Anastomotic Disruption Research Articles

(315) Evidence Analysis for Contemporary Vascular Therapies for Erectile Dysfunction

Abstract Introduction Erectile Dysfunction (ED) is a common male sexual disorder that is caused by various conditions including vascular dysfunction. Different treatment options can be implemented, like lifestyle modifications, pharmacological intervention, or surgical procedures. In select ED cases, vascular procedures such as penile revascularization and venous ligation could be an alternative option. Objective We herein evaluated the current evidence and outcomes of penile revascularization, venous ligation and other vascular surgery with specific emphasis on complications and patients’ satisfaction. Methods A literature search was conducted using PubMed and Google Scholar to examine papers from 1993 to present day. Keywords, such as, “Erectile dysfunction”, “ED vascular surgery”, “Penile venous ligation”, “Penile revascularization”, and “Arterial bypass surgery”, were used in this search. All the papers were in the English language. Results A total of four studies met inclusion criteria for penile arterial bypass and dorsal penile venous ligation procedures with erectile function, clinical outcomes, satisfaction rates and post operative complications. Regarding penile arterial bypass, two studies identified. First study reported inferior epigastric artery (IEA) to the penile dorsal artery of 1500 patients reported success rates of erectile function were 67% and satisfaction rates of 89%. Postoperative complications were anastomotic disruption, penile skin sensation loss and pain. Regarding venous ligation of penile dorsal vein, two studies identified. First study of 100 patients reported success rates of erectile function were 62% at 1 year. Second study of 26 patients reported success rates of erectile function were 42.3% and satisfaction rates of 57.7% at 3.7 years. Postoperative complications were painful erections, skin necrosis, and penile shortening (Table 1). Conclusions Vascular therapies including penile arterial bypass and penile dorsal venous ligation for ED could provide improved clinical outcomes and satisfactions in select patients’ population. Future studies are warranted to further evaluate its surgical outcomes and long-term safety and efficiency. Disclosure No.

Perforation Peritonitis: Clinical Insights from a Three-Year Experience

Background: Peritonitis caused by gastrointestinal perforation is a frequent surgical emergency globally. Early detection and treatment are vital in reducing complications and death. Surgical intervention and good perioperative care improve outcomes. A clinical trial assessed the outcome of perforation peritonitis at a tertiary healthcare institute to identify factors contributing to morbidity and mortality. Materials and Methods: The study conducted at IMS, BHU, was a Prospective Observational Study for 3 years. Patients of all ages presenting with acute abdominal pain and gas under the diaphragm were enrolled. After examination through different methods, after resuscitation, Laparotomy was performed in all patients, followed by thorough peritoneal lavage. The site, size, type, and number of perforations were documented, and biopsy was taken from the edge of the perforation when necessary. Results: The study showed that duodenal ulcer perforation was the leading cause of gastrointestinal perforation, followed by appendicitis, typhoid perforation, and malignancy. Primary closure was the most common surgical procedure, followed by appendectomy, gut resection, and exteriorization. Mortality rate was , and observed morbidity included wound infection, fever, respiratory complications, residual abscess, electrolyte imbalances, burst abdomen, sepsis, cardiac complications, and anastomotic disruption. Conclusion: Gastrointestinal perforation is a common complication of acid peptic disease and typhoid. To control acid peptic disease, NSAIDs and triple therapy for H. pylori eradication can be used. Early and primary treatment for typhoid should be prioritized on a larger scale, and common practitioners should be educated to increase awareness about the disease.

Duhok Technique; A New Modification of The Hypospadias Surgery Technique to Prevent Inadvertent Catheter Removal after Surgery

Introduction: The results of hypospadias surgery had improved greatly over the last decades and the surgical techniques are still evolving. One of the most important steps in the success of surgery is the urinary diversion. Updated guidelines recommend the use of an appropriate sized silastic catheter just inside the bladder and for limited duration to improve the results. Material and methods: This cross section study involved 71 consecutive patients who underwent hypospadias surgery from January, 2018 to August 2020. The external part of urethral catheter was incised into wings which were anchored to the glans circumferentially to prevent stent displacement, we incised the catheter into 4 wings in most patients. None of the wings should be placed over the suture line at the glans to prevent pressure necrosis and wound disruption. The aim of study is to present our new modification in catheter fixation technique in hypospadias surgery to prevent inadvertent catheter removal postoperatively. Discussion: Most of the patients had no complications (85.92%). The commonest reported complications were meatal stenosis and fistula, and other complications were rare. No catheter related complications were reported. Conclusions: Repositioning of the catheter after inadvertent removal may result in anastomotic disruption or fistula. The catheter should be inserted inside the bladder rather than making it a urethral stent. Advantages of our technique were a steadier catheter, the catheter is made as short as possible which decrease the chance of blockage, more easily handled catheter as napkin can be applied easily, and easier removal of catheter

Endoscopic rescue of anastomotic dehiscence after urgent gastric bypass revision.

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Altemeier’s Procedure, an Easy Solution for Rectal Prolapse

Introduction: Rectal prolapse is an embarrassing clinical condition. Most of the time patients get emergency hospital admission. Full thickness rectal prolapse demands surgical treatment. Many surgical procedures and techniques were described but none is adopted as standard. It is challenging to choose appropriate surgical procedure in the emergency situations as many patients come after trial of reduction and maltreatment. We have treated 64 patients of full thickness rectal prolapse by Altemeier’s procedure in emergency admissions. This study was designed to observe the outcomes of Altemeier’s procedure (perineal proctosigmoidectomy) in full thickness rectal prolapse as emergency surgery. Methods: This prospective study was done in Dhaka Medical College Hospital and Cumilla Medical College Hospital over the period of January 2013 to July 2018. Total 64 patients were included in this study. Alteimer’s procedure was done in all patients. Patients were followed up on 2 weeks, 1 month, 3months, 6 months and 1 year. Patients were evaluated by complain of pain, per rectal bleeding, mucous discharge, bowel movement and incontinence. Postoperative data was collected and evaluated. Results: Reduction was achieved in all patients and they were satisfied about their prolapse correction. Two patients needed blood transfusion and laparotomy. Anastomotic disruption and bleeding from the mesenteric vessels were found on laparotomy. All patients had improved evacuation as assessed by history of satisfactory evacuation. No recurrence was reported during the follow up period. Gas and liquid incontinence were noted in 3 patients who improved with sphincter exercise within 3 months. Conclusion: In our series, we found Altemeier’s procedure is safe, effective for complete rectal prolapse specially in emergency situation and can be done under regional anesthesia. J Bangladesh Coll Phys Surg 2022; 40: 229-232

PREDICTING ANASTOMOTIC DISRUPTION AFTER EMERGENT INTESTINAL SURGERY

Introduction Suture line disruption is an important cause of post-operative morbidity and mortality in patients who have undergone bowel surgery. Our aim was to study peri-operative factors causing anastomotic disruption in emergency surgeries and also morbidity and mortality associated with it. AfterMethodology obtaining ethical clearance from Institutional Ethical Committee, the present prospective study was conducted on 68 patients during the study period of two years (September 2017- August 2019) in a tertiary care hospital A total of 68 emergencyResults bowel anastomosis meeting the inclusion criteria were performed with 50 (73.5%) males patients. Anastomotic leak was present in 10 patients ((14.7%). The mean age of subjects in our series sustaining a leak was 62.60±6.95 years. Intra-operative hypotension, colo-colic anastomosis, post-operative vasopressor support, pre-operative hypoalbuminemia, hyponatremia and Intra-operative uid infused were signicantly associated with anastomosis leak. In our study majority of patients with anastomotic leak were of older age group. In anstomotic leak group chest infection, wound infection, septicemia and impaired renal function was present in 8, 10, 3, and 4 patients respectively. Among the 10 cases of anastomotic leak, four patients were managed conservatively and remaining six develop features of peritonitis, who were immediately taken for re-exploration. There were three deaths in the study, all of them were in leak group. Patients who have predisposing factors forConclusion leakage should ideally be considered for a temporary defunctioning stoma to tide the crisis over.

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.

Salvage of infected autogenous arteriovenous fistulas, is it possible?

Infection in autogenous arteriovenous fistulas (AVFs) is a critical situation in patients with end stage renal disease (ESRD) that can lead to life threatening rupture or septicemia. To date, no standard guidelines regarding the surgical repair of the infected AVFs is available. To evaluate the safety and efficacy of the surgical repair in the infected autogenous AVFs. This prospective study involved 64 ESRD patients who presented with infected autogenous AVFs. Repair of the infected autogenous AVFs was done in 50 cases, while ligation was needed in the other 14 cases. Aneurysmorrhaphy was done in the 26 cases of puncture site infection over venous aneurysms. In 20 cases of AVFs with anastomotic disruption, higher recreation in a proximal clean field (AVF loop anastomosis) was performed, while abscess drainage was done in the remaining four cases presented with non-communicating abscess over the vein. The 14 cases of ligated AVFs included 9 cases of infected ruptured AVFs with active bleeding and 4 cases with non-reconstructable puncture site infection. After 1 year of follow up, 41 cases (82%) of the repaired AVFs (n = 50) remained patent and functioning as re-infection occurred in 9 cases. Six tunneled permanent catheters were implanted in the 14 cases with ligated AVFs, while the remaining 8 cases had new AVFs established (7 cases of them retained patent AVFs during the follow up period). Surgical repair of the infected AVFs is an effective procedure that achieves many goals, such as saving patients' lives, maintaining the patency of the native fistula, and avoidance of creation of new AVFs in another site with exhaustion the available veins.

A UNUSUAL PRESENTATION OF KOCHS ABDOMEN WITH MULTIPLE ILEAL PERFORATIONS- A RARE CASE

Hypothesis- whether kochs abdomen causes multiple ileac perforation or not . Methodology- A case report with A 38-year old male presented with- Ø abdominal pain since 1 month Ø Constipation since 4 days Ø Anorexia since 4 days On examination – abdomen was distended, diffuse, tenderness with guarding and rigidity with absent of bowel sounds. Conclusion –TB should always considered in differential diagnosis in patients presenting with abdominal pain/distension, fever and ascites or with abdominopelvic mass. Recurrent bowel obstruction or anastomotic disruptions also give clues of its diagnosis.

EP.FRI.466 Indications and Outcome of Abdominal Re-exploration in the Pediatric Population. A Single Centre Experience

Abstract Abdominal exploration (ARE) is an important complication of abdominal surgery and has an effect on morbidity and mortality. ARE refers to exploration performed within 60 days following initial surgery. The purpose of this study is to know the grounds for performing re-exploration and its effects on the outcome. Methods This retrospective study was carried out in the pediatric surgery unit of Khyber teaching hospital from May 2017 to May 2019. All patients under the age of 16 years who underwent abdominal re-exploration within 60 days of the initial procedure were included in the study. Results A total of 55 re-exploration were done in the study duration of 2 years. The mean age of patients was 41 months (range of 0.06 to 168 months) male patients were 64%. On initial presentation, 56% of cases were emergency cases and 44% were elective. Common indications for re-exploration were, intestinal obstruction 29.1%, peritonitis 16.4%, complications of stoma 16.4%, burst abdomen 10.9%. The mean interval from initial surgery was 12.5±13.7 days. Common operative findings of re-exploration were inter-loop adhesions, anastomotic disruption, burst abdomen, anastomotic leak, intra-abdominal collection, gangrenous stoma, and para-stomal herniation. ARE resulted in 14.5% mortality. Conclusion Abdominal re-exploration is mainly indicated for intestinal obstruction and peritonitis. Inter loop adhesions and anastomotic leak are common surgical findings during re-exploration. The mortality rate is high in patients re-explored for peritonitis, fecal fistula, abdominal collection, and wound dehiscence.

Tertiary peritonitis: considerations for complex team-based care.

Peritonitis, as a major consequence of hollow visceral perforation, anastomotic disruption, ischemic necrosis, or other injuries of the gastrointestinal tract, often drives acute care in the emergency department, operating room, and the ICU. Chronic critical illness (CCI) represents a devastating challenge in modern surgical critical care where successful interventions have fostered a growing cohort of patients with prolonged dependence on mechanical ventilation and other organ supportive therapies who would previously have succumbed much earlier in the acute phase of critical illness. An important subset of CCI patients are those who have survived an emergency abdominal operation, but who subsequently require prolonged open abdomen management complicated by persistent peritoneal space infection or colonization, fistula formation, and gastrointestinal (GI) tract dysfunction; these patients are described as having tertiary peritonitis (TP).The organ dysfunction cascade in TP terminates in death in between 30 and 64% of patients. This narrative review describes key—but not all—elements in a framework for the coordinate multiprofessional team-based management of a patient with tertiary peritonitis to mitigate this risk of death and promote recovery. Given the prolonged critical illness course of this unique patient population, early and recurrent Palliative Care Medicine consultation helps establish goals of care, support adjustment to changes in life circumstance, and enable patient and family centered care.

Results of cryopreserved arterial allograft replacement for thoracic and thoracoabdominal aortic infections

BackgroundPrimary and secondary thoracic aortic infections are rare but associated with high morbidity and mortality. There is currently no consensus on their optimal treatment. Arterial allografts have been shown to be resistant to bacterial colonization. Complete excision of infected material, especially synthetic grafts, combined with in situ aortic repair is considered the best treatment of abdominal aortic infections. The aim of this study was to assess the management of thoracic and thoracoabdominal aortic infections using arterial allografts. MethodsBetween January 2009 and December 2017, all patients with thoracic and thoracoabdominal aortic native or graft infections underwent complete excision of infected material and in situ arterial allografting. The end points were the early mortality and morbidity rates and early and late rates of reinfection, graft degeneration, and graft-related morbidity. ResultsThirty-five patients with a mean age of 65.6 ± 9.2 years were included. Twenty-one (60%) cases experienced graft infections and 14 (40%) experienced native aortic infections. Eight (22.8%) patients had visceral fistulas: 5 (14.4%) prosthetic-esophageal, 1 (2.8%) prosthetic-bronchial, 1 (2.8%) prosthetic-duodenal, and 1 (2.8%) native aortobronchial. In 12 (34.3%) cases, only the descending thoracic aorta was involved; in 23 (65.7%) cases, the thoracoabdominal aorta was involved.Fifteen (42.8%) patients died during the first month or before discharge: 5 of hemorrhage, 4 of multiorgan failure, 3 of ischemic colitis, 2 of pneumonia, and 1 of anastomotic disruption. Eleven (31.5%) patients required early revision surgery: 6 (17.1%) for nongraft-related hemorrhage, 3 (8.6%) for colectomy, 1 (2.9%) for proximal anastomotic disruption, and 1 (2.9%) for tamponade. One (2.9%) patient who died before discharge experienced paraplegia. One (2.9%) patient experienced stroke. Six (17.1%) patients required postoperative dialysis. Among them, four died before discharge. The mean length of stay in the intensive care unit was 11 ± 10.5 days; the mean length of hospital stay was 32 ± 14 days.During a mean follow-up of 32.3 ± 23.7 months, three allograft-related complications occurred in survivors (15% of late survivors): one proximal and one distal false aneurysm with no evidence of reinfection and one allograft-enteric fistula. The 1-year and 2-year survival rates were 49.3% and 42.5%, respectively. ConclusionsAlthough rare, aortic infections are highly challenging. Surgical management includes complete excision of infected tissues or grafts. Allografts offer a promising solution to aortic graft infection because they appear to resist reinfection; however, the grafts must be observed indefinitely because of the risk of late graft complications.

The Role of Endoscopic Stent in Management of Postesophagectomy Leaks.

Anastomotic leak is a dreaded complication following esophagectomy. Conventional management for leaks includes invasive reoperation and even gastrointestinal diversion. The aim of this study was to examine our contemporary outcome of using endoscopic esophageal stenting as primary therapy for management of anastomotic leak following minimally invasive esophagectomy (MIE). We reviewed data on 11 patients who developed an esophageal leak following 111 MIE between January 2011 and December 2019. Of the 11 anastomotic leaks, 10 patients had an anastomotic disruption and underwent endoscopic esophageal stenting as primary therapy for management of leaks, while 1 patient had an anastomotic disruption complicated by an associated tracheoesophageal fistula that required surgical reoperation and subsequent colonic interposition. Main outcome measures focused on the 10 patients who were managed with endoscopic stenting, including length of hospital stay following leak management, need for thoracotomy or gastrointestinal diversion for leak, stent complications, and leak-associated mortality. Of the 10 patients who underwent endoscopic esophageal stenting as primary therapy for management of leaks, there were 8 males with a median age of 66years. The median time to diagnosis of anastomotic leak was 10days postoperatively. One of the ten patients also underwent percutaneous drain placement, while none of the patients required thoracotomy. Median duration of stent placement was 39 (range, 29-105) days. Median length of stay after stent placement was 10 (range, 4-43) days. The median number of stent exchange was 1 (range, 1-3) stent. Gastrointestinal continuity was maintained in all patients. The 90-day leak-associated mortality was 9.1% (1 of 11 patients). Endoscopic stenting is an effective primary therapy in the management of postesophagectomy leak and avoids the need for an invasive, reoperative thoracotomy or gastrointestinal diversion procedure.

Tension-Free Management of Surgical Wound in Paramalleolar Bypass.

Objective: In paramalleolar bypass for critical limb-threatening ischemia (CLTI), excessive skin tension may occur for the closure of surgical wounds around the ankle. Furthermore, these surgical incisions are often proximal to infectious ischemic ulcers. Wound dehiscence caused by skin tension and surgical site infection carries a risk of graft exposure, anastomotic disruption, or graft insufficiency.Patients and Methods: Tension-free wound management was adopted in eight patients who underwent paramalleolar bypass for CLTI. Tension-free closure was adopted for surgical incisions for distal anastomotic site of the paramalleolar bypass, whereas the incisions for saphenous vein harvest were left open. A relief incision was made as needed. The opened incisions were covered with artificial dermis.Results: All surgical incisions and ischemic wounds healed successfully within 1.8 months after bypass. Two postoperative graft stenoses occurred, which were rescued by additional endovascular intervention. Secondary graft patency, wound healing, and limb salvage rates were 100% during an average follow-up period of 30 months.Conclusion: Tension-free wound closure using artificial dermis was effective in selected cases of paramalleolar bypass for CLTI.

Transanal endoscopic operation (TEO) repair of rectovaginal fistula and anastomotic leakage: a case series

Introduction. Interest in transanal endoscopic surgery has increased in the last decade. This approach allows primary procedures such as polypectomy, local tumor excision, as well as the treatment of postoperative complications including bleeding, leakage and fistula formation. The aim of this study was to describe our group’s use of Transanal endoscopic operation (TEO) in the repair of fistulae and anastomotic leakage, performed by one experienced surgeon (F.C.). Case presentation. Here, we describe three patients who developed postoperative complications after been subjected to anterior rectal resection. One of them developed a leakage of the anastomosis in third postoperative day, the others developed recurrent fistulae a long time after the surgery. These complications were all treated using TEO (transanal endoscopic operation) platform. The transanal procedure in one case was performed three times, because of the recurrence of the fistula. In another case it was associated with laparoscopy to treat peritonitis occurred after anastomotic disruption. In the last case, the patient had history of years of fistula recurrence associated with pelvic abscess, TEO approach proved to be determinant in the resolution of the problem. In all cases the transanal surgery definitively repaired the defect, the patients were discharged and, up to date, they are without recurrence. Conclusions. Thus, in the hands of experienced surgeons and in selected cases, TEO system appears to be a valid option to treat post-operative complications, such as fistulae and anastomotic leakage, avoiding major surgery with greater associated morbidity and showing excellent results.

Colorectal anastomosis dehiscence: a call for more detailed morphological classification.

IntroductionA proactive approach is recommended in colorectal anastomosis leak treatment, and early diagnosis is very important. Early postoperative endoscopy would allow rapid diagnosis of anastomotic pathologies and consequent prompt intervention according to anastomotic disruption morphology.AimTo evaluate the effectiveness of close endoscopic follow-up of all patients (including asymptomatic ones) in improving diagnosis of acute leak (AL) and reducing its complications.Material and methodsThis study included 124 patients who had undergone rectum resection for rectal cancer with stapled anastomosis. Endoscopy was performed between the 7th and 10th postoperative day and 1 month postoperatively. For defect morphology assessment, a classification system was created based on four levels of severity. Photographic findings were evaluated by an independent, experienced gastroenterologist.ResultsPostoperative endoscopy revealed 28 (22.6%) patients with acute leakage. Initial endoscopy confirmed AL in 18 patients. Six (31.6%) patients were asymptomatic and 13 (68.4%) were symptomatic. The second endoscopy revealed another 9 (32.1%) leaks (4 (44.5%) asymptomatic and 5 (55.5%) symptomatic). Sixteen (57.1%) patients had grade A leakages, 7 (25.0%) had grade B leakages, and 5 (17.9%) had grade C leakages. Furthermore, 22 of 27 (81%) defects were located posterior and posterior-laterally. Fifteen (55.5%) defects were smaller than 1/3 the circumference, 7 (25.9%) affected 1/3–1/2 of the circumference, and 5 (18.5%) affected more than 1/2 of the circumference.ConclusionsIncorporation of early endoscopy in postoperative management allows rapid diagnosis of AL and allows faster intervention, even in leaks that are clinically silent.

Comparative genetics of Enterococcus faecalis intestinal tissue isolates before and after surgery in a rat model of colon anastomosis.

We have recently demonstrated that collagenolytic Enterococcus faecalis plays a key and causative role in the pathogenesis of anastomotic leak, an uncommon but potentially lethal complication characterized by disruption of the intestinal wound following segmental removal of the colon (resection) and its reconnection (anastomosis). Here we hypothesized that comparative genetic analysis of E. faecalis isolates present at the anastomotic wound site before and after surgery would shed insight into the mechanisms by which collagenolytic strains are selected for and predominate at sites of anastomotic disruption. Whole genome optical mapping of four pairs of isolates from rat colonic tissue obtained following surgical resection (herein named “pre-op” isolates) and then 6 days later from the anastomotic site (herein named “post-op” isolates) demonstrated that the isolates with higher collagenolytic activity formed a distinct cluster. In order to perform analysis at a deeper level, a single pair of E. faecalis isolates (16A pre-op and 16A post-op) was selected for whole genome sequencing and assembled using a hybrid assembly algorithm. Comparative genomics demonstrated absence of multiple gene clusters, notably a pathogenicity island in the post-op isolate. No differences were found in the fsr-gelE-sprE genes (EF1817-1822) responsible for regulation and production of collagenolytic activity. Analysis of unique genes among the 16A pre-op and post-op isolates revealed the predominance of transporter systems-related genes in the pre-op isolate and phage-related and hydrolytic enzyme-encoding genes in the post-op isolate. Despite genetic differences observed between pre-op and post-op isolates, the precise genetic determinants responsible for their differential expression of collagenolytic activity remains unknown.

COMPLICATED COURSE OF LATE PATIENT’S SURVIVAL AFTER THE CLASSIC BENTALL PROCEDURE WITH THE CABROL SHUNT

In the setting of bleeding into the perigraft space, the classic Bentall operation can be modified by the usage of the Cabrol shunt. This shunt is applied in order to drain the blood into the right atrium and it is expected to close gradually. Anastomotic suture line disruption along with concomitant blood flow into the perigraft space may rarely open the shunt and cause the right heart failure. Due to the anastomotic complications, the classic Bentall operation no longer is widely used in clinical practice, but patients who underwent such procedure some decades ago may be coping with various symptoms nowadays. In this article, the cases of anastomotic disruption as well as pseudoaneurysm formation and the opening of the Cabrol shunt 21 years after such kind of operation are presented. The patient underwent surgical repair and was confronted with the reoccurrence of the coronary pseudoaneurysm three years later.

Contained Rupture in Non-aneurysmal Aorta: 10 Years' Experience of Endovascular Repair of Penetrating Aortic Ulcers in Urgent and Elective Setting

Introduction: Penetrating Aortic Ulcers (PAU) are atherosclerotic lesions leading to rupture of the arterial wall even in non-aneurysmal vessels. The incidence of PAU has increased due to a wider use of diagnostic tools, however presentation, natural history, and technical treatment details are not clearly defined. Aim of the study is to analyze a monocentric 10 years' experience of urgent and elective PAU treatment. Methods: Pre, intra and post-operative data of all consecutive patients treated for PAU from 2009 to 2019 were retrospectively analyzed. Pre-discharge, 30-day and follow-up outcomes of patients treated electively and urgently were evaluated and compared. PAU, intended as ulcer-like projection into the medial lining of an artery with aspect of rupture, is characterized by a “neck” (length of intimal defect at the ulcer site), “depth” (its extension outside the aortic wall) and “maximum aortic diameter” at that level (DIAM). PAU with “depth” >20mm or DIAM >40mm were treated and included in the study. Fisher's exact test and T-student test were used for statistical evaluation. Results: Seventy-one patients (age:78±8 years; M 60-85%; F 11-15%; DIAM 51.2±19.2mm, neck 23.3±11.23mm, depth 29.6±17.58mm) were included in the study. Fifty-three patients (M 85%) were treated electively; 18 patients (M 83%) had symptoms (10-56% back/abdominal pain, 2 intestinal occlusions, 2 rectorrhagia, 2 hemorrhagic shock, 1 thoracic pain, 1 unspecified pain) and were treated urgently. Elective and urgent patients had similar characteristic except for Age (Elective:76±7 vs Urgent:81±7 years; p=.03) and ASA score (Elective:3.3±0.5 vs Urgent:3.7±0.5; p=.04). PAU were located in the infrarenal (39 cases-55%), para-visceral (7-10%), and thoracic aorta (10-14%) and in the iliac arteries (15 -21%). No differences among the aortic level presentation was found in the two groups, however there was a significant difference in “depth”(Elective:25.1±17.54mm vs Urgent:42.89±17.67mm; p=.0001) and DIAM (Elective:46.77±19.20mm vs Urgent:64.44±20.17mm; p=.0001) of PAU. All patients were treated by endovascular repair: urgent procedures required more General Anesthesia (Elective:51% vs 78%;p=.003) and more Intensive Care Unit (Elective:49% vs 78%;p=.003). Thirty-day complications occurred in 6 (8%) cases, with one surgical conversion, one iliac occlusion and femoral-femoral crossover bypass, one post-operative nephrectomy and one post-operative dialysis; 30-days mortality occurred in 2 (3%) cases, all in the urgent group (Elective 0% vs Urgent 11%; p=.01). The mean follow-up was 21±20.73 months: 10 cases (14%) had an Endoleak (8 type II, 1 type Ia, 1 very low type III), 2 patients (3%) needed a late Redo (1 Chimney for visceral vessels for proximal aortic rupture, 1 surgical for late anastomotic disruption). There was no difference in the long-term analysis between elective vs urgent treated patients. Conclusion: Endovascular treatment is an effective treatment for PAU; when it is performed electively, perioperative mortality/morbidity is very low with good long term results. Urgent cases have higher mortality rates and need more extensive anesthesiology support, with long-term results similar to non-urgent cases. According to these results, endovascular repair can be proposed as a safe and durable option in patients with PAU and elective repair should be encouraged. Disclosure: Nothing to disclose

Revisiting Vesicourethral Anastomosis during Open Radical Retropubic Prostatectomy; A Simple and Reproducible Technique: A Single Center Experience with 200 Cases.

Vesicourethral anastomosis (VUA) represents a challenging step of open radical prostatectomy (ORP) because of limitation of space in the depth of male pelvis, lack of control on knots during tightening which subse-quently causes inadequate coupling of VUA or breakdown of knots, and also extremely difficult reapplication of sutures. To facilitate this step of ORP, we have developed a simple and reproducible technique and reported our 8-year experience. We used two extra-long DeBakey tissue forceps to approximate the bladder neck to the urethral stump. We found it more beneficial than Babcock clamp especially in obese patients with excess fatty tissue in the pelvic area. In this technique, the surgeon's assistant creates more space for the surgeon's hand by sweeping the fatty tissue away from the anastomotic area and then pushes the reconstructed bladder neck down while the sutures are being tied. We analyzed data from 200 patients with prostatic cancer who underwent open radical prostatectomy performed from 2009 to 2017. There were only 2 sutures disrupted during knot tying. In two cases (1%), drain output was more than 30 mL/day on postoperative day 2 and drainage was left in place for a longer duration. With the help of medications, time voiding and dedicated pelvic floor exercise whenever needed,.the goal of full urinary continence (0- 1 pad/day) was achieved in 85%, 94% and 98% of patients immediately after catheter removal, 3 months and 6 months after surgery, respectively. Eight patients (4%) developed urethral stricture. The surgical technique has been shown to be an independent predictor of urinary continence. We introduce a new simple modification of vesicourethral anastomosis during RP. Using this technique; in addition to reducing anastomotic disruption rate and increasing knot tying control, postoperative urinary continence after ORP may also be improved.