate medical students with no prior cardiothoracic surgical skills training were eligible for inclusion. Both groups received a guided didactic lecture followed by modified Objective Structured Assessment of Technical Skills (OSATS) assessment for baseline. The control group then received traditional teaching and the intervention group received additional teaching with SSM before being reassessed. Modified OSATS score were the primary outcome, adjudicated by two senior cardiothoracic registrars. Performance time (PT), self-assessment (SA), confidence (CON) and global rating scale (GRS) were secondary outcomes. Results 48 novice medical students were randomised. OSATS scores were significantly higher in SSM group compared to TM group (13.2 vs 9.8, p<0.01). The secondary outcomes PT (17.7 minutes vs 22.2 minutes, p<0.01) and CON (3.04 vs 1.73, p<0.01) were also significantly different between groups, favouring SSM. SSM participants were more likely to want to pursue a career in cardiothoracic surgery (12 participants vs 2 participants). All participants agreed that SSM improved visualisation and comprehension of surgical procedure. SSM cost £0.75 per model. Conclusions Supersized simulation is effective for coronary anastomosis surgical training with technical skills successfully transferred to a clinical task. Supersized models can accelerate the novice trainee's surgical skill progression and represents a valuable resource in one's educational armamentarium.

Comparison of early results between intracorporeal and extracorporeal anastomosis in laparoscopic colectomy

Abstract Introduction: The study aim was to compare the operative time, estimated blood loss, number of harvested lymph nodes, intraoperative and postoperative complications, as well as postoperative recovery between intracorporeal and extracorporeal anastomosis in laparoscopic colectomy for colon cancer. Patients and methods: Retrospective study, case series. From 01/2021 to 8/2022, there were 99 patients, divided into two groups: intracorporeal anastomosis (n = 47) and extracorporeal anastomosis (n = 52). The operative time, estimated blood loss, number of harvested lymph nodes, intraoperative and postoperative complications were compared between two groups. Results: The intracorporeal anastomosis group has significantly shorter time to first flatus (2,7 ± 0,9 vs 3,1 ± 1,0 days; p=0,04) and shorter postoperative hospital stay (6,6 ± 1,7 vs 7,3 ± 1,1 days; p=0,03). Intracorporeal anastomosis can be performed within a comparable time frame as extracorporeal anastomosis, although the anastomosis forming time is significantly longer (33,4 ± 6,0 vs 24,2 ± 6,1 minutes; p<0,001). There was no difference in estimated blood loss, number of harvested lymph nodes, time to first stool, as well as overall complications between two groups. Conclusions: Intracorporeal anastomosis in laparoscopic colectomy is safe, feasible, and does not increase the overall complications and the overall operative time. Intracorporeal anastomosis significantly decreases the time to first flatus, the postoperative hospital length of stay, but prolong the anastomosis forming time as compared to extracorporeal anastomosis. Keywords: intracorporeal anastomosis, extracorporeal anastomosis, laparoscopic colectomy.

The use of objective assessments in the evaluation of technical skills in cardiothoracic surgery: a systematic review.

Summary OBJECTIVESWith reductions in training time and intraoperative exposure, there is a need for objective assessments to measure trainee progression. This systematic review focuses on the evaluation of trainee technical skill performance using objective assessments in cardiothoracic surgery and its incorporation into training curricula.METHODSDatabases (EBSCOHOST, Scopus and Web of Science) and reference lists of relevant articles for studies that incorporated objective assessment of technical skills of trainees/residents in cardiothoracic surgery were included. Data extraction included task performed; assessment setting and tool used; number/level of assessors; study outcome and whether the assessments were incorporated into training curricula. The methodological rigour of the studies was scored using the Medical Education Research Study Quality Instrument (MERSQI).RESULTSFifty-four studies were included for quantitative synthesis. Six were randomized-controlled trials. Cardiac surgery was the most common speciality utilizing objective assessment methods with coronary anastomosis the most frequently tested task. Likert-based assessment tools were most commonly used (61%). Eighty-five per cent of studies were simulation-based with the rest being intraoperative. Expert surgeons were primarily used for objective assessments (78%) with 46% using blinding. Thirty (56%) studies explored objective changes in technical performance with 97% demonstrating improvement. The other studies were primarily validating assessment tools. Thirty-nine per cent of studies had established these assessment tools into training curricula. The mean ± standard deviation MERSQI score for all studies was 13.6 ± 1.5 demonstrating high validity.CONCLUSIONSDespite validated technical skill assessment tools being available and demonstrating trainee improvement, their regular adoption into training curricula is lacking. There is a need to incorporate these assessments to increase the efficiency and transparency of training programmes for cardiothoracic surgeons.

Impact of retrograde anastomosis during supermicrosurgical lymphaticovenous anastomosis for cancer-related lower limb lymphedema: A retrospective cohort propensity-score-matched outcome analysis

BackgroundIn addition to antegrade anastomosis, retrograde anastomosis has been thought to offer further improvements after lymphaticovenous anastomosis (LVA) by bypassing the retrograde lymphatic flow. However, this concept has yet to be validated. The aim of this study was to determine the impacts on outcomes of performing both retrograde and antegrade anastomosis, as compared to antegrade-only anastomosis for treating lower limb lymphedema. Study designThis was a retrospective cohort propensity score-matched study. Eighty-seven patients with gynecologic cancer-related lower limb lymphedema were enrolled, including 58 patients who had received both antegrade and retrograde anastomoses (Group I) and 29 patients who had received antegrade-only anastomoses (Group II) as the control group. LVA was the primary treatment. Patients who had previous LVA, liposuction, or excisional therapy were excluded. Patient characteristics, intraoperative findings, and functional parameters including the ratio of indocyanine green-enhanced and flow-positive lymphatic vessels were recorded. Magnetic resonance volumetry was used for outcome assessments. The primary endpoint was the volume change at 6 months after LVA. ResultsAfter matching, a total of 26 patients have remained in each group. All parameters were matched except that Group I still had significantly more median LVA performed compared to Group II (8 [IQR: 5.3–10.0] vs. 5.5 [4.3–6.0], p = 0.001, respectively). Group II showed more post-LVA improvements at six-month and one-year follow-up compared to Group I but without statistically significant differences. ConclusionThe use of supplementary retrograde anastomoses is discouraged since it may lead to inferior post-LVA outcome compared to antegrade-only anastomoses.

Comparison of total anastomosis time between four different combinations of suturing and knot tying techniques in microsurgical anastomosis

Background Various techniques have been described for performing microsurgical anastomosis with providing high patency rates. Although the total anastomotic time may not be an issue when dealing with a single set of anastomoses, using a faster technique may save significant amount of time in cases of transferring flaps with shorter critical ischemia time or where multiple anastomoses are required. This study compares the total anastomosis time between four different combinations of commonly used suturing and knot tying techniques. Methods Twenty-four rats were divided into 4 groups. Simple interrupted suture with conventional knot tying technique (SIS-CT) was used in group I, continuous suture technique with conventional knot tying (CST) was used in group II, simple interrupted suture with airborne knot tying technique(SIS-AT) was used in group III, and continuous-interrupted suture with airborne knot tying technique(CIS-AT) was used in group IV for microsurgical anastomosis. Total anastomosis time and patency rates with each technique and samples from anastomotic sites were analyzed. Results The mean time required for microvascular anastomosis of the femoral artery was 1075 s in group I, 799 s in group II, 844 s in group III, and 973 s in group IV. The difference between four groups was statistically significant. The anastomoses in group II and group III were completed in the shortest period of time. Intergroup comparison revealed that the difference between group II and group III was not statistically significant, however, total anastomosis time for completion of the anastomosis was significantly longer for group I, followed by group IV. Thrombosis rates and histological analysis revealed no significant differences among four groups. Conclusion CST and SIS-AT techniques can significantly reduce microsurgical anastomosis time and provide high patency rates. Also, the time needed to complete an anastomosis was significantly shorter for CIS-AT when compared to SIS-CT.

Application of Half-Transected and Self-Pulling Esophagojejunostomy in Total Laparoscopic Gastrectomy for Gastric Cancer: A Safe and Feasible Technique.

Objective This study introduces a technique for esophagojejunostomy with half transected and self-pulling (HTSP) and evaluates the safety, feasibility, and clinical results of this technique in totally laparoscopic total gastrectomy (TLTG). Materials and Methods From May 2019 to March 2021, 42 patients (HTSP group) who underwent HTSP-TLTG surgery in the Department of Abdominal Tumor Surgery of Jiangxi Cancer Hospital were included in this study. The control group consisted of 50 patients undergoing conventional TLTG surgery (conventional anastomosis group) performed by the same surgical team from March 2018 to March 2020. The clinical data of the two groups were retrospectively analyzed and compared. Results The mean operation time of the HTSP-TLTG surgery was 166.7 ± 13.1 minutes and the anastomosis time was 20.8 ± 2.0 minutes, which were significantly shorter than those of traditional TLTG (P < 0.05). There were no significant differences between the two groups in blood loss, time to first exhaust, postoperative hospital stay, and incidence of surgery-related complications. Conclusion HTSP is a safe and feasible way of endoscopic esophagojejunal anastomosis, which requires a relatively low suture technique under endoscopy, and is suitable for promotion.

A novel receptor-interacting protein-1 (RIP1) inhibitor (547) protects human cardiac cells from ischemia/reperfusion-triggered necroptotic cell death

Abstract Funding Acknowledgements Type of funding sources: Public grant(s) – National budget only. Main funding source(s): M.M.C.P. is supported by a Netherlands Cardiovascular Research Initiative (CVON) grant (REMAIN 2014B27) and J.P.G.S is supported by Horizon2020 ERC-2016-COG-EVICARE [725229] and BRAVE (grant number 874827. Purpose Restoring perfusion, either by coronary angioplasty or bypass anastomosis, is performed around 2 million times per year throughout Europe to treat patients after myocardial infarction. Although this treatment is highly efficient to resolve myocardial ischemia, reperfusion is accompanied by damage through the release of reactive oxygen species (ROS). This ischemia/reperfusion (I/R) injury is manifested by cardiomyocyte death, caused to a certain extent by necroptosis. As a potential means of cardioprotection, we applied the small molecule compound 547 inhibiting RIP1-kinase, a central mediator of the necroptosis pathway, in an in vitro model of human cardiac I/R injury. Methods Human foetal cardiomyocyte progenitor cells (hfCPCs) were cultured and characterized for cell type defining markers before being subjected to simulated I/R damage using hydrogen peroxide (H2O2). Cardioprotective effects of 547 were assessed 24 hours after induction of damage and application of the compound. Cell viability and necroptosis pathway activation were assessed by flow cytometry, immunocytochemistry, and western blotting. Furthermore, mitochondrial damage was determined by JC-1 staining. Results hfCPCs expressed indicative markers SCA1, GATA4, PECAM-1, VEGF and C-KIT. Treatment with compound 547 significantly protected hfCPCs from H2O2 induced damage (viable cells: 84,3 ± 4,3% vs 1,6 ± 0,31%; P&amp;lt;0,0001). 547 decreased the necrotic cell population (DAPI+ AnnV-) (3,0 ± 1,1% vs 10,1 ± 1,5%, P&amp;lt;0,0001) and reduced phosphorylation of necrosome components RIP1 (1,3 ± 0,35 fold vs 3,7 ± 0,78 fold; P&amp;lt; 0,01), RIP3 (1,0 ± 0,46 fold vs 4,3 ± 1,5 fold; P&amp;lt; 0,05), and MLKL (1,1 ± 0,15 fold vs 5,7 ± 1,7 fold; P&amp;lt; 0,01) without decreasing unphosphorylated protein or mRNA levels. Interestingly, 547 treatment prevented oxidative stress induced loss of nuclear RIP1 and RIP3 as measured by immunocytochemistry and western blotting of cell fractions (nuclear/cytoplasmic ratio RIP1: 0,80 ± 0,0006 [Control] vs 1,5 ± 0,17 fold [547]; P&amp;lt; 0,01; nuclear/cytoplasmic ratio RIP3: 0,76 ± 0,10 [Control] vs 1,6 ± 0,18 fold [547]; P&amp;lt; 0,01). Remarkably, compound 547 also decreased H2O2–induced mitochondrial depolarization (JC-1 staining/membrane depolarization index: 4,5 ± 0,85% vs 1,2 ± 0,38%; P&amp;lt; 0,05)) and expression and activation of CAMKII (0,46 ± 0,13 fold; P&amp;lt;0,01), a protein mediating mitochondria-dependent cell death. Conclusions Administration of compound 547 led to inhibition of necroptosis, increased cell viability and reduced mitochondrial damage in an in vitro human cardiac I/R injury model, emphasizing the potential of necroptosis inhibition for cardioprotection. Assessing clinical applicability will require further studies in relevant in vivo models.

Establishment and Application of a Multiplex PCR Assay for the Rapid Detection of Rhizoctonia solani Anastomosis Group (AG)-3PT, the Pathogen Causing Potato Black Scurf and Stem Canker.

Rhizoctonia solani anastomosis group 3 (AG-3) is the main causative agent of the soil-borne disease known as potato black scurf, which poses a huge threat to potato production. Rapid and accurate identification of R. solani AG-3 isolates in soil and potato seed tubers prior to planting is essential for good production. In this study, a multiplex PCR assay was established for the detection of R. solani AG-3. Two pairs of target-specific primers were designed from sequences for endopolygalacturonase and pyridoxine biosynthesis genes downloaded from GenBank. The main factors influencing PCR amplification, such as annealing temperature and primer concentration, were optimized. Results show that the proposed multiplex PCR assay is highly sensitive and specific for the target genes in the pathogen even when the DNA concentration is reduced to 20 fg/μL. The resulting calibration plot shows a linear relationship between electrophoretic band peaks and genomic DNA concentration (R2 = 0.98). The primer specificity was confirmed by applying them to other R. solani AG groups and plant pathogen species on which no amplicons were produced. Using the primers, we successfully detected small amounts of R. solani AG-3 present in soil and potato tuber samples. Taken together, the detection assay developed in this study has high sensitivity, strong specificity, and accuracy and can be used to detect and identify soil and potato seed tubers infected with Rhizoctonia solani AG-3.

Clinical Analysis of C-Shaped Embedded Pancreaticojejunostomy in Pancreaticoduodenectomy.

Background Comparing the effects of C-shaped embedded anastomosis and pancreatic duct-jejunal mucosal anastomosis on the incidence of pancreatic fistula after pancreaticoduodenectomy (PD) to find a better pancreaticojejunal anastomosis method that can reduce the occurrence of complications during the operation and benefit the patients. Methods A retrospective subresearch method was used to select the clinical data of patients who have undergone pancreaticoduodenectomy in our hospital from December 2019 to March 2021. The indicators to be collected for this study include gender, age, body mass index, preoperative liver function (total bilirubin, alanine aminotransferase, and albumin), preoperative comorbidities (diabetes, chronic pancreatitis), and pancreatic condition (texture, pancreatic duct diameter). The patients were divided into two groups according to the method of pancreaticojejunostomy: C-shaped embedded anastomosis group (n = 38) and pancreatic duct-jejunal mucosal anastomosis group (n = 30). The duration of pancreaticojejunostomy, biliary-enteric anastomosis, gastrointestinal anastomosis, intraoperative blood loss, upper abdominal surgery history, pathological type, intraoperative blood loss, pancreaticojejunostomy time, combined pancreatic fistula, biliary fistula, hemorrhage, and abdominal infection were observed and compared. According to the different methods of pancreaticojejunostomy during operation, they were divided into group A: C-shaped embedded pancreaticojejunostomy group (38 cases), and group B: pancreatic duct-jejunal mucosal anastomosis group (30 cases). The postoperative complications were compared between the two groups, and the observed indicators were analyzed with statistical methods. Results The average pancreaticojejunostomy time in group A was 32.13 ± 4.52 min, and the average pancreaticojejunostomy time in group B was 43.23 + 4.31 min. The difference was statistically significant (p < 0.05). Neither group A nor group B had a grade C fistula. The incidence of biochemical fistula in group A was 21.05% (8/38), and the incidence of biochemical fistula in group B was 13.3% (4/30). The difference was not statistically significant (p > 0.05). The incidence of grade B fistula in group A was 5.20% (2/38), and the incidence of grade B fistula in group B was 26.67% (8/30). The difference was statistically significant (p < 0.05). There were no perioperative deaths in the two groups. Conclusion According to the results of data analysis, it can be seen that both the two types of pancreaticojejunostomy have good clinical effects, but that in terms of reducing the grade of pancreatic fistula, the C-shaped embedded pancreaticojejunostomy is obviously better and safer. At the same time, the C-shaped embedded pancreaticojejunostomy can shorten the time of pancreaticojejunostomy and is easier to operate, thus worthy of clinical promotion.

Results of CABG Using Microsurgical Technique and Endarterectomy for Diffuse Lesions of the Coronary Arteries

Background. The number of patients (pts) with diffuse lesions among coronary artery bypass grafting (CABG) candidates has increased; they are expected to have worse results. Complex reconstructions, such as coronary endarterectomy (CEAE) and prolonged anastomoses with arteries less than 1.5mm in diameter, are being used more often. There is no sufficient evidence data and accepted guidelines for surgical treatment of this most complicated category of pts. Aim to evaluate the effectiveness of CABG with and without endarterectomy in pts with diffuse lesion and compare it with standard CABG in pts with local lesion. Materials and methods. In 20102017 CABG were performed in 2.927 pts. 1276 had diffuse coronary artery disease and in 154 cases the surgeon was forced to perform CEAE. After excluding 38 pts with comorbidities, the study group was formed (group 1, n = 116). We selected 2 equally large control groups with propensity score matching: from pts with diffuse lesion operated without CEAE (group 2, n = 116) and pts with local lesion operated as standard (group 3, n = 116). Cardiopulmonary bypass and microsurgical techniques were used. Hospital and long-term (up to 8 years; median follow-up of 60 (42; 74) months results were compared. The endpoints were all-cause and cardiac mortality, myocardial infarction (MI), angina recurrence and repeated revascularization. Results. In group 1 the frequency of perioperative MI was significantly higher compared to groups 2 and 3 (6.9% vs 0.7 and 0.7% resp, p 0.05) Hospital mortality was comparable in groups (p = 0.444). In the long-term period, the angina recurrence frequency was insignificantly lower in both control groups compared with the study group (p = 0.418). Autovenous grafts had significantly more dysfunctions compared with the internal thoracic artery grafts in symptomatic pts (57.5 versus 12.1%, p 0.05; odds ratio OR = 9.82; 95% CI: 3.2429.79). Also the severity of the target coronary artery lesion 4 points scaled by the diffuse lesion index were more frequent cause of graft dysfunction in this group (60.9 versus 41.6%; p 0.05; OR = 2.13; 95% CI: 1.134.24). Conclusion. Coronary endarterectomy is related to the high risk of perioperative myocardial infraction, while do not significantly increase the hospital mortality and adverse events in the long-term period. It should be considered to use coronary endarterectomy when there is no other option for surgery. The using of other adjunctive techniques demonstrate high efficiency in patients with diffuse lesions of the coronary arteries, comparable to surgery in patients with local lesion.

A New Risk Factor for Cervical Anastomotic Leakage-Role of The Relative Gastric Length in the Surgical Treatment of Esophageal Cancer.

Blood supply is especially weak near the gastric fundus. Making the anastomosis in this area would increase the risk of anastomotic leakage (AL). In cervical anastomosis, the gastric conduit needs to travel through the thorax. Therefore, the relative length between the stomach and the thorax is an essential factor in deciding if the poorly supplied area could be removed. This study was to explore if a small relative gastric length was a risk of cervical AL. If all other conditions are equal, could intrathoracic anastomosis be a better choice? Patients who underwent esophagectomy with a preoperative barium swallow in West China Hospital between 2014 and 2017 were included. The length of the greater curvature and the thorax were obtained from the barium esophagogram. The ratio between the length of the greater curvature and the thorax was the relative gastric length calculated from the greater curvature (RGL-G). A total of 782 patients were enrolled in the final analysis. The cervical AL group had a significantly higher ratio of patients with an RGL-G less than 1.3 (26.7% vs. 8.9%, p = 0.003). The multivariate logistic regression proved that RGL-G less than 1.3 was a risk factor for cervical anastomotic leakage (p = 0.012). Correspondingly, RGL-G less than 1.3 was not a risk factor (6.3% vs. 14.3%, p = 0.289) in the intrathoracic anastomosis group. RGL-G less than 1.3 was a new risk factor for cervical AL, but it would not be a problem for intrathoracic anastomosis.

The impact of gastrojejunostomy orientation on delayed gastric emptying after pancreaticoduodenectomy: a single center comparative analysis.

Delayed gastric emptying (DGE) represents the most frequent complication after pancreaticoduodenectomy (PD). Aim of this study was to evaluate the impact of gastrojejunostomy (GJ)orientation on DGE incidence after PD. One-hundred and twenty-one consecutive PDs were included in the analysis and divided in the horizontal (H-GJ group) and vertical GJ anastomosis groups (V-GJ group). Postoperative data and the value of the flow angle between the efferent jejunal limb and the stomach of the GJ anastomosis at the upper gastrointestinal series were registered. Seventy-five patients (62%)underwent H-GJ, while 46 patients (38%)underwent V-GJ. The incidence of DGE was significantly lower in the V-GJ group as compared to the H-GJ group (23.9%vs45.3%; p=0.02). V-GJ was also associated to a less severe DGE manifestation (p=0.006). The flow angle was significantly lower in case of V-GJ as compared to H-GJ (24.5°vs37°; p=0.002). At the multivariate analysis, ASA score≥3 (p=0.02), H-GJ (p=0.03), flow angle>30°(p=0.004) and Clavien-Dindo≥3 (p=0.03) were recognized as independent prognostic factors for DGE. These same factors were independent prognostic features also for a more severe DGE manifestation. VGJ and the more acute flow angle appear to be associated to a lower incidence rate and severity of DGE. This modified technique should be considered by surgeons in order to reduce postoperative DGE occurrence.

10: INTRATHORACIC VERSUS CERVICAL ANASTOMOSIS AFTER MINIMALLY INVASIVE OESOPHAGECTOMY FOR OESOPHAGEAL CANCER: A RANDOMISED CONTROLLED TRIAL

Abstract Background and aim Transthoracic minimally invasive oesophagectomy (MIO) is increasingly performed as part of curative multimodality treatment. There is no robust evidence on the preferred location of the anastomosis after transthoracic MIO. The aim of this study was to compare an intrathoracic with a cervical anastomosis in a randomised controlled trial. Methods An open multicentre randomised controlled superiority trial was performed. Patients with mid to distal oesophageal or gastro-oesophageal junction cancer planned for curative resection were included. Patients were randomly assigned (1:1) to transthoracic MIO with intrathoracic or cervical anastomosis. The primary endpoint was anastomotic leakage requiring endoscopic, radiologic or surgical intervention. Secondary outcomes were overall anastomotic leak rate, other postoperative complications, length of stay, mortality and quality of life. The ICAN trial is registered in the Dutch trial register under number NTR4333. Results Two hundred and sixty-two patients were randomised and 245 were eligible for analysis. Anastomotic leakage necessitating re-intervention occurred in 15 of 122 (12.3%) patients with intrathoracic anastomosis and in 39 of 123 (31.7%) patients with cervical anastomosis (risk difference − 19.4%, 95% CI -29.5%—-9.3%). Overall anastomotic leak rate was 12.3% in the intrathoracic anastomosis group and 34.1% in the cervical anastomosis group (risk difference − 21.9%, 95% CI -32.1%—-11.6%). ICU length of stay, mortality rates and overall quality of life were comparable between groups, but intrathoracic anastomosis was associated with less severe complications, lower incidence of recurrent laryngeal nerve palsy and better quality of life in three subdomains. Conclusion Intrathoracic anastomosis is the preferred technique for patients treated with transthoracic MIO for mid to distal oesophageal or gastro-oesophageal junction cancer.

Graft repair of arteriovenous fistula aneurysms is associated with decreased long-term patency

IntroductionArteriovenous fistula (AVF) aneurysms are a chronic complication which can be disfiguring, painful, and can rupture. Here, we compare the outcomes between three different methods of AVF aneurysm repair. MethodsOne-way ANOVA, Chi-square, and Fisher Exact analyses were used to compare demographics. Multivariate logistic regression compared outcomes. Kaplan-Meier estimate illustrated long-term fistula patency. ResultsThere were no differences between demographics in the aneurysmorrhaphy, end-to-end anastomosis, and synthetic graft groups. The odds of patients who received graft repair losing primary patency within one year compared to the aneurysmorrhaphy group was 3.5 (p = 0.025). Graft repair patients were 6.7 times more likely to develop an infection compared to aneurysmorrhaphy (p = 0.014). Synthetic grafts also exhibited accelerated rates of complete access loss compared to autogenous methods (p = 0.034). ConclusionsGraft repair of AVF aneurysms results in higher rates of infection and decreased primary and ultimate patency compared to autogenous repair techniques. Therefore, synthetic grafts should be avoided whenever possible.

Six Novel Mycoviruses Containing Positive Single-Stranded RNA and Double-Stranded RNA Genomes Co-Infect a Single Strain of the Rhizoctoniasolani AG-3 PT.

Six novel mycoviruses that collectively represent the mycovirome of Rhizoctonia solani anastomosis group (AG)-3 PT strain ZJ-2H, which causes potato black scurf, were identified through metatranscriptome sequencing and putatively designated as Rhizoctonia solani fusarivirus 4 [RsFV4, positive single-stranded RNA (+ssRNA)], Rhizoctonia solani fusarivirus 5 (RsFV5, +ssRNA), Rhizoctonia solani mitovirus 40 (RsMV40, +ssRNA), Rhizoctonia solani partitivirus 10 [RsPV10, double-stranded RNA (dsRNA)], Rhizoctonia solani partitivirus 11 (RsPV11, dsRNA), and Rhizoctonia solani RNA virus 11 (RsRV11, dsRNA). Whole genome sequences of RsFV4, RsMV40, RsPV10, RsPV11, and RsRV11, as well as a partial genome sequence of RsFV5, were obtained. The 3’- and 5’- untranslated regions of the five mycoviruses with complete genome sequences were folded into stable stem-loop or panhandle secondary structures. RsFV4 and RsFV5 are most closely related to Rhizoctonia solani fusarivirus 1 (RsFV1), however, the first open reading frame (ORF) of RsFV4 and RsFV5 encode a hypothetical protein that differs from the first ORF of RsFV1, which encodes a helicase. We confirmed that RsPV10 and RsPV11 assemble into the spherical virus particles (approximately 30 nm in diameter) that were extracted from strain ZJ-2H. This is the first report that +ssRNA and dsRNA viruses co-infect a single strain of R. solani AG-3 PT.

Intrathoracic versus cervical anastomosis in esophagectomy for esophageal cancer: A meta-analysis of randomized controlled trials

BackgroundIntrathoracic anastomosis and cervical anastomosis are very common in the esophagectomy of esophageal cancer; we aimed to evaluate the effects and safety of intrathoracic anastomosis versus cervical anastomosis in the esophagectomy. MethodsWe searched PubMed, EMBASE, Cochrane Library, Web of Knowledge, China National Knowledge Infrastructure, and WanFang databases up to September 30, 2021, for randomized controlled trials focused on cervical anastomosis versus intrathoracic anastomosis for the treatment of esophageal cancer. ResultsIn total, 12 randomized controlled trials involving 1,493 patients were finally included. The incidence of anastomotic leak [relative risk = 2.76, 95% confidence interval (1.94∼3.94), P < .001] and recurrent laryngeal nerve injury [relative risk = 6.12, 95% confidence interval (3.02∼12.41), P < .001] in the intrathoracic anastomosis group were less than that of the cervical anastomosis group. There were no significant differences in the incidence of anastomotic stenosis [relative risk = 1.33, 95% confidence interval (0.88∼2.00), P = .18], pneumonia [relative risk = 1.31, 95% confidence interval (0.82∼2.09), P = .25], postoperative chylothorax [relative risk = 1.01, 95% confidence interval (0.40∼2.52), P = .99], and mortality [relative risk = 0.93, 95% confidence interval (0.52∼1.68), P = .82] between the 2 groups. ConclusionIntrathoracic anastomosis is associated with significantly reduced risk of leak and recurrent laryngeal nerve injury compared with cervical anastomosis.

AVOID; a phase III, randomised controlled trial using indocyanine green for the prevention of anastomotic leakage in colorectal surgery

IntroductionAnastomotic leakage (AL) is one of the major complications after colorectal surgery. Compromised tissue perfusion at the anastomosis site increases the risk of AL. Several cohort studies have shown that...

Molecular identification and pathogenicity of Rhizoctonia solani and Pythium spp. associated with damping‐off disease on baby leafy vegetables in Greece

AbstractIn the last years, leafy vegetables cultivated as baby leaves have been established in the market and have attracted the interest of consumers throughout the world. During the growing seasons of 2019 and 2020, 97 isolates of Rhizoctonia solani and 112 isolates of Pythium spp. were obtained from baby leaf vegetables exhibited damping‐off symptoms. Representative isolates of R. solani from each surveyed plant species were characterized using sequence analysis of the internal transcribed spacer (rDNA‐ITS) region. Isolates were identified as belonging to four anastomosis groups (AGs): AG2‐1, AG‐IB, AG4‐HGI and AG4‐HGIII. AG4‐HGI was the most prevalent group and phylogenetic analysis showed that the isolates were distinctly separated according to their AGs. Pathogenicity among the four AGs on 23 plant species varied considerably, from not susceptible to highly susceptible, while, in general, AGs did not exhibit host specificity. Furthermore, a total of 112 Pythium spp. isolates were obtained. The ITS region and the cytochrome oxidase II (coxII) gene were amplified, and three Pythium spp. were identified (P. ultimum, P. aphanidermatum and P. sylvaticum), which were used further for maximum‐likelihood phylogenetic analysis. The pathogenicity of representative isolates was assessed in vitro and in vivo on 10 plant species. In general, all three tested Pythium spp. were virulent when used in vitro, while P. ultimum was the most virulent in vivo. This is the first comprehensive study aimed at determining the occurrence of specific R. solani AGs and Pythium spp. derived from baby leafy vegetables exhibiting damping‐off symptoms in Greece.