Anastomotic Leakage Research Articles

Robotic-Assisted Endoluminal Resection of Gastroesophageal Junction Leiomyoma with Transoral Specimen Extraction: Technique, Outcome, and Safety.

Leiomyomas are benign smooth muscle tumors found at the gastroesophageal junction (GEJ) ( Mathew G, Osueni A, Carter YM. Esophageal Leiomyoma. StatPearls. StatPearls Publishing Copyright © 2024, StatPearls Publishing LLC; 2024.). Traditional management often involves total gastrectomy with esophagojejunostomy, a highly morbid procedure that impacts quality of life ( Teh JL, Shabbir A. Resection of Gastroesophageal Junction Submucosal Tumors (SMTs). In: Lomanto D, Chen WT-L, Fuentes MB (eds). Mastering Endo-Laparoscopic and Thoracoscopic Surgery: ELSA Manual. Springer Nature Singapore; 2023. pp. 207-211.). We present a case of a large endophytic GEJ leiomyoma managed with robotic-assisted endoluminal mass resection and transoral specimen extraction. A 46-year-old female with upper abdominal pain was diagnosed with a 9×3 cm lobular leiomyoma at the GEJ via computed tomography and endoscopic biopsy. The tumor was excised using the da Vinci Xi system, with transgastric endoluminal trocar placement. The GEJ defect was closed over a gastroscope, allowing visualization and continuous insufflation. Complete resection was achieved without creating a full-thickness defect. The mass was retrieved transorally with an endoscope, and the defect was repaired to minimize the risk of stenosis. The procedure lasted 236min with minimal blood loss (150mL) and with no complications. Pathology confirmed leiomyoma with negative margins. The patient was discharged on postoperative day 4 on a full liquid diet, requiring no narcotics, and was later advanced to a regular diet. No complications, readmissions, or mortality were reported at the 7-month follow-up. Robotic-assisted endoluminal GEJ mass resection is a feasible, safe technique for large benign tumors, preserving the stomach and GEJ, and thereby obviating lifestyle changes from total gastrectomy. It minimizes the risk of anastomotic leak, stricture, vagus nerve injury, gastroparesis, and reflux (Levine et al. AJR Am J Roentgenol. 157:1189-1194). Closure of the GEJ defect using an endoscope allows for adequate insufflation of the proximal stomach. When feasible, combining transoral specimen extraction enhances the benefits of this minimally invasive approach (Yin et al. Chin Clin Oncol. 13:6).

Safety and feasibility of robotic surgery in geriatric patients with rectal cancer.

The incidence of rectal cancer is increasing in the elderly population, yet the safety of surgical interventions in this group, particularly robotic surgery, is still debated. This study aims to investigate the safety and short-term postoperative outcomes of robotic surgery in geriatric patients (aged ≥ 70years) with rectal cancer. Patients diagnosed with rectal cancer and undergoing robotic surgery between March 2021 and September 2023 were divided into two groups based on age: the elderly group (aged ≥ 70years) and the younger group (aged < 70years), totaling 108 patients. The study included 80 younger patients in group 1 and 28 elderly patients in group 2. The groups had similar gender distribution and tumor characteristics. The elderly group had higher ASA scores and lower albumin levels and underwent the Miles procedure more frequently. The stoma rate was higher in the elderly group. Operation duration, tumor diameter, lymph node dissection numbers, pathological stage, and other histopathological features were similar in the two groups. Postoperative outcomes like hospital stay, complication rates, anastomotic leakage, reoperation rates, unplanned readmissions, and mortality were comparable between the groups. Robotic surgery for rectal cancer in elderly patients is technically feasible and safe. Age should not be a determining factor in patient selection for robotic surgery or be considered a risk factor for postoperative complications.

Employing innovation to enhance the safety and reliability of restorative surgical techniques for patients with familial adenomatous polyposis at a national referral centre.

Restorative proctocolectomy (RPC) and total colectomy with ileorectal anastomosis (TC-IRA) are traditional surgical options for individuals with familial adenomatous polyposis (FAP). Re-appraisal and modification to these techniques, such as near-total colectomy with ileo-distal sigmoid anastomosis (NT-IDSA) and RPC with robotic intracorporeal single-stapled anastomosis (RPC-RiSSA), have been implemented in recent years. This study aimed to evaluate the early postoperative outcomes associated with novel techniques employed in a single centre for restorative surgery in patients with FAP. A retrospective analysis was conducted using data from patients with FAP who underwent prophylactic restorative surgery between January 2008 and December 2022 at St Mark's Hospital. Two hundred fifty-three individuals underwent restorative surgery over the 15-year period; 102/253 (40.3%) underwent TC-IRA, 84 (33.2%) had NT-IDSA, and 67 (26.5%) underwent RPC. Laparoscopic approach was the most common (88.2%) operative access. Seventeen patients (6.7%) underwent robotic operations. For robotic-assisted procedures, no conversions were reported. No anastomotic leaks or 30-day reoperations were reported in the NT-IDSA group compared to 8% (0/84 vs 8/102, p = 0.009) and 11% (0/84 vs 11/102, p = 0.002), respectively, in the TC-IRA group. Regarding RPC, following the introduction of robotic RPC-RiSSA in 2019, no anastomotic leakage was observed compared with 9% (0/11 vs 5/56, p = 0.3) in those undergoing conventional RPC. Our institution has transitioned from TC-IRA to NT-IDSA since 2014 and conventional RPC to RPC-RiSSA in 2019. To date, since refinement of the techniques there have been no anastomotic failures amongst these cohorts. The reported results may offer future horizons for patients undergoing similar procedures for alternative colorectal diseases.

Ghost-ileostomy versus conventional loop ileostomy in patients undergoing low anterior resection for rectal cancer: results of a randomised controlled multicentre pilot trial (DRKS00013997).

The objective of the current pilot trial was to evaluate whether ghost ileostomy is a safe alternative to the current standard of care in terms of a conventional loop ileostomy in patients undergoing low anterior resection with total mesorectal excision (LAR/TME) for rectal cancer. This randomized controlled pilot trial included patients undergoing LAR/TME, randomly assigning them to ghost ileostomy or conventional loop ileostomy intraoperatively. Follow-up spanned 6months, evaluating the following endpoints: comprehensive complication index (CCI), postoperative morbidity, transformation of ghost ileostomy, presence of ostomy at 6months, Wexner score, and quality of life (EORTC QLQ-C30 & CR29). Exploratory statistical analysis based on the intention-to-treat principle was conducted. Recruiting 30 patients from May 2018 to September 2022, the trial was prematurely stopped due to slow recruitment. The mean CCI was comparable between groups at any point of time (at 6months: 30.7 vs. 29.7, p = 0.889). There was no mortality and no need for creation of a terminal ostomy. Anastomotic leakage rates were similar in ghost ileostomy and loop ileostomy groups (p > 0.99). The ghost ileostomy was converted into a conventional loop ileostomy in 6 of 15 (40.0%) patients. Neither postoperative function, nor the overall quality of life showed significant differences. Ghost ileostomy appears as a viable and safe option for selectively deciding ileostomy creation in LAR/TME for rectal cancer. However, challenges in patient selection, excluding those at high risk for anastomotic leakage, limit widespread application and call for optimization in future research. German Clinical Trials Register ( https://drks.de/ ): DRKS00013997; date of registration: April 9th 2018.

Non-Thermal Atmospheric Pressure Plasma as an Adjunct to Intestinal Anastomosis: A Pilot Study on Preventing Anastomotic Leaks

Anastomotic leaks remain a significant challenge in intestinal surgery, often leading to severe complications. This study investigated a novel approach to enhance anastomotic healing and reduce the risk of leaks by combining traditional suturing and stapling techniques with non-thermal atmospheric pressure plasma (NTAPP) application. NTAPP, a cold atmospheric plasma generated through the ionization of ambient air, has been shown to possess antimicrobial, hemostatic, and wound-healing properties. NTAPP promotes sterilization, coagulation, and tissue regeneration by generating reactive oxygen and nitrogen species, potentially strengthening anastomotic union. This pilot study evaluated the efficacy of NTAPP in three patients undergoing intestinal anastomosis. Following the standard surgical procedure, NTAPP was applied directly to the anastomotic site. Postoperative outcomes were monitored for six months, including anastomotic leaks and healing rates. Preliminary results demonstrated promising outcomes. All three patients exhibited successful sealing of the anastomosis, with no evidence of leakage during the follow-up period, providing reassurance and confidence in the potential of sutures, staples, and NTAPP. These findings suggest that NTAPP can significantly improve the safety and efficacy of intestinal surgeries by reducing the incidence of anastomotic leaks. While further research with a larger sample is necessary to confirm these initial findings, the results of this study provide a strong foundation for exploring the potential of NTAPP as a valuable adjunct to conventional surgical techniques for preventing anastomotic leaks. This innovative approach could reduce postoperative complications, improve patient outcomes, and enhance the overall quality of care in intestinal surgery.

In Situ Forming Injectable Gelatin-Based Antibacterial Bioadhesives for Preventing Postoperative Leakage and Abdominal Adhesions.

Postoperative anastomotic leakage (AL) and abdominal adhesions are two major complications after intestinal surgery, with an incidence of 2-25% for AL and 93% for adhesion. Until now, there is no method addressing AL and abdominal adhesions simultaneously. In this work, Bi-PEG-succinimidyl succinate (PEG-NHS), amino-gelatin (Agel) is combined with cefoperazone-sulbactam (SCF) to prepare a multifunctional bioadhesive (SCF/SEAgel) for the postoperative leakage and adhesion prevention. SCF/SEAgel possesses a great sealing capability for tissue, with a bursting pressure of 54kPa. The loaded SCF endows the systems with good antibacterial properties. The in vivo antiadhesion experiments show that SCF/SEAgel possesses better anti-adhesion properties than the commercially used sodium hyaluronate gel. In the cecum leakage model, the SCF/SEAgel effectively seals the leakage with a survival rate of 100%, superior to commercial products (Sainaoning). Meanwhile, it significantly reduces tissue adhesion. Finally, the laparoscopic surgery with dogs shows that the SCF/SEAgel can be injected through minimally invasive surgery, demonstrating its ease of use. Combined with its great biocompatibility, SCF/SEAgel is very promising in intestinal surgery.

An Observational Study on Implication of Postoperative Visceral Edema, Assessed by CT Scan, on Complications Following Bowel Resection and Anastomosis, in a Tertiary Care Hospital in Maharashtra, India

Introduction: Surgeries involving bowel resection and anastomosis are quite common. Fluid overload, leading to tissue edema and impaired tissue perfusion, may contribute to anastomotic leak, which is one of the most dreaded complication. Methods: In our current study, CT scan, done on postoperative day-4, was used to assess visceral edema, and its effect on development of complications post bowel anastomosis and increase in value of cross section of body trunk area ≥20% was taken as an independent risk factor of severe complication. Results: Twenty three patients were enrolled in the study, 7 of them developed complications. The most common complication observed was wound infection (Clavein Dindo grade II). Only 2 patients (28.57%) had an increase in CT area &gt;20%. Among patients who developed complications, 33.3% had an increase in CT area and 28.6% did not. Various other factors – preoperative albumin level, timing of surgery, duration of surgery – also lead to development of complications. Statistically, no significant association could be derived between the increase in CT area and development of complications. Conclusion: As per the findings of the current study, higher fluid balance was not reflected by an increase in body surface area on CT Scan. Hence, use of CT scan as a tool to assess visceral edema needs further evaluation.

Endoscopic vacuum therapy for gastrointestinal transmural defects: a literature review.

Endoscopic vacuum therapy (EVT) has emerged as a transformative approach for managing gastrointestinal (GI) transmural defects, offering a less invasive and more promising alternative to surgery. Initially developed to address anastomotic leaks after rectal surgery, the application of EVT has expanded to include other locations within the GI tract. This review investigated the principles, indications, procedures, outcomes, challenges, and future perspectives of EVT for the management of GI transmural defects. In conclusion, EVT has demonstrated favorable outcomes in GI defect closure, with reduced complications, shortened hospital stay, and decreased morbidity rates as compared with conventional treatments. Although EVT faces challenges in some specific anatomical locations and in managing severe complications such as major bleeding, ongoing advancements in technology and standardization efforts offer promise for broader indications and better outcomes. Future perspectives include exploring novel EVT devices, refining patient selection criteria and pre-emptive applications, and standardizing procedural protocols.

Is It Necessary to Endoscopically Evaluate the Anastomosis in Robotic or Laparoscopic Surgical Procedures for Colorectal Cancer?

Background: In the surgical treatment of colorectal cancers, disease-free survival and life expectancy are inversely proportional to the increase in complications. We evaluated the superiority of colonoscopy and air and water tests in detecting anastomotic leaks in sigmoid and rectosigmoid junction colon cancers. Methods: Data of patients who underwent robotic/laparoscopic surgical procedures for sigmoid and rectosigmoid junctional colon cancers at a single center between January 2018 and February 24 were retrospectively evaluated. The anastomoses were evaluated by intraoperative colonoscopy (IOC) and intraoperative air leak test (IALT), and two groups were formed. Intraoperative leaks, intraoperative repair techniques, and postoperative anastomotic leaks were evaluated. Results: In our study, there were 125 patients in the IOC group and 148 patients in the IALT group, totaling 273 patients. Leakage was detected in 7 patients (4.7%) in the IALT group and 14 patients (11.2%) in the IOC group (P = .06). In the IALT group, 5 of 7 patients were repaired primary, and the anastomosis was reconstructed in 2 patients. In the IOC group, 10 of 14 patients were repaired primary, 2 patients underwent reanastomosis, and 2 patients needed colostomy. Of these 15 patients with postoperative leakage, 4 had intraoperative leakage (2 patients in the IALT group and 2 patients in the IOC group), and all of them underwent primary repair. Conclusion: In the anastomotic evaluation of sigmoid colon and rectosigmoid junction tumors, we found that IOC detected more leaks than IALT, but in these leaks, reanastomosis and/or diversion ostomy was superior to primary repair.

Impact of diversion ileostomy on postoperative complications and recovery in the treatment of locally advanced upper-half rectal cancer.

The efficacy of diversion ileostomy followed by radical surgery for locally advanced upper-half rectal cancer remains uncertain. This study seeks to compare the effectiveness of treatment with and without diversion ileostomy in preventing anastomotic leakage (AL) and to identify a subset who may benefit from diversion ileostomy after AL occurs in Chinese patients with stage II and III upper-half rectal cancer. A retrospective study enrolled a total of 809 patients with locally advanced upper-half rectal cancer between 2017 and 2021, with 27.6% (n = 223) treated with diversion ileostomy and 72.4% (n = 586) treated without diversion ileostomy. The Diversion(+) group (n = 172) and Diversion(-) group (n = 172) were compared for perioperative outcomes through 1:1 propensity score matching (PSM). The selection of variables for multivariable logistic regression was determined through bivariate logistic regression analysis. Additionally, optimal cutoff values for risk factors were identified using ROC curve analysis. Within the entire cohort, patients in the Diversion(+) group exhibited a lower distance from the anal verge (DAV) and higher rates of chemoradiotherapy (CRT), diabetes, cN2 stage, mrCRM positivity, EMVI positivity, and CEA elevation compared to those in the Diversion(-) group. Following PSM, a satisfactory balance of baseline variables was achieved between the two groups. There were no statistically significant differences in AL rates (7.0% vs. 5.8%, p = 0.659) or AL grade distribution (Grade A: 0.6% vs. 0%, Grade B: 5.2% vs. 4.1%, Grade C: 1.2% vs. 1.7%, p = 0.691) between the two groups. However, the Diversion(+) group demonstrated a higher incidence of postoperative complications (30.8% vs. 17.4%, p = 0.004), Clavien‒Dindo III-IV complications (2.9% vs. 2.3%, p = 0.013), particularly wound infections (8.1% vs. 1.2%, p = 0.002), and early postoperative inflammatory small bowel obstruction (EPISBO) (8.7% vs. 1.2%, p = 0.001) compared to the Diversion(-) group. Results from multivariate logistic regression analysis revealed that male gender (OR = 2.354, p = 0.014) was the only independent risk factor associated with AL, while the presence of diversion ileostomy (with vs. without, OR = 1.144, p = 0.686) did not show significant associations. In patients with AL, the onset of the AL was observed to occur later in the Diversion(+) group compared to the Diversion(-) group (7.0 ± 3.3 vs. 3.4 ± 1.4 days, p < 0.001), while the recovery time was significantly shorter (11.3 ± 4.7 vs. 20.3 ± 7.2 days, p < 0.001). Similarly, in Grade C AL patients, the occurence time was delayed in the Diversion(+) group compared to the Diversion(-) group (8.7 ± 4.7 vs. 3.2 ± 1.5 days, p = 0.008), with a shorter recovery time (19.3 ± 2.1 vs. 25.7 ± 6.7 days, p = 0.031). A trend was observed indicating a longer interval before ileostomy restoration in the AL patients compared to the non-AL patients (7.6 ± 4.9 months vs. 5.5 ± 2.9 months, p = 0.079). In addition, DAV (OR = 0.078, p = 0.002) was identified as the only independent factor associated with potential-diversion-benefit in patients with AL, with an optimal cutoff point of 8.6cm. The utilization of diversion ileostomy as a preventative measure for AL in cases of locally advanced upper-half rectal cancer is not universally endorsed due to potential complications such as small bowel obstruction and wound infection. Nevertheless, in the occurrence of AL, diversion ileostomy may prove advantageous for patient recuperation. Particularly, male patients with a DAV ranging from 7 to 8.6cm may experience benefits from undergoing diversion ileostomy subsequent to AL in cases of locally advanced upper-half rectal cancer.

What Is the Role of the Gut Microbiota in Anastomotic Leakage After Colorectal Resection? A Scoping Review of Clinical and Experimental Studies

Background: Anastomotic leakage (AL) still remains a common complication after colorectal anastomosis that leads to increased morbidity and mortality. The gut microbiota has been hypothesized as one of the risk factors associated with anastomotic leakage. The aim of the present study was to summarize all existing clinical and experimental studies that evaluate the impact of intestinal microbiota on anastomotic leakage after colorectal resection. Methods: The present scoping review was designed according to PRISMA recommendations and a systematic search in Medline, Scopus, EMBASE, Clinicaltrials.gov, Google Scholar, and CENTRAL was conducted until September 2024. Results: Overall, 7 clinical and 5 experimental studies were included. A diminished α-diversity of the gut microbiota in patients suffering from AL was demonstrated. Specific microbe genera, such as Lachnospiraceae, Bacteroidaceae, Bifidobacterium, Acinetobacter, Fusobacterium, Dielma, Elusimicronium, Prevotella, and Faecalibacterium, seem to be associated with AL. However, specific genera, like Prevotella, Streptococcus, Eubacterium, Enterobacteriaceae, Klebsiella, Actinobacteria, Gordonibacter, Phocaeicola, and Ruminococcus2, seem to be protective against AL. Experimental studies highlighted that the Western diet seems to affect microbiota diversity and increases the AL rate, whereas anastomotic healing seems to be impaired by high metalloproteinase production and increased collagenase activity. Conclusions: The intestinal microbiota seems to play an important role in anastomotic leakage after colorectal resection. Specific interventions targeting the microbiota’s composition and the pathophysiological mechanisms by which it impairs anastomotic healing could diminish the risk for anastomotic leakage and improve clinical outcomes. However, future studies should be based on prospective design and eliminate heterogeneity.

The Current State of Robot-Assisted Minimally Invasive Esophagectomy (RAMIE): Outcomes from the Upper GI International Robotic Association (UGIRA) Esophageal Registry.

Robot-assisted minimally invasive esophagectomy (RAMIE) is increasingly adopted in centers worldwide, with ongoing refinements to enhance results. This study aims to assess the current state of RAMIE worldwide and to identify potential areas for improvement. This descriptive study analyzed prospective data from esophageal cancer patients who underwent transthoracic RAMIE in Upper GI International Robotic Association (UGIRA) centers. Main endpoints included textbook outcome rate, surgical techniques, and perioperative outcomes. Analyses were performed separately for intrathoracic (Ivor-Lewis) and cervical anastomosis (McKeown), divided into three time cohorts (2016-2018, 2019-2020, 2021-2023). A sensitivity analysis was conducted with cases after the learning curve (> 70 cases). Across 28 UGIRA centers, 2012 Ivor-Lewis and 1180 McKeown procedures were performed. Over the time cohorts, textbook outcome rates were 39%, 48%, and 49% for Ivor-Lewis, and 49%, 63%, and 61% for McKeown procedures, respectively. Fully robotic procedures accounted for 66%, 51%, and 60% of Ivor-Lewis procedures, and 53%, 81%, and 66% of McKeown procedures. Lymph node yield showed 27, 30, and 30 nodes in Ivor-Lewis procedures, and 26, 26, and 34 nodes in McKeown procedures. Furthermore, high mediastinal lymphadenectomy was performed in 65%, 43%, and 37%, and 70%, 48%, and 64% of Ivor-Lewis and McKeown procedures, respectively. Anastomotic leakage rates were 22%, 22%, and 16% in Ivor-Lewis cases, and 14%, 12%, and 11% in McKeown cases. Hospital stay was 13, 14, and 13 days for Ivor-Lewis procedures, and 12, 9, and 11days for McKeown procedures. In Ivor-Lewis and McKeown, respectively, the sensitivity analysis revealed textbook outcome rates of 43%, 54%, and 51%, and 47%, 64%, and 64%; anastomotic leakage rates of 28%, 18%, and 15%, and 13%, 11%, and 10%; and hospital stay of 11, 12, and 12days, and 10, 9, and 9days. This study demonstrates favorable outcomes over time in achieving textbook outcome after RAMIE. Areas for improvement include a reduction of anastomotic leakage and shortening of hospital stay.

Gastro-tracheal fistula following esophageal cancer surgery through the retrosternal route: a case report

BackgroundGastro-tracheal fistula is a rare but serious complication after esophageal surgery, often requiring long-term treatment and invasive procedures. Gastro-tracheal fistula usually occurs through the posterior mediastinal route and rarely through the retrosternal route. No previous reports have described gastro-tracheal fistula after retrosternal route reconstruction was cured by conservative treatment.Case presentationA 70-year-old man with lower thoracic esophageal cancer underwent thoracoscopic esophagectomy in the prone position and gastric tube reconstruction through the retrosternal route with neck anastomosis after neoadjuvant chemotherapy. Despite anastomotic leakage on postoperative day 10, his general condition was stable, and he was managed conservatively with antibiotics and gastric tube decompression. On day 29, he presented with high fever and a gastro-tracheal fistula was observed by esophagography. Conservative management was continued because the patient remained stable. On day 48, esophagography showed that the fistula was undetectable. The patient was able to take fluids orally. He progressed well on an oral diet and was transferred to a different hospital.ConclusionsA gastro-tracheal fistula, although rare, can occur after retrosternal route reconstruction. When a patient is stable, gastro-tracheal fistula after retrosternal route reconstruction may be cured by conservative treatment.

Non-surgical treatment of anastomotic leakage after rectal resection - a case report

Non-surgical treatment of anastomotic leakage after rectal resection - a case report

Drainage Fluid Amylase as a Biomarker for the Detection of Anastomotic Leakage After Low Anterior Resection of Rectal Cancer: A Two-center Study.

This study aimed to investigate the utility of measuring amylase levels in drainage fluid (DFA) for early, non-invasive detection of anastomotic leakage (AL) in undergoing low anterior resection (LAR) for rectal cancer. This prospective observational cohort study analyzed drainage fluid samples from patients who underwent LAR for rectal cancer at two medical centers between February 2021 and December 2023. DFA levels were measured on postoperative days (PODs) 1, 3, and 5. AL was confirmed by clinical evidence and radiological imaging. Statistical analyses were performed to evaluate the diagnostic performance of DFA. Of 120 LAR cases, AL occurred in five (4.16%). DFA levels on POD 3 and 5 were significantly higher in the AL than in the non-AL group (p<0.0001). DFA on POD 5 had the highest diagnostic accuracy for early AL detection, with an area under the curve of 0.99, achieving 100% sensitivity and 99.5% specificity at a cutoff of 846 U/l. A DFA >846 U/l predicted AL with negative predictive and positive predictive values of 83.3% and 100%, respectively, on POD 5. Measuring DFA is a non-invasive, simple and cost-effective method for early AL detection in patients with rectal cancer undergoing LAR. Our findings also suggested that drain placement may be useful for the early detection of AL through DFA measurement.

Evaluating the Impact of Elective Endotracheal Tube Replacement on Postoperative Outcomes in Esophageal Atresia: A STROBE-guided Study

ABSTRACT Background: Elective ventilation and paralysis have been shown to decrease the anastomosis-related complications following primary repair of esophageal atresia (EA). Repeated endotracheal tube (ETT) block and replacement can increase these complications. We evaluated the results of our strategy of electively changing the ETT just before shifting the patient to the postoperative ward for elective ventilation. Materials and Methods: A retrospective study was conducted using the case records of patients from July 2015 to February 2024 including all the patients of EA with tracheoesophageal fistula who underwent primary repair with end-to-end esophageal anastomosis. The patients were divided into two groups Group A: ETT was changed and Group B: ETT was not changed immediately before shifting. The groups were compared for anastomotic leak and ETT tube block in the first 48 h. Results: Ninety-one patients were included in the study, 36 in Group A and 55 in Group B. Elective replacement of ETT decreased the tube block rates in the first 48 h following surgery (P = 0.032). Tension in the anastomosis was associated with a higher leak rate. The leak was present in 58.3% and 3.6% in cases with and without tension in the anastomosis (P = 0.001). Overall, the anastomotic leak was similar in both groups. In the subgroup of patients with anastomosis under tension, the rate of anastomotic leak was higher in patients with ETT block (P = 0.028). Conclusion: Elective replacement of EET decreases the tube block rates and anastomotic leak rates in cases with anastomosis under tension.

Modern approaches and technologies to prevent anastomotic leakage in the gastrointestinal tract

The healing of gastrointestinal anastomoses is acomplex biological process influenced by numerous factors. Various strategies to support healing and prevent anastomotic leakage (AL) exist, encompassing preoperative, intraoperative and postoperative measures. Preoperative interventions aim to optimize the patient and the tissue environment, particularly the gut microbiome. Intraoperative measures are technical in nature and include the choice of surgical access, the anastomotic technique and anastomotic reinforcement. Various procedures of the intraoperative diagnostics enable identification of such anastomoses requiring additional protective measures. Recently, indocyanine green (ICG) fluoroscopy has become established for evaluation of tissue perfusion, while newer techniques such as spectral microscopy offer promising possibilities. Postoperative diagnostic methods aim to identify potential AL as early as possible to enable initiation of therapeutic steps even before the onset of symptoms. These procedures range from various imaging techniques to innovative bioresorbable, pH-sensitive implants for early AL detection. Due to the multifactorial genesis of AL and the diverse technical possibilities, no single method will become established for prevention of AL. Instead, acombination of measures will ultimately lead to optimal anastomotic healing. The use of artificial intelligence and analyses based on the data promises a better interpretation of the vast amount of data and therefore to be able to provide general recommendations.

Anastomotic leakage following surgical resection in the upper gastrointestinal tract

Surgical resection is the consistent component of curative treatment strategies for primary malignant diseases of the stomach and the esophagus. The placement of anastomoses for the necessary reconstruction still accounts for substantial morbidity and in the case of afailure to rescue also for mortality, especially for esophagojejunostomy and esophagogastrostomy. The diagnostics of anastomotic leakage routinely involve computed tomography and endoscopy and timely performance appears to be essential. Endoscopy can simultaneously initiate the essential treatment step. Amajor reason for the improvement of postoperative outcomes after resection in the upper gastrointestinal tract in the last decades is the successful and mostly endoscopically performed management of anastomotic leakage, whereby different endoscopic treatment options are now available. Endoscopic vacuum therapy has become established as the standard, normally with an endoscopic vacuum sponge technique but is also now supplemented by acombination system of vacuum sponge and stent. Furthermore, afoil-coated multiple lumen nasogastric tube represents another available option, which can possibly especially be used as aprophylactic measure. The longest established endoscopic therapy option for anastomotic leaks, the endoluminal metal stent, has been replaced as the standard by the vacuum treatment but is still used in suitable situations. Additionally, there are endoscopic suture devices that are currently only used very occasionally. Surgical revision is always available as treatment escalation but is only recommended for very early occurrences and possibly technically related anastomotic leakage and in the case of failure of endoscopic treatment. This article describes and summarizes the diagnostics and treatment of anastomotic leakages after surgical procedures of the upper gastrointestinal tract.

Lessons learned from 150 total gastrectomies for prevention of cancer.

Prophylactic total gastrectomy (PTG) is performed in carriers of CDH1 pathogenic and likely pathogenic (P/LP) variants and is becoming more frequent with broader use of germline genetic testing. There is an unmet need to standardize care and enhance outcomes in patients undergoing surgery for prevention of gastric cancer. We performed a retrospective analysis of 150 individuals with germline CDH1 P/LP variants who underwent prophylactic total gastrectomy as part of a prospective natural history study from October 2017 to May 2023. All individuals received multidisciplinary, protocolized care before and after total gastrectomy. A total of 150 asymptomatic patients with germline CDH1 P/LP variants underwent prophylactic total gastrectomy with the aid of a multidisciplinary enhanced recovery after surgery pathway. We demonstrated that acute major morbidity (Clavien-Dindo Grade ≥3) was low (11.3%, 17/150) and the most common complication was anastomotic leak (7.3%, 11/150) in the setting of a comprehensive preoperative and postoperative care pathway. Nearly all (88%, 132/150) gastrectomy specimens harbored occult signet ring cell lesions on final pathology. There were no gastric cancer recurrences or gastric cancer-related deaths during the study period with a median overall follow-up of 36 months (IQR 24-48) from gastrectomy. Prophylactic total gastrectomy can be performed with low surgical morbidity in a high-volume center. The delivery of patient-centered care by a multidisciplinary team and application of an enhanced recovery after surgery pathway may improve short-term outcomes. Interventions that can ameliorate the chronic morbidity associated with total gastrectomy, however, warrant further study.

Configuration of anastomotic doughnuts of stapled anastomoses in upper gastrointestinal surgery is associated with anastomotic leakage

Configuration of anastomotic doughnuts of stapled anastomoses in upper gastrointestinal surgery is associated with anastomotic leakage