End-to-end Anastomosis Research Articles

Stapled enterectomy reduces surgical time when compared with sutured enterectomy: a retrospective review of 54 cats.

Feline enterectomy is commonly performed in referral and general veterinary practice; however, existing studies in the veterinary literature lack significant case numbers to guide clinical decision-making. In addition, no studies have evaluated the use of surgical staplers in cats for this procedure. This study aimed to compare the use of surgical staplers for functional end-to-end anastomosis (SFEEA) with hand-sewn end-to-end anastomosis (EEA) in cats. Additional aims included investigating the feasibility of surgical staplers in cats as well as assessing short- and long-term complications and outcomes. The medical records of four referral hospitals were retrospectively searched for cats that had undergone enterectomy between 2003 and 2022. Preoperative, intraoperative and postoperative data were compared between the SFEEA and EEA groups, with a median long-term follow-up time of 488 days (interquartile range 255-1030). In total, 54 cats met the inclusion criteria for this study, with 24 undergoing an SFEEA while 30 underwent EEA. There was a significant difference in surgical time between the two groups. The SFEEA group had a mean surgical time 34.3 ± 9.274 mins faster than the EEA group (P <0.001). Unique complications reported for the SFEEA group included haemo abdomen and anastomotic stricture. SFEEA should be considered in cats where anaesthetic time should be kept as short as possible, such as patients with American Society of Anesthesiologists scores of 3-4. Stricture at the anastomotic site may be seen in the long term for cats undergoing SFEEA.

End-to-Side Venous Anastomosis with IJV: Improving Outcomes of Microvascular Anastomosis in Head and Neck Reconstruction.

Background End-to-side (ES) venous anastomosis is an established approach for head and neck reconstruction and has several benefits over conventional end-to-end (EE) anastomosis. However, this is not preferred by all, which may be due to technical preferences for an EE anastomosis by many surgeons. We present here our experience of routine ES venous anastomosis for head and neck reconstruction over the past 8 years. Materials and Methods All consecutive head and neck malignancy patients reconstructed with free flap and our routine ES internal jugular vein (IJV) anastomosis approach between 2015 and 2023 have been included in this study. Flap-related variables are reviewed retrospectively. Results Reconstruction was done with a total of 585 free flaps including 303 radial forearm flaps (RFFs), 143 osteocutaneous fibula flaps (OCFFs), and 139 anterolateral thigh (ALT) flaps. The flap survival rate was 573/585 (97.95%). Re-exploration and salvage rates were 45/585 (7.69%) and 38/45, respectively (84.44%). Conclusion Routine use of ES anastomosis simplifies microvascular anastomosis by avoiding efforts related to the selection of recipient vessels, providing a single large-caliber venous outlet, the favorable geometric orientation of the pedicle, and ease of re-exploration. The vascular anastomosis for RFF, ALT, and OCFF flap is feasible with 7-0 sutures and under 4.5X loupe magnification with this approach quite conveniently with similar outcomes to the reported flap survival rate in the contemporary practice.

The current status and challenges of surgical treatment for chronic Achilles tendon rupture

With the growing demand for physical activity, an increasing number of individuals with chronic Achilles tendon ruptures are opting for surgical intervention. Surgical approaches encompass end-to end anastomosis, tendon flap techniques, tendon transfer procedures, and free tendon grafting, among others. When selecting the appropriate surgical method and determining the surgical indications, it is imperative to consider factors like the length of the Achilles tendon defect, patient age, aesthetic preferences, functional requirements, and local tissue conditions. As medical devices evolve and surgical techniques advance, the criteria for surgical intervention are also evolving. Drawing from existing literature evidence, it becomes crucial to define reasonable parameters for addressing Achilles tendon defects with each surgical technique, aligning more closely with clinical needs. Additionally, auxiliary technologies such as biologic therapy and innovative biomaterials have demonstrated promising results in laboratory or animal models. The focal point of advancing these auxiliary technologies lies in facilitating the translation of pertinent clinical outcomes in the future.

(128) Penile Replantation in Patient with Klingsor Syndrome; Case Report and Review of Literature

Abstract Introduction Penile amputation has multiple etiologies including self-mutilation, work-related accidents, circumcision, assault motivated by jealousy, rage and feelings of betrayal and animal attacks. By far self –mutilation due to underlying psychiatric disorders (Klingsor Syndrome) are the commonest cause. Re-implantation is the gold standard for management, however it may always not be possible to achieve because of significant local ischemia, tissue damage and prolonged duration post trauma. Objective We are reporting our experience with one case of Klingsor Syndrome and its stepwise management. Methods A 31 years old male Schizophrenic patient self-mutilated his penile shaft due to fixed illusion (get rid of devil in his penis). He also attempted to remove his entire scrotum. His father brought his son with the amputated penile part put in ice. Immediate application of wet saline towel to penile stump and putting of amputated penile part into cold iced saline. Anti-tetanic serum was given together with i.v. antibiotics. Urology team, Plastic microsurgery team together with Psychiatry treating consultant all were emergently called at once. Amputated penile shaft was prepared by the microsurgeon to identify the dorsal artery, vein and nerves and marked by micro-bulldogs. Urology team started by fixation of s.p. cath and preparing, cleaning penile stump. End-to end anastomosis of the urethra was done. Next, the corporal bodies, were reattached using interrupted sutures. Dorsal vein and artery were re-anastomosed microsurgically Results Few days post-operatively skin necrosis started inspite of positive needle brick to the glans indicating healthy underlying glans. Second stage debridement of necrotic skin with later skin grafting resulted in cosmetically and functionally excellent penis regarding erectile and voiding functions Conclusions Penile amputation is a rare surgical emergency mostly found in the literature as isolated case reports. Klingsor syndrome is well known etiology for this type of penile injury and warrants psychiatric control. A multidisciplinary approach involving a urologist, micro-vascular surgeons as well as a psychiatrist ensures good outcome. Microvascular re-implantation remains the treatment of choice with the highest probability of adequate cosmetic as well as functional outcomes Disclosure No.

Less invasive bonnet bypass with subcutaneous tunneling method for common carotid artery occlusion - A technical note.

Common carotid artery occlusion (CCAO) sometimes requires vascular reconstruction. Ipsilateral superficial temporal artery (STA)-middle cerebral artery (MCA) bypass is unsuitable due to insufficient blood flow to the external carotid artery. The bonnet bypass, one treatment option for CCAO, requires a long coronal incision and bone groove to prevent malposition and collapse of an interposition graft. However, this long incision might lead to skin complications and reduced collateral blood flow. A 60-year-old man who experienced recurrent ischemic stroke presented with the right internal carotid artery occlusion and left CCAO. The left STA was unavailable; however, both branches of his right STA were well-developed. Minimizing skin invasion was a priority because the patient had diabetes mellitus. We performed a right STA parietal branch - right MCA anastomosis, followed by a right STA frontal branch - left radial artery graft (RAG) - left MCA bonnet bypass using small intermittent skin incisions. We drilled a bone groove extending across the entire length of the interposition graft through the small intermittent skin incisions. Furthermore, we applied a right STA-RAG end-to-side anastomosis instead of an endto-end anastomosis to preserve collateral skin anastomosis. Postoperatively, the bypass remained patent, and the patient was discharged without complications. The bonnet bypass is a potential treatment for CCAO, but the procedure is invasive. Our modified bonnet bypass method enables less invasive management, preventing collapse and malposition of the interposition graft and minimizing skin complications.

From Crafoord’s End-to-End Anastomosis Approach to Percutaneous Interventions: Coarctation of the Aorta Management Strategies and Reinterventions

First described in 1760 by the anatomist Morgagni, coarctation of the aorta (CoA) is a congenital heart defect characterized by narrowing the aorta, typically distal to the left subclavian artery. It accounts for approximately 5–8% of all congenital heart diseases, with an incidence estimated at 4 per 10,000 live births. In 1944, the Swedish surgeon Clarence Crafoord achieved the first successful surgical CoA repair by performing an aortic end-to-end anastomosis on two patients aged 12 and 27 years old. Presently, the most prevalent techniques for surgical repair, particularly in infants and neonates with isolated coarctation, involve resection with end-to-end anastomosis (EEA) and the modified Crafoord technique (extended resection with end-to-end anastomosis (EEEA)). Subclavian flap aortoplasty (SCAP) is an alternative surgical option for CoA repair in patients under two years of age. In cases where the stenosis extends beyond resection and end-to-end anastomosis feasibility, patch aortoplasty (PP) employing a prosthetic patch can augment the stenotic region, especially for older patients. Despite advances in pediatric cardiology and cardiac surgery, recoarctation remains a significant concern after surgical or interventional repair. This comprehensive review aims to provide a thorough analysis of coarctation management, covering the pioneering techniques introduced by Crafoord using end-to-end anastomosis and now extending to the contemporary era marked by percutaneous interventions as well as the recoarctation rate associated with each type.

The impact of circular stapler size on the risk of anastomotic stricture following total mesorectal excision in rectal cancer patients: A retrospective cross-sectional study.

Colorectal cancer (CRC) surgery complications are a major issue affecting morbidity and mortality rates. Anastomotic stricture, which occurs in almost 30% of patients after surgery for rectal cancer, is one of the most serious but underreported side effects. In this study, we tried to assess the effect of stapler size on anastomotic stricture rate. At our facility, all patients underwent low anterior resections (LAR) performed using an open laparotomy technique. A contour-curved stapler and an end-to-end anastomosis (EEA) circular stapler were used in the double stapling technique (DST). All patients also underwent a protective loop ileostomy. Patients who developed stricture following leakage were excluded. This study comprised a total of 173 rectal cancer patients. A 29-mm circle stapler was used to anastomose 77 patients (44.5%), while a 31-mm circular stapler was used to anastomose 96 patients (55.5%). Six individuals experienced strictures; two had a 29 mm stamper and four (4.4%) had a 31 mm one. There was no significant difference between the two groups (p:0.575). On aggregate, 8 patients experienced leakage; 3 (3.8%) of these patients received treatment with a 29 mm stapler, whereas 5 (5.2%) received treatment with a 31 mm stapler. this study found no statistically significant difference in the stricture rates and stapler size. The findings of this study provide credibility to the notion that in rectal cancer patients having LAR, strictures can be safely avoided by performing the anastomoses with both staplers.

Kimura extrathoracic esophageal elongation for the treatment of complex esophageal atresia: Primary versus secondary treatment when other strategies failed

IntroductionThe Kimura´s extrathoracic esophageal elongation (KEEE) procedure uses upper esophageal pouch traction to induce its growth, as an alternative to repair long gap esophageal atresia (LGEA). It can be used as a first option in the neonatal period (primary Kimura) or as a rescue procedure when another strategy fails (secondary Kimura).The aim of our study is to compare the results of the primary versus secondary Kimura procedure after unsuccessful Puri procedure or end-to-end esophageal anastomosis. MethodsThe present work is a retrospective review of patients with complex esophageal atresia (CEA) who underwent Kimura procedure at our institution from 1997 to 2021. We divided the patients into two groups, primary group: patients who underwent primary Kimura extrathoracic esophageal elongation (KEEE), esophagostomized in the first surgical intervention; and secondary group: those who underwent secondary KEEE, esophagostomized due to complications of the primary end-to-end anastomosis (EEA), or due to failure of preservation of native esophagus (PNE) techniques. Demographic variables (gestational age, birth weight, type of esophageal atresia (EA) and associated malformations) and evolution variables related to the elongations and reconstruction (days of mechanical ventilation (MV), days of hospitalization and complications of the anastomosis, feeding/oral aversion, need for nutritional support, gastroesophageal reflux disease (GERD), and mortality) were evaluated. ResultsDuring the 24-year period, 31 patients were evaluated, nine patients belonged to the primary group (of which 7 were reconstructed) and the remaining twenty-two to the secondary group (of which 12 completed the procedure).Regarding demographic variables, there was a statistical difference in gestational age (p = 0.016). Regarding the variables associated with the elongations, there was a statistically significant lower number of elongations (p = 0.0547), longer hospitalization time (p = 0.045) and more complications (p = 0.027) for the secondary group. Regarding the final reconstruction, the primary group had a significantly shorter postoperative hospital stay (p = 0.03), and also fewer days on MV, although these variables did not reach a statistically significant difference.Two patients died before the final reconstruction (one from each group). DiscussionWe believe that KEEE is a useful tool for both primary treatment and rescue in case of failure of other esophageal preservation strategies. In addition, it allows preserving the native esophagus and also performing esophageal replacement strategies with other organs if it fails. Level of evidenceAccording to the Journal of Pediatric Surgery this research corresponds to type of study level III for retrospective comparative study.

Evaluating outcomes among surgeons who changed their technique for gastric bypass: a state-wide analysis from 2011 to 2021.

Technical variation exists when performing the gastrojejunostomy during Roux-en-Y gastric bypass (RYGB). However, it is unclear whether changing technique results in improved outcomes or patient harm. Surgeons participating in a state-wide bariatric surgery quality collaborative who completed a survey on how they perform a typical RYGB in 2011 and again in 2021 were included in the analysis (n = 31). Risk-adjusted 30-day complication rates and case characteristics for cases in 2011 were compared to those in 2021 among surgeons who changed their gastrojejunostomy technique from end-to-end anastomosis (EEA) to either a linear staple or handsewn anastomosis (LSA/HSA). In addition, case characteristics and outcomes among surgeons who maintained an EEA technique throughout the study period were assessed. A total of 15 surgeons (48.3%) changed their technique from EEA to LSA/HSA while 7 surgeons (22.3%) did not. Nine surgeons did LSA or HSA the entire period and therefore were not included. Surgeons who changed their technique had significantly lower rates of surgical complications in 2021 when compared to 2011 (1.9% vs 5.1%, p = 0.0015), including lower rates of wound complications (0.5% vs 2.1%, p = 0.0030) and stricture (0.1% vs 0.5%, p = 0.0533). Likewise, surgeons who did not change their EEA technique, also experienced a decrease in surgical complications (1.8% vs 5.8%, p < 0.0001), wound complications (0.7% vs 2.1%, p < 0.0001) and strictures (0.2% vs 1.2%, p = 0.0006). Surgeons who changed their technique had a significantly higher mean annual robotic bariatric volume in 2021 (30.0 cases vs 4.9 cases, p < 0.0001) when compared to those who did not. Surgeons who changed their gastrojejunostomy technique from circular stapled to handsewn demonstrated greater utilization of the robotic platform than those who did not and experienced a similar decrease in adverse events during the study period, despite altering their technique. Surgeons who chose to modify their operative technique may be more likely to adopt newer technologies.

Lower Extremity Reconstruction with Anterolateral Thigh Free-Flap Anastomoses: A Computational Fluid Dynamic Analysis.

The anterolateral thigh free flap is an option for repairing soft tissue defects of the distal lower extremity. This flap uses the descending branch of the lateral circumflex femoral (LCF) artery as the flap vessel. The recipient vessel in these flaps is often the anterior tibial (AT), posterior tibial (PT), or peroneal (P) arteries. Computational fluid dynamic (CFD) evaluation of anastomoses between these vessels can optimize outcomes. Thirty-eight CFD models were created to model end-to-side (ETS) and end-to-end (ETE) anastomoses for lower extremity reconstruction. Seven out of thirty-eight models represented ETS anastomoses between the LCF and AT arteries with varying anastomotic angles. Nine out of thirty-eight models represented 45-degree ETS anastomoses between varying diameters of the LCF and AT, PT, and P arteries. Nine out of thirty-eight models represented stenosis on the flap vessel and recipient vessel, pre- and post-bifurcation. Nine out of thirty-eight models represented ETE anastomoses, rather than ETS, with varying vessel diameters. Four out of thirty-eight models represented ETE anastomoses with varying regions and levels of stenosis. Stasis of blood flow in ETS models increased as anastomotic angle increased in a logarithmic relationship (R 2 = 0.918). Flow was optimized overall as flap and recipient vessel diameters approached one another. In ETS models, flap vessel and postbifurcation recipient vessel stenosis were found to substantially increase stasis. Selection of flap and recipient vessels with similar diameters can optimize outcomes in microvascular anastomoses. In the context of lower extremity reconstruction with the ALT flap, the PT artery can be recommended as a first-line recipient vessel due to its similar vessel caliber to the LCF and relative ease of surgical access compared with the P artery. Avoidance of areas of stenosis is recommended to ensure laminar flow and reduce the operative difficulty associated with performing anastomoses on nonpliable arteries. Striving for increased acuity of anastomotic angles is recommended to optimize the flow in ETS microvascular anastomoses.

Diverticular disease of the sigmoid colon, complicated by a tubular intestinal fistula of the anterior abdominal wall and cicatricial stricture of the sigmoid colon (case report)

Aim of the study was to consider a clinical example of diverticular disease of the sigmoid colon, complicated by a tubular intestinal fistula of the anterior abdominal wall and cicatricial stricture of the sigmoid colon.Material and methods.Patient B., 76 years old, was admitted to the proctology department with complaints of the presence of a fistula with purulent discharge in the area of the surgical scar. Preoperative examination with MRI, colonoscopy, fistulography revealed diverticular disease of the sigmoid colon, complicated by a tubular intestinal fistula of the anterior abdominalwall and stricture of the sigmoid colon at the level of the internal opening of the fistula.Results.The operation was performed in the following volume - excision of the fistula, resection of the sigmoid colon bearing the fistula, with endto-end anastomosis in the area without diverticula.

Cryopreserved allografts versus end-to-end anastomosis for the reconstruction of a segment-resected portomesenteric vein during advanced pancreatic cancer surgery

BackgroundPorto-mesenteric vein (PMV) infiltration of pancreatic cancer is classified as borderline resectable cancer. For en-bloc resectability, the probability of PMV resection and reconstruction is the most decisive factor. The purpose of this study was to compare and analyze PMV resection and reconstruction during pancreatic cancer surgery using end-to-end anastomosis (EA) and a cryopreserved allograft (AG) and to verify the effectiveness of reconstruction using an AG. MethodsBetween May 2012 and June 2021, 84 patients (65 underwent EA, and 19 received AG reconstruction) underwent pancreatic cancer surgery with PMV reconstruction. An AG is a cadaveric graft with a diameter of 8–12 mm and is obtained from a liver transplant donor. Patency after reconstruction, disease recurrence, overall survival, and perioperative factors were assessed. ResultsThe median age was higher in EA patients (p = .022) and neoadjuvant therapy (p = .02) was more in AG patients. Upon histopathological examination, the R0 resection margin did not show a significant difference by reconstruction method. During a 36-month survival analysis, primary patency was significantly superior in EA patients (p = .004), and there was no significant difference in recurrence-free survival (p = .628) or overall survival (p = .638) rates. ConclusionCompared with EA, AG reconstruction after PMV resection during pancreatic cancer surgery showed a lower primary patency, but there was no difference in recurrence-free or overall survival rates. Therefore, the use of AG can be a viable option for borderline resectable pancreatic cancer surgery if the patient is properly followed-up postoperatively.

The first robotic STORRM: A case report

Abstract Parastomal hernias present a continued challenge to the general surgeon. There are a myriad of techniques available, with hernia recurrence rates varying between 10 to greater than 50%. Mesh reinforcement and underlay or sublay placement are associated with lower hernia recurrence rates. Many patients with parastomal hernia have associated comorbidities which increase their risk for perioperative wound complications. Robotic and minimally invasive techniques offer decreased rate of wound complications, but can be challenging to perform if the stoma needs to be relocated. For patients with complex parastomal hernias requiring abdominal wall reconstruction with transversus abdominis release and retromuscular mesh placement, it can be difficult to align the layers of the abdominal wall and create an aperture in the mesh to allow for a straight passage of the conduit and prevent subsequent angulation of the bowel. Stapled Transabdominal Ostomy Reinforcement with retromuscular mesh, or STORRM technique, has been previously described elsewhere as a technique whereby a circular EEA (End-to-End Anastomoses) stapler is used to create a straight tunnel through the mesh and abdominal wall layers, standardize sizing, fixate the mesh, and substitute traditional cruciate incisions with a stapled reinforcement of the aperture in the mesh/tissues.

Abstract 15015: Long Term Outcomes After Interrupted Aortic Arch Repair: A Study From the Pediatric Cardiac Care Consortium

Introduction: Interrupted aortic arch (IAA) is a congenital heart disease that can be successfully repaired. Children are at risk of multiple procedures and residual abnormalities. We used the Pediatric Cardiac Care Consortium (PCCC) to describe post-repair survival of patients with IAA. Methods: We queried the PCCC for patients receiving IAA repair 1982-2003. Death was ascertained from the PCCC and US National Death Index (NDI) to December 2019. Kaplan Meier (KM) plots and multivariable analysis assessed overall long-term survival and baseline characteristics associated with increased hazard of death post-repair. Results: We identified 380 patients (male 200; female 180) with IAA repair (excluding truncus arteriosus). Most had end-to-end anastomosis (n=234, 83.6%), 87 (31.1%) by interposition graft, and 47 (16.78%) by subclavian or carotid flap. There was no data for 11 patients. A total of 280 survived to discharge. Over a median of 22.9 years (IQR 19.78-27.52 years), 39 died. The 25-year survival post-discharge after repair was 86% (Figure 1). Type B2 IAA (aberrant right subclavian artery) was associated with increased death (aHR=1.814; 95% CI=0.891-3.694) versus non-type B IAA and cases with normal subclavians (A1+B1)) after adjusting for era, sex, presence of chromosomal anomalies, and type of surgery. Interposition graft was associated with increased hazard versus end-to end anastomosis (aHR=1.942; 95% CI=0.946-3.988) or vascular flaps (aHR=1.144; 95% CI=0.456-2.870). Other risk factors were female sex and chromosomal anomalies (DiGeorge syndrome primarily) (aHR = 1.948; 95% CI=0.946-4.011 and aHR=1.090; 95% CI=0.429-2.770). Conclusions: Patients with repaired IAA have decreased long-term survival. Female sex, chromosomal anomalies, type B IAA, aberrant right subclavian artery, and interposition graft were risk factors for poor long-term outcomes. Additional analysis of risk factors for long-term outcomes and causes of death is underway.

Patency rates of hepatic arterial resection and revascularization in locally advanced pancreatic cancer.

Arterial resection (AR) for pancreatic adenocarcinoma is increasingly considered at specialized centers. We aimed to examine the incidence, risk factors, and outcomes of hepatic artery (HA) occlusion after revascularization. We included patients undergoing HA resection with interposition graft (IG) or primary end-to-end anastomoses (EE). Complete arterial occlusion (CAO) was defined as "early" (EO) or "late" (LO) before/after 90 days respectively. Kaplan-Meier and change-point analysis for CAO was performed. HA resection was performed in 108 patients, IG in 61% (66/108) and EE in 39% (42/108). An equal proportion (50%) underwent HA resection alone or in combination with celiac and/or superior mesenteric artery. CAO was identified in 18% of patients (19/108) with arterial IG least likely to occlude (p=0.019). Hepatic complications occurred in 42% (45/108) and correlated with CAO, symptomatic patients, venous resection, and postoperative portal venous patency. CAO-related operative mortality was 4.6% and significantly higher in EO vs LO (p=0.046). Median CAO occlusion was 126 days. With change-point analysis, CAO was minimal beyond postoperative day 158. CAO can occur in up to 18% of patients and the first 5-month post-operative period is critical for surveillance. LO is associated with better outcomes compared to EO unless there is inadequate portal venous inflow.

Cervical Fibroids - Key Surgical Steps

<h3>Study Objective</h3> To review critical steps during robotic assisted total laparoscopic hysterectomy in patients with large cervical fibroids, focusing on tips for safely performing ureterolysis, isolation of uterine vasculature, and colpotomy. <h3>Design</h3> Stepwise demonstration of the technique with narrated video footage. <h3>Setting</h3> Surgery is the primary therapy for cervical leiomyomas, which account for 0.6-2% of uterine fibroids. Cervical fibroids significantly alter anatomy, making a minimally invasive approach prohibitive to many providers. The size and location of the fibroid can cause alterations in ureter course and uterine vasculature, inability to use a uterine manipulator, and deformation of the colpotomy. <h3>Patients or Participants</h3> The first case depicts a patient with a 7.9-cm, midline, cervical fibroid. She received preoperative Leuprolide twice, resulting in a decrease in maximum diameter to 5.5 cm intra-operatively. The second case demonstrates a patient with a 13-cm cervical fibroid on imaging, noted to be at least 15 cm intra-operatively, causing bilateral hydroureters and hydronephrosis. <h3>Interventions</h3> This video demonstrates how to navigate the main challenges afforded by cervical fibroids when performing robotic hysterectomy. It includes how to create the space needed for ureterolysis and demonstrates using the ureter as a tool for navigation in the altered retroperitoneum. It highlights the importance of ligating the uterine arteries at their origin and reflecting the uterine arteries from medial to lateral. Finally, it reviews tips for completing a colpotomy using an end-to-end anastomosis (EEA) sizer as a guide and dynamic tool. <h3>Measurements and Main Results</h3> Both patients did well postoperatively with resolution of their symptoms. The second case had complete resolution of hydroureters and hydronephrosis. <h3>Conclusion</h3> Surgery is the primary therapy for cervical leiomyomas. A minimally invasive approach has proven benefits over open surgery but poses challenges due to distortion of normal anatomy. In the appropriate patient with a large cervical fibroid, robotic and laparoscopic hysterectomy can safely be performed by a skilled minimally invasive surgeon.

Persistent retrograde venous-lymphatic reflux in side-to-end lymphaticovenous anastomosis in a lower extremity with lymphedema: a case report

End-to-end (ETE) and side-to-end (STE) anastomosis are two common configurations of lymphaticovenous anastomosis (LVA); however, it remains inconclusive which method is better. A 62-year-old man with lower extremity lymphedema underwent LVA with the STE method on the ankle. When the lymphatic vessel was cut for additional LVA at the proximal lower leg, blood drained out from the cut end of a lymphatic vessel, which suggested venous-lymphatic reflux at the STE anastomosis at the ankle. Because the reflux continued until 1 hour after the previous LVA at the ankle, the STE anastomosis at the ankle was re-explored and converted to ETE by ligation of the proximal lymphatic vessel. Reverse venous-lymphatic reflux was corrected, and a lymphovenous shunt was created immediately after the ligation. The current case suggests that STE anastomosis can be inferior to ETE anastomosis for creating a lymphovenous shunt when venous backflow exists.

Ileostomy closure

Introduction: Faecal diversion is an effective procedure to protect bowel anastomosis at high risk for leak. Loop ileostomy is more or less acceptable method for faecal diversion. Some concerns still exist regarding the risk for a significant morbidity and complications associated to ileostomy creation itself and moreover to its closure. Surgical expertise and closure techniques are considered potential factors influencing mortality. Aim of the study is to present a single institutional experience with ileostomy closures, in a high-volume training hospital, where ileostomy reversal is mainly performed by young surgeons. Methods: A retrospective study was done to evaluate data of patients who underwent loop ileostomy and ileostomy closure between June 2017 to June 2021 at Dhiraj Hospital Sumandeep Vidyapeeth , Pipariya , vadodara. Ileostomy closure was always done in hand-sewn fashion, performing either a direct closure (DC) or a resection plus end-to-end anastomosis (EEA). Postoperative morbidity was graded according to Clavien-Dindo classification. Outcomes after both methods were compared by Fisher’s exact test and Wilcoxon rank-sum test. Results: Hundred and four patients were included. Ileostomy reversal was performed by EEA in 86 patients (82.69%) and by DC in 18 patients (17.30%). Surgery was performed with a peristomal access in 93 cases (89.42%).

Analysis of Failure Causes of Open Airway Reconstruction in Children With Combined Subglottic and Posterior Glottic Stenosis

Background and Objectives Airway reconstruction surgery in children is still challenging, especially in cases of combined subglottic and posterior glottic stenosis (PGS). The aim of this study was to review the underlying reasons of failure in open airway reconstruction surgeries performed for children with combined subglottic and PGS.Subjects and Method We reviewed medical records of seven children who received more than two open airway reconstruction surgeries to finally achieve and maintain decannulation status for more than one year. Twenty-two reconstructive surgeries were performed and they consisted of 19 laryngotracheal reconstruction (LTR), 2 cricotracheal resection with end-toend anastomosis (CTR) and one extended CTR. For each patient, the following potential causes of failure were evaluated; preoperative evaluation (PE), type of reconstruction (TR), single vs. double staging (SDS), type of stent (TS), and perioperative optimization (PO).Results The median age of patients at the time of surgery was 32 months (range, 4-64 months). Successful decannulation was achieved after the median open surgery of three (range, 2-5 times for each patient). Recognized causes of failure were as follows: 8 insufficient PE, 10 inadequate TR, 3 improper SDS, 8 ill-chosen TS, and 2 inappropriate PO.Conclusion PE of dynamic airway is important, especially vocal fold mobility and tracheomalacia. Types of reconstruction should be carefully decided after full consideration of potential causes of failure, and adequate laryngotracheal stent is essential.

Anastomotic Stricture in End-to-End Anastomosis-Risk Factors in a Series of 261 Patients with Esophageal Atresia.

To assess the risk factors for anastomotic stricture (AS) in end-to-end anastomosis (EEA) in patients with esophageal atresia (EA). With ethical consent, hospital records of 341 EA patients from 1980 to 2020 were reviewed. Patients with less than 3 months survival (n = 30) with Gross type E EA (n = 24) and with primary reconstruction (n = 21) were excluded. Outcome measures were revisional surgery for anastomotic stricture (RSAS) and number of dilatations required for anastomotic patency without RSAS. The factors that were tested for risk of RSAS or dilatations were distal tracheoesophageal fistula (TEF) at the carina in C-type EA (congenital TEF [CTEF]), type A/B EA, antireflux surgery (ARS), anastomotic leakage, recurrent TEF, and Spitz group and congenital heart disease. A total of 266 patients, Gross type A (n = 17), B (n = 3), C (n = 237), or D (n = 9) underwent EEA (early n = 240, delayed n = 26). Early anastomotic breakdown required secondary reconstruction in five patients. Of the remaining 261 patients, 17 (6.1%) had RSAS, whereas 244 patients with intact end to end required a median of five (interquartile range: 2-8) dilatations for anastomotic patency. Main risk factors for RSAS or (> 8) dilatations were CTEF, type A/B, ARS, and anastomotic leakage that increased the risk of RSAS or dilatations from 4.6- to 11-fold. The risk of severe AS is associated with long-gap EA, significant gastroesophageal reflux, and anastomotic leakage.