Hand-sewn Anastomosis Research Articles

Assessment of colorectal anastomosis perfusion with confocal laser endomicroscopy − an experimental study

Introduction: Early diagnosis of complicated healing of colorectal anastomosis can increase the chance for salvage surgery and thus reduce overall morbidity. Confocal laser endomicroscopy (CLE) enables in vivo assessment of tissue perfusion without disturbing its integrity. This experimental study evaluates the potential of CLE for postoperative monitoring of colorectal anastomosis. Methods: A hand-sewn colorectal anastomosis was performed in 9 pigs. The animals were subsequently divided into groups with normal (N=3) and ischemic anastomosis (N=6). Microscopic signs of hypoperfusion were evaluated postoperatively at regular intervals using CLE. Results: Uneven saturation of the images was evident in the group with ischemic anastomosis. The epithelium had inhomogeneous edges and more numerous crypt branching was visible. Tissue oedema quantified as the number of crypts per visual field was already more extensive at the first measurement after induction of ischemia. There was also a significant difference between the values measured before and 10 minutes after ischemia – 8.7±1.9 vs. 6.0±1.1 (p=0.013). Conclusion: Postoperative monitoring of the colorectal anastomosis using CLE enables prompt detection of perfusion disorders.

S100 Long-Term Outcomes of S-Pouch Configured Ileal Pouch-Anal Anastomosis

Background: The ileal pouch-anal anastomosis (IPAA) is the gold standard for restoration of intestinal continuity after a total proctocolectomy, with the J-pouch most commonly used. S-pouches are more recently infrequently performed, and often in the setting of mesenteric length problems. We analyzed the indications and outcomes of S-pouches in the prior to and since the 21st century. Methods: A prospectively maintained pouch database (1983 - 2015) was queried to identify patients with an S-pouch with underlying inflammatory bowel disease. The cohort was stratified into groups based on the time of operation: before 2000 (group 1) and after 2000 (group 2). Patients’ demographics, postoperative complications, cumulative Kaplan – Meier pouch survival, function, and quality of life (QoL) were analyzed. Results: A total of 349 patients were identified: group 1 – 314 patients and group 2 – 35 patients. The median follow-up in group 1 was 12 years (16-24) vs 4 (2-10) years in group 2 (P < 0.001). Patients were comparable in terms of age, gender, BMI, and ASA scores (all p>0.05). The histopathological diagnoses were also similar in group 1 (UC 77%, CD 10%, IC 13%) vs group 2 (UC 65%, CD 6%, IC 29%), P = 0.07. The median preoperative duration of IBD was significantly longer in group 2: 11(4 - 18) years vs group 1: 7 (3-11), P < 0.001. Group 1 was treated with steroids more (62% vs 25%, P < 0.001). The majority underwent colectomy for medically refractory disease; however, dysplasia was present more in group 2 (28% vs 14%), P < 0.001. After 2000, the 3-stage approach was utilized more frequently: 18.5% vs 31%; P = 0.01. Single-stage IPAA were more common in group 1 (5% vs 0%), while handsewn anastomoses were more common in group 2: 69% vs 36%, P = 0.003. The majority had challenges reaching the pelvis leading to S-pouch creation with 37% patients in group 2 sighting bulky and short mesentery due to obesity and had proximal stoma creation. The median hospital length of stay was significantly longer in the group 1: 9 (8-11) days compared to group 2: 5 (4-6.5) days, P < 0.001. The overall morbidity was similar between the groups (group 1 vs group 2, 85% vs 74%, P = 0.12). There were significantly more anastomotic separations in group 2: 25% compared to group 1 (5%), P = 0. 001. The rates of anastomotic stricture and fistula were comparable. The estimated Kaplan-Meier pouch survival was better in group 1 compared to group 2: at 1-year (99% vs 90%), 5-years (96% vs 85%), and at 10-years (94% vs 85.3%), respectively, P = 0.001. The number of stools were also comparable between the groups, group 1 vs 2: 6 (4-9) vs 6 (5-9), P = 0.81. The quality of life did not differ in group 2 vs 1: 0.7 (0.6 – 0.9) vs 0.8 (0.7 – 0.9), P = 0.18. Conclusion(s): S-pouches are less frequently used since 2000, with more recent S-pouch construction showing higher rates of leak and pelvic sepsis yet allowing adequate reach to allow pouch construction in most patients.

Development and Initial Assessment of a Novel and Customized Bile Duct Simulator for Handsewn Anastomosis Training.

Simulation-based medical education allows for the training and maintenance of healthcare skills in a safe and controlled environment. In this technical report, the development and initial evaluation of a bile duct anastomosis simulator are described. The simulator was developed using additive manufacturing techniques such as three-dimensional (3D) printing and silicone work. The final product was produced by maxSIMhealth, a research lab at Ontario Tech University (Oshawa, ON, Canada), and included four individual silicone bile ducts, based on the expert opinions from surgeons at the Centre Hospitalier de l'Université de Montréal (Montreal, QC, Canada), and a 3D-printed maxSIMclamp, which was described in a previous report. The evaluation was conducted by nine individuals consisting of surgeons, surgical residents, and medical students to assess the fidelity, functionality, and teaching quality of the simulator. The results from the evaluation indicate that the simulator needs to improve its fidelity by being softer, thinner, and beige. On the other hand, the results also indicate that this simulator is extremely durable and can be used as a training tool for surgical residents with some minor improvements.

Minimally Invasive Hand-Sewn Barbed Anastomosis After Total and Near-Total Gastrectomy: Standardized Azagra’s Technique

Minimally Invasive Hand-Sewn Barbed Anastomosis After Total and Near-Total Gastrectomy: Standardized Azagra’s Technique

Entrapment of a jejunocecostomy anastomosis in the epiploic foramen in a horse

A mare aged 9 years underwent surgical correction of a small intestinal volvulus using a side-to-side, hand-sewn jejunocecal anastomosis. Nine months after the jejunocecostomy, the horse developed colic signs and ultrasonographic examination revealed gas in the large colon in the upper right flank region and several enlarged loops of the small intestine in the lower right flank area. The differential diagnosis was right dorsal displacement of the large colon or small intestinal strangulation. The exploratory celiotomy found epiploic foramen entrapment (EFE) of the jejunocecostomy anastomosis, including parts of the distal jejunum and cecum. Manual reduction of herniation of the bowel in the epiploic foramen (EF) was impossible and the horse was euthanized. The postmortem gross finding revealed the enlarged edematous at the distal end of the jejunum and the initial body portion of the cecum had passed into the EF in the right-to-left (antegrade) direction. To the authors’knowledge, this is the first report of the antegrade epiploic foramen entrapment of a jejunocecostomy bowel part and this may be one of the complications encountered during the long-term survival period of a surgical jejunocecostomy in horses.

Anastomotic Leak in Ovarian Cancer Cytoreduction Surgery: A Systematic Review and Meta-Analysis.

Anastomotic leaks (AL) following ovarian cytoreduction surgery could be detrimental, leading to significant delays in commencing adjuvant chemotherapy, prolonged hospital stays and increased morbidity. The aim of this study was to investigate risk factors associated with anastomotic leaks after ovarian cytoreduction surgery. The MEDLINE (via PubMed), Cochrane Library, EMBASE and Scopus bibliographical databases were searched. Original clinical studies investigating risk factors for AL in ovarian cytoreduction surgery were included. Eighteen studies with non-overlapping populations reporting on patients undergoing cytoreduction surgery for ovarian cancer (n = 4622, including 344 cases complicated by AL) were included in our analysis. Patients undergoing ovarian cytoreduction surgery complicated by AL had a significantly higher rate of 30-day mortality but no difference in 60-day mortality. Multiple bowel resections were associated with an increased risk of postoperative AL, while no association was observed with body mass index (BMI), American Society of Anesthesiologists (ASA) score, age, smoking, operative approach (primary versus interval cytoreductive, stapled versus hand-sewn anastomoses and formation of diverting stoma), neoadjuvant chemotherapy and use of hyperthermic intraperitoneal chemotherapy (HIPEC). Multiple bowel resections were the only clinical risk factor associated with increased risk for AL after bowel surgery in the ovarian cancer population. The increased 30-day mortality rate in patients undergoing ovarian cytoreduction complicated by AL highlights the need to minimize the number of bowel resections in this population. Further studies are required to clarify any association between neoadjuvant chemotherapy and decreased AL rates.

Impact of Rater Training on Residents Technical Skill Assessments: A Randomized Trial

The ACS/APDS Resident Skills Curriculum's Objective Structured Assessment of Technical Skills (OSATS) consists of task-specific checklists and a global rating scale (GRS) completed by raters. Prior work demonstrated a need for rater training. This study evaluates the impact of a rater-training curriculum on scoring discrimination, consistency, and validity for handsewn bowel anastomosis (HBA) and vascular anastomosis (VA). A rater training video model was developed, which included a GRS orientation and anchoring performances representing the range of potential scores. Faculty raters were randomized to rater training or no rater training and were asked to score videos of resident HBA/VA. Consensus scores were assigned to each video using a modified Delphi process (Gold Score). Trained and untrained scores were analyzed for discrimination and score spread and compared to the Gold Score for relative agreement. Eight general and eight vascular surgery faculty were randomized to score 24 HBA/VA videos. Rater training increased rater discrimination and decreased rating scale shrinkage for both VA (mean trained score: 2.83, variance 1.88; mean untrained score: 3.1, variance 1.14, p = 0.007) and HBA (mean trained score: 3.52, variance 1.44; mean untrained score: 3.42, variance 0.96, p = 0.033). On validity analyses, a comparison between each rater group vs Gold Score revealed a moderate training impact for VA, trained κ=0.65 vs untrained κ=0.57 and no impact for HBA, R1 κ = 0.71 vs R2 κ = 0.73. A rater-training curriculum improved raters' ability to differentiate performance levels and use a wider range of the scoring scale. However, despite rater training, there was persistent disagreement between faculty GRS scores with no groups reaching the agreement threshold for formative assessment. If technical skill exams are incorporated into high stakes assessments, consensus ratings via a standard setting process are likely a more valid option than individual faculty ratings.

Comparison of hand-sewn and circular stapled esophagogastric anastomoses in the neck after esophagectomy for thoracic esophageal cancer: a propensity score-matched analysis.

Esophagectomy is a highly invasive surgical procedure; however, anastomotic leakage is one of the major surgical complications that should be prevented. Institutions have their own inherited or specialized anastomosis methods. The superior anastomosis procedure remains unknown despite the many studies to determine the optimal method. The present study enrolled 341 patients who underwent esophagectomy at Keio University Hospital, Tokyo, Japan, between January 2009 and January 2019. The anastomosis method was changed from circular stapled anastomosis to hand-sewn anastomosis in February 2014 to reduce the risk of anastomotic leakage. We retrospectively compared short-term results (anastomotic leakage and stricture) between hand-sewn and circular stapled anastomoses. Analysis of heterogeneity after propensity score matching between the 107 patients in the hand-sewn anastomosis group and 107 patients in the circular stapled anastomosis group revealed almost equal distributions. The incidence rate of anastomotic leakage was significantly lower in the hand-sewn anastomosis group than in the circular stapled anastomosis group (9 vs. 20%, hazard ratio: 2.521; 95% confidence interval: 1.112-5.716; P = 0.027). No significant difference was found in the incidence of anastomotic stricture (16 vs. 18%, P = 0.844). Furthermore, no significant difference was found in the incidence of anastomotic leakage in any of the tumor locations between the two anastomosis procedures. For esophagogastric anastomosis in the neck after esophagectomy, hand-sewn anastomosis is superior to circular stapled anastomosis with regard to reducing the risk of anastomotic leakage.

Influence of interrupted versus continuous suture technique on intestinal anastomotic leakage rate in patients with Crohn’s disease — a propensity score matched analysis

PurposeIntestinal anastomosis is a crucial step in most intestinal resections, as anastomotic leakage is often associated with severe consequences for affected patients. There are especially two different techniques for hand-sewn intestinal anastomosis: the interrupted suture technique (IST) and the continuous suture technique (CST). This study investigated whether one of these two suture techniques is associated with a lower rate of anastomotic leakage.MethodsA retrospective review of 332 patients with Crohn’s disease who received at least one hand-sewn colonic anastomosis at our institution from 2010 to 2020 was performed. Using propensity score matching 183 patients with IST were compared to 96 patients with CST in regard to the impact of the anastomotic technique on patient outcomes.ResultsOverall anastomotic leakage rate was 5%. Leakage rate did not differ between the suture technique groups (IST: 6% vs. CST: 3%, p = 0.393). Multivariate analysis revealed the ASA score as only independent risk factor for anastomotic leakage (OR 5.3 (95% CI = 1.2–23.2), p = 0.026). Suture technique also showed no significant influence on morbidity and the re-surgery rate in multivariate analysis.ConclusionOur data suggest that the chosen suture technique (interrupted vs. continuous) has no influence on postoperative outcome, especially on anastomotic leakage rate. This finding should be confirmed by a randomized controlled trial.

S2112 Receptive Anal Intercourse in IBD Patients: Impact on Treatment of Anorectal Disease

Introduction: Receptive anal intercourse (RAI) is a common practice both among men and women. For patients with medically refractory ulcerative colitis (UC) or UC with dysplasia who practice RAI,, it has been cited anecdotally as a reason not to pursue IPAA surgery. There remains a lack of formal studies investigating the true extent of and impact of RAI on IBD patients who have anorectal disease. Case Description/Methods: A 40-year-old man with a 15-year history of pancolonic UC presented with worsening abdominal pain and hematochezia. Flexible sigmoidoscopy revealed Mayo 3 inflammation. Stool infectious studies were negative and he was started on 40 mg of prednisone tapered over 8 weeks. Due to a history of treatment failure with infliximab, vedolizumab was started as an outpatient. He had clinical response but his symptoms worsened when prednisone was decreased below 20 mg. Despite 2 consultative visits with colorectal surgery, he refused an elective total colectomy with IPAA. He presented a year later with a UC flare despite being on continuous prednisone. After a week of intravenous steroids, inpatient flexible sigmoidoscopy still showed Mayo 3 inflammation. Urgent colectomy with IPAA was recommended. Despite being known to our health system for over one year, he admitted to regularly practicing RAI for the first time and state that was the reason he declined IPAA surgery. Biopsies from his flexible sigmoidoscopy revealed CMV infection, and he has treated with valacyclovir. His symptoms eventually remitted and he was successfully weaned off prednisone. He continues to be on maintenance vedolizumab. Discussion: Our case presents several major challenges in caring for IBD patients who practice RAI. Due to the social stigma associated with it, some patients may be reluctant to discuss with their providers how RAI impacts their overall health. In some instances, the patients instead rely on non-medical sources of information. There is lack of consensus in the surgical literature and anecdotally on whether RAI is permissible after IPAA surgery. Conceivably, a hand-sewn anastomosis may be the technique of choice compared to stapled anastomosis to allow for continued RAI practice after IPAA surgery. Additional considerations and discussion may be needed when deciding the pouch length. Overall, IBD patients who practice RAI represent an under-studied population with likely specialized medical and surgical needs.

Outcome Comparison of Stapled Versus Hand-Sewn Anastomosis in Elective Gastrointestinal Surgeries

Bowel loop anastomosis is considered as major part of elective gastrointestinal surgeries. The anastomotic procedures being used now a days include hand sewn and stapled anastomosis. For appropriate gastrointestinal anastomosis, many factors should be considered such as intraoperative duration, restoration of blood supply, restoration of normal function of gastrointestinal tract and decrease tissue damage. Objective: The objective of the study was to compare the outcome of stapler and hand sewn anastomosis in elective gastrointestinal surgeries. Methods: Cross-sectional observational study conducted in department of surgery, Sheikh Zayed Hospital, Rahim Yar Khan from May 1, 2021 to August 31, 2022. Total 60 patients included in study and outcome variables such as anastomotic integrity, duration of procedure, post-operative hospital stay and return of bowel activity compared in hand sewn and stapled anastomosis. Results: The study included total 60 patients out of which 38 (63.33%) underwent stapled anastomosis and 22 (36.66%) underwent hand sewn anastomosis. Age (P value: 0.373), gender (p value: 0.372), anastomotic site (p value: 0.284) and return of bowel activity (p value: 0.331) did not show statistically significant difference between two groups. Anastomotic integrity (p value: 0.025), duration of procedure (p value: 0.002), post-operative hospital stay (p value: 0.037) show statistically significant difference between hand sewn and stapled anastomosis. Conclusions: Stapled anastomosis has better anastomotic integrity, reduced duration of procedure and decreased post-operative hospital stay as compared to hand sewn anastomosis with statistically significant difference between two groups.

Objective metrics for hand-sewn bowel anastomoses can differentiate novice from expert surgeons.

Assessing performance automatically in a virtual reality trainer or from recorded videos is advantageous but needs validated objective metrics. The purpose of this study is to obtain expert consensus and validate task-specific metrics developed for assessing performance in double-layered end-to-end anastomosis. Subjects were recruited into expert (PGY 4-5, colorectal surgery residents, and attendings) and novice (PGY 1-3) groups. Weighted average scores of experts for each metric item, completion time, and the total scores computed using global and task-specific metrics were computed for assessment. A total of 43 expert surgeons rated our task-specific metric items with weighted averages ranging from 3.33 to 4.5 on a 5-point Likert scale. A total of 20 subjects (10 novices and 10 experts) participated in validation study. The novice group completed the task significantly more slowly than the experienced group (37.67 ± 7.09 vs 25.47 ± 7.82min, p = 0.001). In addition, both the global rating scale (23.47 ± 4.28 vs 28.3 ± 3.85, p = 0.016) and the task-specific metrics showed a significant difference in performance between the two groups (38.77 ± 2.83 vs 42.58 ± 4.56 p = 0.027) following partial least-squares (PLS) regression. Furthermore, PLS regression showed that only two metric items (Stay suture tension and Tool handling) could reliably differentiate the performance between the groups (20.41 ± 2.42 vs 24.28 ± 4.09 vs, p = 0.037). Our study shows that our task-specific metrics have significant discriminant validity and can be used to evaluate the technical skills for this procedure.

Esophageal magnetic compression anastomosis in dogs.

BACKGROUNDMagnetic compression anastomosis (MCA) is a novel suture-free reconstruction of the digestive tract. It has been used in gastrointestinal anastomosis, jejunal anastomosis, cholangioenteric anastomosis and so on. The traditional operative outcomes of congenital esophageal atresia and benign esophageal stricture are poor, and there are too many complications postoperatively.AIMTo test MCA technology to reconstruct the esophagus in dogs, prior to studying the feasibility and safety of MCA in humans.METHODSThirty-six dogs were randomized into either the study or control group (n = 18 per group). The dogs in the study group were subjected to end-to-end esophageal anastomosis with the magnetic compression device, while those in the control group underwent hand-sewn anastomosis with 4-0 absorbable multifilament Vicryl. We used interrupted single-layer inverting sutures. The anastomosis time, gross appearance, weight and pathology of the anastomosis were evaluated at one month, three months and six months postoperatively.RESULTSThe anastomosis time of the MCA group was shorter than that of the hand-sewn group (7.5 ± 1.0 min vs 12.5 ± 1.8 min, P < 0.01). In the MCA group, X-ray examination was performed every day to locate the magnetic device in the esophagus before the magnetic device fell off from the esophagus. In the hand-sewn group, dogs did not undergo X-ray examination. One month after the surgeries, the mean weight of the dogs in the hand-sewn group had decreased more than that of the dogs in the MCA group (11.63 ± 0.71 kg vs 12.73 ± 0.80 kg, P < 0.05). At 3 mo and 6 mo after the operation, the dogs’ weights were similar between the two groups (13.75 ± 0.84 kg vs 14.03 ± 0.82 kg, 14.93 ± 0.80 kg vs 15.44 ± 0.47 kg). The number of inflammatory cells in MCA group was lower than that in hand-sewn group on 1 mo after operation.CONCLUSIONMCA is an effective and safe method for esophageal reconstruction. The anastomosis time of the MCA group was less than that of the hand-sewn group. This study shows that MCA technology may be applied to human esophageal reconstruction, provided these favorable results are confirmed by more publications.

Robotic vs laparoscopic approach for single anastomosis duodenal-ileal bypass with sleeve gastrectomy: a propensity score matching analysis

Biliopancreatic diversion with duodenal switch and single anastomosis duodenal-ileal bypass with sleeve gastrectomy (SADI-S) are technically demanding hypo-absorptive bariatric procedures. They are often indicated in superobese patients (BMI ≥ 50 kg/m2), as robotic platform could improve ergonomics against a thick abdominal wall, preventing bending of instruments and simplifying hand-sewn anastomoses. We aimed to report our experience with robotic SADI-S (R-group) and to compare outcomes with the laparoscopic (L-group) approach. Among 2143 patients who underwent bariatric procedures at our institution between July 2016 and June 2021, 116 (5.4%) consenting patients were scheduled for SADI-S as primary or revisional procedure: 94 L-group, 22 R-group. R-group and L-group patients were matched using PSM analysis to overcome patients selection bias. Postoperative complications, operative time (OT), post-operative stay (POS) and follow-up data were compared. After PSM, 44 patients (22 patients for each group) were compared (Chi-square 0.317, p = 0.985). Median age, gender, median BMI, preoperative rates of comorbidities, previous abdominal bariatric and non-bariatric surgeries and type of surgical procedures (SADI-S/SADI) were comparable. Median OT was shorter in the L-group (130 Vs 191 min, p < 0.001). 30-days’ re-operative complications and late complications rates were comparable. At 25-months’ mean follow-up, the median Percentage Excess Weight Loss (72%) was comparable between the groups (p = 0.989). L-group and R-group were comparable in terms of re-operative complication rate and short-term outcomes. The robotic platform may increase the rate of single step procedure in challenging cases. Larger studies with longer follow-up and cost-analysis are necessary to draw definitive conclusions.

575. MANUAL LAYER EMBEDDED ANASTOMOSIS: A NEW TECHNIQUE TO REDUCE ANASTOMOSIS LEAKAGE AFTER ESOPHAGECTOMY

Abstract The suturing after esophagectomy includes mechanical anastomosis and hand-sewn anastomosis. At present, various of anastomosis methods with potential anastomosis leakage, the optimal anastomosis methods still remain debates. This study described a new technique for creation of an anastomosis in thought to reduce the incidence of anastomosis leakage. Between September 2020 to December 2021, the patients who received this new anastomosis technique enrolled into this retrospective study. The anastomosis method as follows. Firstly, the gastric conduit was shaped secondary to get adapt embedded length and anger. Secondary, the embedded posterior wall was sutured and layer sew anastomosis. And then, embedded the anastomosis after layer sew into gastric tube and suture the embedded anterior wall lastly. And the anastomosis was pushed into thorax from neck to ended this anastomosis procedure. A total of 56 patients enrolled into this study comprised 51 males and 5 females with mean age of 65.4 years. Among of them 9 patients received neoadjuvant therapy. And all of them performed minimally invasive surgery by thoracoscope combined laparoscopic. The median intraoperative blood loss volume was 79.8ml (range 20-150ml). The median operate time was 331 minutes (range 220-465 minutes). The median postoperative feeding time was 6.3 days (range 3-8 days). All the patients without anastomosis leakage. The incidence of anastomotic stricture and the acid reflux ration were lower than the average of literature reports. This new manual layered embedded esophagogastric anastomosis significantly reduce the incidence of anastomosis leakage and stricture, prevent the acid reflux. This technique has good short outcome and suitable for popularization and application.

587. ROLE OF THORACOSCOPIC HAND-SEWN ESOPHAGO-GASTRIC ANASTOMOSIS IN 2-STAGE TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY. REPORT OF 200 CONSECUTIVE CASES

Abstract Esophagectomy is the mainstay of treatment of esophageal and gastro-esophageal junction cancer. Minimally invasive esophagectomy has been introduced in the 2000s in an effort to reduce post-operative pulmonary and cardiac complications. 2-stage totally minimally invasive esophagectomy combines laparoscopic abdominal phase followed by thoracoscopic thoracic phase. The rate limiting step of the procedure is the construction of esophago-gastric anastomosis. We aim to present our technique and results on hand-sewn thoracoscopic esophago-gastric anastomosis in prone position. This is prospective analysis of consecutive patients that underwent 2-stage totally minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers. All operations were identical in terms of patient positioning, lymphadenectomy and type of anastomosis formed. Study included adult patients with no upper age limit (&amp;gt;18 years); all hybrid esophagectomies, esophagectomies for malignancy and emergency operations were excluded from the study. The anastomosis was manually facilitated thoracoscopic in prone position, in 2-layers, using barbed sutures. Primary endpoints were anastomotic leakage and anastomotic stricture rate. Secondary endpoints were 30- and 90-day mortality rates. During a 5-years-period, n=200 consecutive patients underwent 2-stage totally minimally invasive esophagectomy for cancer. Most patients were males. Median age was 65.5 years. Median operative time was 280 minutes while median suturing time for the anastomosis was 50 minutes. Anastomosis was thoracoscopic, hand-sewn constructed in prone position in all cases. There was no conversion to open. Anastomotic leak complicated n=5 patients (2.5%); n=4 were type I anastomotic leaks and n=1 was type I, which was treated with chest drainage. Anastomotic stricture was presented in n=13 patients (6.5%). 30-day mortality rate was 1% and 90-day mortality rate was 2.5%. Formation of the esophago-gastric anastomosis is one of the most challenging aspects during 2-stage totally minimally invasive esophagectomy. Most surgeons prefer the construction using circular or linear staplers. Our anastomotic technique, present a safe and effective anastomosis, with favorable clinical outcomes. It can be reproduced and established in the hand of experts, offering all the advantages of manual anastomosis and reduction of devastating post-operative anastomotic leakage, which still complicates stapled constructed anastomosis with significant incidence.

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

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

Exploring the learning curve of a new robotic microsurgical system for microsurgery

SummaryRobotic systems have recently been introduced into micro- and supermicrosurgery showing potential benefits for reconstructive surgery. After showing the feasibility and safety of using the Symani Surgical System® for lymphatic microsurgical procedures in humans, we present the results of the first twenty-two patients operated with the robot. The main goal of the study was to determine the learning curve using the Symani Surgical System® . In addition, we aimed at exploring the potential of robot-assisted anastomosis for lymphatic, free flap, and nerve reconstruction and defining the advantages and drawbacks of implementing the system into our daily routine. The operating times were compared between robotic-assisted and hand-sewn anastomoses. Moreover, outcomes and complications were recorded. In this first patient series, anastomotic times were significantly faster with the hand-sewn technique (14.1±4.3 min) when compared with the robot-assisted technique (25.3±12.3 min; p<0.01). However, the learning curve was very steep, and the time needed to perform the anastomosis has been consistently decreasing over time to the point where in the last operations, the times to perform particularly lympho-venous anastomoses were comparable between the two groups. Based on our experience up to date, robot-assisted surgery shows a promising potential in opening up new frontiers in reconstructive microsurgery, e.g., the reliable performance of anastomoses on even smaller blood and lymphatic vessels or on structures deeper within the body cavities, e.g., the thoracic duct.

CLINICAL OUTCOMES OF REVERSAL OF HARTMANN’S PROCEDURE

Background. Reversal of Hartmann’s procedure (HP) is one of the most complex surgical interven­tions in abdominal surgery with high morbidity rates of up to 58% in the patients after HP and mortality of up to 3.6%. Objective. This was a retrospective observational study to analyze the Hartmann’s reversal (HR) outcomes. Methods. The study involved 31 patients (16 males and 15 females), average age 59.6±10.31 (range 26-80), who underwent HR at Ternopil Regional Hospital in 2010 - 2021. The reasons for the HP were: cancer in 20 (64.5%) cases, perforation of the diverticulum – 6 (19.3%), traumatic rupture – 3 (9.7%) and Crohn’s disease - 2 (6.4%) cases. Results. Median time from Hartmann’s procedure to reversal was 11.13±9.24 months (interval 3-38). Intraoperative time was 210.33±56.91 minutes (range 120-330). HR was performed in 30 (96.8 %) patients. Dense pelvic adhesions of the stump of the rectum was diagnosed in 13 (41.9%) patients. Hand-sewn anastomosis was performed for 22 (71%) patients, stapler anastomosis – 4 (12.9%), pull-through technique – 3 (9.7%) patients. AL occurred in 3 (9.7%) patients on the 15th, 23rd and 35th postoperative days. pseudomembranous colitis was diagnosed in 2 (6.4%) patients with AL. The mortality rate was 1 (3.3%) as a result of septic complications due to AL; this case was not operated by a colorectal surgeon due to administrative issue in the hospital. Conclusions. Hartmann’s reversal is still one of the most difficult operations in colorectal surgery with high incidence of postoperative complications. Sound selection of patients with low comorbidity and in suitable time period is crucial for successful HR.

Stapled Antimesenteric Functional End-to-End Anastomosis Following Intestinal Resection for Crohn's Disease.

Anastomotic recurrence after bowel resection is problematic in patients with Crohn's disease. Antimesenteric functional end-to-end handsewn (Kono-S) anastomosis is associated with a low risk of anastomotic recurrence in patients with Crohn's disease. Kono-S anastomosis is effective but may be time-consuming. This study aimed to describe stapled antimesenteric functional end-to-end anastomosis for patients with Crohn's disease. The mesentery of the affected bowel segment was divided. A 5-cm-wide stapled functional end-to-end anastomosis was performed approximately 6 cm from the affected segment. The bowel was divided transversely exactly 90° to the intestinal lumen and the mesentery, and a supporting column was then constructed. From January 2018 to June 2021, 17 stapled antimesenteric functional end-to-end anastomoses were performed. The mean operative time was 106 (range, 80-135) minutes, and the time to construct the stapled antimesenteric functional end-to-end anastomosis was 21 (range, 18-28) minutes. The mean follow-up time was 8.9 (range, 1-15) months. In total, 10 patients underwent surveillance endoscopy. The average Rutgeerts score was 0.8 (range, 0-4), and the incidence of endoscopic recurrence was 11.8%. No postoperative mortality or anastomotic leakage was observed. Stapled antimesenteric functional end-to-end anastomosis may be a safe and time-saving procedure for patients with Crohn's disease. Further prospective studies with a large sample size are warranted.