High-risk Anastomoses Research Articles

Treatment of anastomotic leak in colorectal surgery by endoluminal vacuum therapy with the VACStent avoiding a stoma - a pilot study

PurposeAnastomotic leak (AL) represents the most relevant and devastating complication in colorectal surgery. Endoscopic vacuum therapy (EVT) using the VACStent is regarded as a significant improvement in the treatment of upper gastrointestinal wall defects. The innovative concept of the VACStent was transferred to the lower GI tract, gaining initial experience by investigating safety and efficacy in 12 patients undergoing colorectal resections.MethodsThe pilot study, as part of a German registry, began with 2 patients suffering from AL, who were treated with the VACStent after stoma placement. Subsequently, 6 patients with AL were treated with the VACStent omitting a stoma placement, with a focus on fecal passage and wound healing. Finally, the preemptive anastomotic coverage was investigated in 4 patients with high-risk anastomoses to avoid prophylactic stoma placement.ResultsIn total 26 VACStents were placed without problems. The conditioning and drainage function were maintained, and no clogging problems of the sponge cylinder were observed. No relevant clinical VACStent-associated complications were observed; however, in 2 patients, a dislodgement of a VACStent occurred. The 6 patients with AL but without stoma had a median treatment with 3 VACStents per case with a laytime of 17 days, leading to complete wound healing in all cases. The 4 prophylactic VACStent applications were without complications.ConclusionThe clinical application of the VACStent in the lower GI tract shows that successful treatment of anastomotic colonic leaks and avoidance of creation of an anus praeter is possible.Trial registration numberClinicaltrials.gov NCT04884334, date of registration 2021-05-04, retrospectively registered.

Role of ileal diversion in pediatric inflammatory bowel disease.

Surgical intervention is often indicated in pediatric inflammatory bowel disease (IBD) for medically refractory disease or complications of severe disease. Specifically, surgical intervention via ileal diversion allows for fecal flow to be redirected away from diseased distal bowel and through an ileostomy. It is utilized in patients who have medically refractory colitis, severe perianal disease, or irreversible bowel damage. In patients with ulcerative colitis, it is primarily performed during a restorative proctocolectomy with ileal pouch anal anastomosis to protect the high-risk anastomoses. In the setting of Crohn's disease, ileal diversion reduces the exposure of diseased distal intestine to pro-inflammatory stool. During perioperative planning, it is crucial for the gastroenterologist to partner early with a multidisciplinary team including surgeons, nutritionists, wound ostomy care nurses, psychologists, and social workers. Patients should be assessed for malnutrition and should be optimized nutritionally with enteral or parenteral nutrition. As they are associated with increased risk of postoperative complications, corticosteroids should be significantly reduced or completely discontinued preoperatively. Though ileal diversion may reduce the complications associated with anastomosis, serious postoperative complications can include diversion colitis and high-output fistulae. This review aims to provide an overview of the role of ileal diversion in the treatment of pediatric IBD to pediatric gastroenterologists to inform their medical decision-making and discussions with patients and families.

Experimental models of high-risk bowel anastomosis in rats: A systematic review.

Anastomotic leaks remain one of the most dreaded complications in gastrointestinal surgery causing significant morbidity, that negatively affect the patients' quality of life. Experimental studies play an important role in understanding the pathophysiological background of anastomotic healing and there are still many fields that require further investigation. Knowledge drawn from these studies can lead to interventions or techniques that can reduce the risk of anastomotic leak in patients with high-risk features. Despite the advances in experimental protocols and techniques, designing a high-quality study is still challenging for the investigators as there is a plethora of different models used. To review current state of the art for experimental protocols in high-risk anastomosis in rats. This systematic review was performed according to The Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. To identify eligible studies, a comprehensive literature search was performed in the electronic databases PubMed (MEDLINE) and Scopus, covering the period from conception until 18 October 2023. From our search strategy 102 studies were included and were categorized based on the mechanism used to create a high-risk anastomosis. Methods of assessing anastomotic healing were extracted and were individually appraised. Anastomotic healing studies have evolved over the last decades, but the findings are yet to be translated into human studies. There is a need for high-quality, well-designed studies that will help to the better understanding of the pathophysiology of anastomotic healing and the effects of various interventions.

Ileostomy: Early and Late Complications

Abstract Introduction Ileostomy formation is performed for multiple purposes related to intestinal pathology, such as obstructive malignant or benign tumors, inflammatory bowel diseases, intestinal ischemia, and, for the most part, as a protective stoma in high-risk anastomosis. The creation of this surgical opening, despite being considered a simple procedure, is undoubtedly followed by complications in certain cases. Materials and Methods We conducted an electronic literature search in the MEDLINE database using the PubMed search engine. A total of 43 articles were included in the present review. Results/Discussion Over the course of the present work, we were able to explore different types of complications that can arise in patients with an ileostomy. High-output stomas were found to be associated with dehydration and electrolyte imbalance. Skin-related morbidity was shown to be present in a great percentage of patients. More severe complications, such as peristomal pyoderma gangrenosum and necrosis, are less frequent and require urgent management. Several risk factors were identified in cases of retraction, obstruction, prolapse, and parastomal herniation. Conclusion Even though ileostomies may present numerous benefits in certain patients, they are also associated with many complications, which should be avoided and quickly managed, because they can severely affect the quality of life of the patients. Surveillance and follow-up by a multidisciplinary team is strongly advisable, bearing in mind that a good performance on the part of the responsible surgeon is also a key factor.

A 10-year experience with anastomotic leaks in upper gastrointestinal surgery–Retrospective cohort study

BackgroundAnastomotic leak (AL) in upper gastrointestinal (UGI) surgery continues to be a diagnostic challenge. We seek to identify clinical parameters that predict AL and examine the effectiveness of investigations in evaluating AL following UGI surgeries. Methods592 patients underwent UGI surgeries with an anastomosis between January 2011 and January 2021. Data on patient characteristics, surgery, postoperative investigations and outcomes were prospectively collected and analysed. ResultsThe overall occurrence of AL was 6.4 %. Tachycardia >120 BPM (OR 6.959, 95 % CI 1.856–26.100, p = 0.004) and leukocyte count >19 × 109/L (OR 3.327, 95 % CI 1.009–10.967, p = 0.048) were independent predictors of AL. On multivariate analysis, patients whose anastomosis was deemed high risk and had pre-emptive investigation done postoperatively to exclude a leak were less likely to require intervention and were more likely to be managed conservatively (66.7 % vs 14.3 %, p = 0.025). Methylene blue test, oral contrast study and Computed Tomography scan with intravenous and oral contrast had 50.0 %, 20.0 % and 9.1 % false negative results, while esophagogastroduodenoscopy had none. There was no misdiagnosed AL when more than 1 investigation (n = 15, 39.5 %) were performed. ConclusionOur study demonstrates that the presence of a triad including desaturation, tachycardia and leucocytosis predicts for AL following UGI surgery and for confirmation of a leak, evaluation with 2 or more investigation is needed. A practice of evaluating high risk anastomosis prior to commencement of feeding decreased the need for surgical intervention and improves success of conservative treatment.

The Role of Adipose Tissue Mesenchymal Stem Cells in Colonic Anastomosis Healing in Inflammatory Bowel Disease: Experimental Study in Rats.

(1) Background: A surgical operation on an inflamed bowel is, diachronically, a challenge for the surgeon, especially for patients with inflammatory bowel disease. Adipose tissue-derived mesenchymal stromal cells are already in use in clinical settings for their anti-inflammatory properties. The rationale of the current study was to use AdMSCs in high-risk anastomoses to monitor if they attenuate inflammation and prevent anastomotic leak. (2) Methods: a total of 4 groups of rats were subjected to a surgical transection of the large intestine and primary anastomosis. In two groups, DSS 5% was administered for 7 days prior to the procedure, to induce acute intestinal inflammation. After the anastomosis, 5 × 106 autologous AdMSCs or an acellular solution was injected locally. Macroscopic evaluation, bursting pressure, hydroxyproline, and inflammatory cytokine expression were the parameters measured on the 8th post-operative day. (3) Results: Significantly less intra-abdominal complications, higher bursting pressures, and a decrease in pro-inflammatory markers were found in the groups that received AdMSCs. No difference in VEGF expression was observed on the 8th post-operative day. (4) Conclusions: AdMSCs attenuate inflammation in cases of acutely inflamed anastomosis.

392. PLANNING IS THE KEY—ESOPHAGECTOMY WITH COLONIC INTERPOSITION FOLLOWING: WHIPPLE’S, LEFT LOWER LOBECTOMY, RIGHT PLEURECTOMY AND COLONIC SURGERY

Abstract Link to Video: https://www.dropbox.com/s/wpr3s097g50oadl/Colonic%20interposition%20%28ISDE%20SUBMISSION%29.mp4?dl=0. Description of Video: We report our learnings from a complex surgical case of Ivor Lewis esophagectomy with colonic conduit in a patient who had undergone multiple previous abdominal and thoracic operations. This seventy-two-year-old man was found to have an esophageal adenocarcinoma (T4N0M0) in the distal esophagus with a significant surgical background: Whipple’s procedure for pancreatic cancer; Left lower lobectomy for lung cancer; Right pneumonectomy for recurrent pneumothoraces and a defunctioning stoma for chemotherapy associated anal fistula. To our knowledge, no such case of colonic interposition for esophagectomy has been reported in the literature for a patient with such extensive surgical history. This presented significant surgical and anaesthetic challenges which are explored in the video. Principally the need for extensive planning to anticipate risk and modify procedural steps to account for these accordingly. For example, the operation began with a right thoracotomy, given the possibility that dense adhesions from previous surgery could obstruct safe dissection and subsequently the procedure could be aborted before any critical steps were made. Additionally, we consider the importance of involving other surgical specialities to aid with safe dissection and delineation of anatomy. Each of the key operative steps are described and paired with real-time video footage. Post-operatively we describe how the risk of anastomotic leak given a high-risk anastomosis may be reduced through pre-emptive Endoluminal Vacuum therapy. We also discuss the importance of recognising and managing feculent aspiration pneumonia which is common following this surgery. Discussion of this case and our operative approach would serve to highlight how surgery remains a feasible option for patients despite complex anatomy and surgical history; provided risks are anticipated and appropriately managed.

How i do it: microscope augmented pancreaticojejunostomy.

Post-operative pancreatic fistula (POPF) is perhaps one of most dreaded pancreatoduodenectomy-related complications. Various approaches to mitigate this risk have been explored, with conflicting results and no clear consensus on the comparative superiority of any one technique. We postulate that regardless of technique, the key to reducing POPF is a robust pancreatic anastomosis with careful apposition of tissues, in particular the duct-to-mucosa anastomosis. We describe the fashioning of a pancreatojejunostomy with an external pancreatic stent in the setting of a high-risk anastomosis with help of a 10 × magnification surgical microscope. A technical description with a short, edited video is presented.

Preemptive endoluminal vacuum therapy with the VACStent-A pilot study to reduce anastomotic leakage after Ivor Lewis hybrid esophagectomy.

Endoscopic treatment by vacuum therapy (EVT) or covered stents has emerged as an improved treatment option for upper gastrointestinal wall defects and is regarded as an improved treatment option for anastomotic leakage (AL) after esophagectomy. However, endoluminal EVT devices may lead to obstruction of the GI tract; and a high rate of migration and missing functional drainage has been shown for covered stents. The recently developed VACStent, a combination of a fully covered stent within a polyurethane sponge cylinder may overcome these issues allowing EVT while stent passage is still open. Initial clinical applications have demonstrated efficacy, practicability and safety in the treatment of esophageal leaks (AL). In this pilot study, 9 patients with high-risk anastomosis after neoadjuvant therapy undergoing hybrid esophagectomy received the VACStent in a preemptive setting for the assessment of the reduction of the AL rate, postoperative morbidity and mortality. Technical success of the application of the VACStent® was achieved in all interventions. One patient experienced anastomotic leakage 10 days after esophagectomy and was successfully treated with two consecutive VACStents and a VAC Sponge. In summary, mortality in-hospital was 0% and anastomotic healing was uneventful without septic episodes. No severe device-related adverse events (SADE) nor significant local bleeding or erosion could be observed. Oral intake of liquids or food was documented in all patients. The device handling was regarded uncomplicated. The preemptive application of the VACStent offers a promising new option for improved clinical treatment avoiding of critical situations in hybrid esophagectomy, which should be validated in a large clinical study.

OGC P37 Towards an era of eliminating leak related morbidity from major oesophago-gastric surgery

Abstract Background A leak following oesophago-gastric surgery remains a life-threatening complication associated with a long intensive care stay and high mortality and morbidity. We hypothesised that Endoluminal Vacuum Therapy (EVT) could be used prophylactically to provide source control, prevent mediastinitis and minimise sepsis related morbidity if breakdown of an oesophageal or gastric anastomosis or repair occurred. In the first instance, this could be a particularly attractive adjunct in cases where technical and/or patient factors deem an anastomosis or repair as high risk. Methods We collected data prospectively from all patients where a prophylactic EVT device was placed during elective oesophago-gastric surgery. Primary outcome measures included length of stay (LOS) and post-operative leak rate. Prophylactic EVT was provided using an ad-hoc EVT device constructed by suturing a piece of V.A.C granufoam (KCI) to the end of an 18Fr NG tube and positioning this intraluminally across the anastomosis or area of repair at the time of surgery using endoscopic guidance. Continuous negative pressure of between 75 and 125mmHg was applied. Following removal of the EVT device, assessment of the integrity of the anastomosis or repair was made using one, or a combination of endoscopic assessment, CT with oral contrast, and clinical assessment. Results Prophylactic EVT was utilised in 9 patients; M:F ratio=7:2, median age 72 years (range 50–80). 8 patients had ASA 3, and 1 had ASA 2. The index surgery was resection of an epithelial cancer in 7 patients (3 partial/total gastrectomies, 4 oesophagectomies), resection of a gastric GIST in 1 patient, and a Hellers myotomy in 1 patient. All anastomosis/repairs were deemed high risk due to technical(n=3), patient(n=4) or combined (n=2) factors. Prophylactic EVT was placed for a median of 6 days (range 4–10). The integrity of the anastomosis/repair was assessed using both CT and gastroscopy (n=3), CT alone (n=3), gastroscopy alone (n=2), and clinical grounds (n=1). One patient was found to have a full thickness oesophageal defect at their first endoscopic assessment. This was managed with a further period of intraluminal EVT until the oesophageal defect healed. The patient remained clinically well throughout and was managed entirely with ward-based care. The median LOS was 11 days (range 7–96). The two longest stays were secondary to a prolonged chyle leak and longer term sequelae of a life threatening on-table bleed. In all cases the site of repair remained healthy with no evidence of early stricturing. Conclusions Prophylactic EVT therapy was safe and did not result in any short-term adverse events in this small cohort of patients. Although it may not prevent breakdown at the site of oesophageal anastomosis/repair and is not an alternative to sound surgical technique, the use of prophylactic EVT in high risk anastomosis could be beneficial in preventing life threatening sepsis and associated systemic effects resulting from inadequate source control. Current studies are under way to look at longer term outcomes in the form of prospective cohort studies and randomised controlled trials. This provides the oesophago-gastric community the unique opportunity to collectively eliminate life threatening leak related morbidity and mortality for once and for all.

384. A 10-YEAR EXPERIENCE WITH ANASTOMOTIC LEAKS IN UPPER GASTROINTESTINAL SURGERY

Abstract Anastomotic leak (AL) in upper gastrointestinal (UGI) surgery continues to be a diagnostic challenge despite advancements in surgical techniques and investigation modalities. We seek to identify key clinical parameters that predict AL and examine the effectiveness of investigations in evaluating AL following UGI surgeries in our practice. 592 patients underwent UGI surgeries with an anastomosis in a single center between January 2011 and Jan 2021. The cohort comprises were 237 (40.0%) distal gastrectomies, 120 (20.3%) total gastrectomies, 104 (17.6%) Roux-en-y bariatric bypasses, 53 (9.0%) Ivor-Lewis esophagectomies, 41 (6.9%) proximal gastrectomies, 17 (2.8%) palliative gastro-jejunostomies and 20 (3.4%) Mckeown esophagectomies. Data on patient characteristics, surgery, postoperative investigations and outcomes were prospectively collected and analysed. The overall occurrence of AL was 6.4%. AL was highest in esophagectomies (13.7%) and total gastrectomies (10.0%). Clinical parameters associated with AL include HR >120 BPM, desaturation, bilious or food contents in drain and leukocytosis. On multivariate analysis, HR >120 BPM and leukocyte count >19x1000000000/L were independent predictors of AL. Patients with high-risk anastomosis who had pre-emptive investigations, were more likely to be managed with antibiotics instead of requiring invasive therapy (p = 0.025). Methylene blue test, oral contrast study and Computed Tomography scan with intravenous and oral contrast had respective false negatives of 50.0%, 20.0% and 9.1%, while esophagogastroduodenoscopy had none. Our study demonstrates that the presence of a triad including desaturation, tachycardia and leukocytosis predicts for AL following UGI surgery and for confirmation of a leak, evaluation with 2 or more investigation is needed to exclude a AL. A practice of evaluating high risk anastomosis prior to feeding decreases need for surgical intervention and improves the chances of successful conservative treatment.

The evolving role of the superficial temporal vessels as anastomotic recipients in challenging microvascular reconstruction of the upper two-thirds of the face

Free-tissue transfer is now the standard of care in reconstructing head and neck defects. Microvascular reconstruction of the upper two-thirds of the face, particularly following recurrent malignant disease, however, remains a challenge. Retrospective review of all patients undergoing microsurgical reconstruction for defects of the upper two-thirds of the face between 2015 and 2019 revealed 17 free-tissue transfers where the superficial temporal vessels (STVs) were used as recipient vessels. Perioperative data, including return to theatre (RTT) and flap success rates were evaluated. Three patients required reoperation for vascular compromise. One of these patients ultimately lost the flap resulting in flap survival of 94%. This flap failure was, however, secondary to external factors distant to the flap and the anastomosis. In this patient, subsequent attempt at microvascular reconstruction was carried out successfully using contralateral neck vessels and vein grafts. We demonstrate the STVs are safe and reliable in microsurgical reconstruction for a variety of defects. Close proximity to the resection, reconstructing with flaps with a short pedicle, negating the need for neck access and/or high-risk anastomosis in a previously irradiated/operated vessel depleted neck are all highlighted indications. The pre-auricular/temporal access is familiar to the reconstructive surgeon and has excellent post-operative aesthetic results. We discuss key advantages of this approach and highlight potential complications and learning points - underlining the benefit of this approach for the head and neck reconstructive surgeon.

Preoperative biomarkers related to inflammation may identify high-risk anastomoses in colorectal cancer surgery: explorative study.

BackgroundColorectal anastomotic leakage can be considered a process of failed wound healing, for which related biomarkers might be a promising research area to decrease leak rates.MethodsPatients who had elective surgery with a primary anastomosis for non-metastatic colorectal cancer, at two university hospitals between 1 January 2010 and 31 December 2015 were included. Patients with an anastomotic leak were identified and matched (1:1) to complication-free controls on the basis of sex, age, tumour stage, tumour location, and operating hospital. Preoperative blood samples were analysed by use of protein panels associated with systemic or enteric inflammation by proteomics, and enzyme-linked immunosorbent assays. Multivariable projection methods were used in the statistical analyses and adjusted for multiple comparisons to reduce false positivity. Rectal cancer tissue samples were evaluated with immunohistochemistry to determine local expression of biomarkers that differed significantly between cases and controls.ResultsOut of 726 patients undergoing resection, 41 patients with anastomotic leakage were matched to 41 controls. Patients with rectal cancer with leakage displayed significantly elevated serum levels of 15 proteins related to inflammation. After controlling for a false discovery rate, levels of C-X-C motif chemokine 6 (CXCL6) and C-C motif chemokine 11 (CCL11) remained significant. In patients with colonic cancer with leakage, levels of high-sensitivity C-reactive protein (hs-CRP) were increased before surgery. Local expression of CXCL6 and CCL11, and their receptors, were similar in rectal tissues between cases and controls.ConclusionPatients with anastomotic leakage could have an upregulated inflammatory response before surgery, as expressed by elevated serological levels of CXCL6 and CCL11 for rectal cancer and hs-CRP levels in patients with colonic cancer respectively.

High-risk pancreatic anastomosis vs. total pancreatectomy after pancreatoduodenectomy: Postoperative outcomes and quality of life analysis

High-risk pancreatic anastomosis vs. total pancreatectomy after pancreatoduodenectomy: Postoperative outcomes and quality of life analysis

Outcome of prophylactic endoscopic vacuum therapy for high-risk anastomosis after esophagectomy

Background: Endoscopic vacuum therapy (EVT) has become an established procedure for the treatment of anastomotic leaks (AL) in upper gastrointestinal surgery. A novel approach is the use of EVT for preventing leaks in high-risk anastomosis. The aim of this study was to analyze the outcome of prophylactic EVT (pEVT) in patients receiving surgical revision of the anastomosis after oncological Ivor-Lewis esophagectomy (ILE) due to AL. Material and methods: Between June 2016 and February 2019, all patients who underwent anastomotic revision after ILE due to a confirmed AL were included. The primary outcome was the success rate of pEVT, which was defined as absence of an AL after revision. Secondary outcome parameters were duration of treatment, inflammatory levels, and ICU/hospital stay. Results: Twenty-one patients underwent anastomotic revision due to an AL. The cause of the AL was ischemia in nine patients (42.9%) and non-ischemia (other) in 12 patients (57.1%). PEVT was performed in 14 patients (66.6%). The overall success rate of pEVT was five out of 14 patients (35.7%). Conclusions: Prophylactic EVT cannot prevent a re-leak in patients with high-risk anastomosis due to surgical revision of an AL after oncological ILE. However, pEVT might help to control the clinical condition of these patients.

Prophylactic endoluminal vacuum therapy after major gastrointestinal surgery: a systematic review

In the last decade, endoluminal vacuum therapy (eVAC) has emerged as an effective treatment for anastomotic leak (AL); however, little is known regarding its prophylactic use. In this systematic review we evaluated overall outcomes in patients undergoing major gastrointestinal surgery and treated with prophylactic eVAC. A systematic review of English articles on four electronic databases was performed according to the PRISMA statement up until January 2022. References of selected articles weremanually screened to identify relevantmissing papers. Primary endpoints were AL and mortality rates estimates. Secondary endpoints included analysis of eVAC-associated morbidity, treatment duration, long-term complications, and general indications for the eVAC management in the perioperative period. A total of 11 studies (5 case reports, 5 retrospective case series and a retrospective, case-control study) were included in the analysis. AL ranged from 0 to 25%. No major eVAC-associated complications were observed, except for sponge dislocation or obstruction. Overall mortality ranged between 0 and 12.5%; however, these fatalities were neither related to the use of eVAC, nor to AL-associated complications. The most frequent long-term complication was anastomotic stenosis responsive to endoscopic dilatation in most cases. The operating negative pressure ranged from -25 to -125mmHg among different papers. In all studies but two, prophylactic eVAC was applied to anastomoses at high risk of dehiscence based on the subjective evaluation of the leading surgeon. In conclusion,prophylactic eVAC is safe and it could lead to potential benefit for prevention of AL, especially in high-risk anastomoses.

Predictive Technical Factors for Postoperative Pancreatic Fistula, Video Analysis of Robot-Assisted Pancreatoduodenectomy

Introduction: The objective was to use video analysis of robot-assisted pancreatico-jejunostomy (PJ) to identify technical intraoperative risk factors for clinically-relevant postoperative pancreatic fistula (CR-POPF). Methods: Retrospective analysis of the LAELAPS-3 study. All consecutive patients who underwent a robot-assisted PD from 2017 – June 2020 were included. Technical intraoperative factors of the PJ were collected by a blinded assessor through analysis of the recorded videos. The main outcome was CR-POPF, defined as grade B/C fistula. All PJ’s were performed using the modified Blumgart technique. Results: The videos of 153 robotic assisted PJ’s were analyzed. The CR-POPF rate was 22.9% (n=35). Based on uaFRS criteria, 72 (47.1%) patients had intermediate or high-risk anastomoses. In 14 patients (9.2%) a defect of >1mm between stitches of the duct to mucosa was observed. Patients with a defect of >1mm had an increased risk to develop a CR-POPF; adjusted odds ratio (OR) 4.07 (95%CI 1.18 – 14.04, p=0.026). In four patients (2.6%) more than half of the stitches from the duct-to-mucosa did not pass through the mucosa of the jejunum. These patients had an increased risk to develop a grade C fistula (OR 29.7, 95%CI 1.409 - 596, p=0.027). Conclusions: Using video analysis of robot-assisted PJ, we found that a defect of >1mm and a duct-to-mucosa stitch not incorporating the mucosa are associated with CR-POPF. Video analysis can be used to improve outcomes especially in the learning curve. FP02-5.

Video Grading of the Pancreatico-Jejunostomy in Robotic Pancreatoduodenectomy to Determine the Learning Curve and the Risk of Postoperative Pancreatic Fistula

Introduction: Video grading may be used to assess the surgical learning curve and could predict complications. Predicting the risk of postoperative pancreatic fistula (POPF) could guide treatment, quality control, or be used for benchmarking however a cut-off variable regarding surgical expertise is lacking. We graded the pancreatico-jejunostomy of robotic pancreatoduodenectomy (RPD) to assess learning curve and the risk of POPF. Methods: We included patients who underwent RPD for all indications from a recently completed multicenter training program in RPD (LAELAPS-3). Technical performance was graded by two blinded graders using the Objective Structured Assessment of Technical Skills (OSATS) score, ranging from 12-60. Cumulative sum (CUSUM) analysis was used to assess a learning curve inflection point. Logistic regression was used to determine the cut-off OSATS score to predict the increased chance of POPF grade B/C. Results: Videos of 153 patients from four centers were assessed. POPF B/C occurred in 35 patients (22.9%). Based on uaFRS criteria, 72 (47.1%) patients had intermediate or high-risk anastomoses. Median OSATS was 48 [interquartile range 41–52]. CUSUM analysis of OSATS found an inflection point after 33 procedures. An OSATS score below 49 was associated with a higher risk of POPF, OR 2.27 (1.04–4.99, p=0.041). Conclusion: This multicenter study demonstrates that video grading of the pancreatico-jejunostomy can determine both the learning curve and the risk of POPF after RPD.

Incisional hernia following ileostomy closure: who's at risk? The Gold Coast experience.

Diverting ileostomy is utilized to protect high-risk anastomoses, though it is not shown to reduce the leak rate it may reduce the severe consequences of an anastamotic leak. In recent years mesh development has advanced to allow placement of meshes into potentially contaminated fields, such as an ostomy closure site. A retrospective review of all ileostomy closure procedures in Gold Coast from 1st January 2011 until 31st December 2018 were included. Patient demographics and surgical outcomes and follow up reviewed to identify any cases of incisional hernia relating to ostomy closure. A total of 193 patients were identified, after exclusions 171 were suitable for analysis within the study, a total of 25 incisional hernia detected radiologically or clinically. Two independent risk factors were identified BMI >30 and ASA 3-4. Both had significant association with development of incisional hernia with a 3- and 2-fold RR increase, respectively. This was also reflected in a subset analysis of BMI ranges demonstrating increased risk in the obese and severely obese group. The high-risk group in our population was elevated BMI and ASA, these are the patients we would expect to benefit the most from targeted therapy to reduce the incidence of incisional hernia. Future studies to look at whether reducing BMI or prophylactic mesh placement are effective.

Double purse-string telescoped pancreaticogastrostomy is not superior in preventing pancreatic fistula development in high-risk anastomosis: a 6-year single-center case-control study.

The double purse-string telescoped pancreaticogastrostomy (PG) technique has been suggested as an alternative approach to reduce the risk of postoperative pancreatic fistula (POPF). Its efficacity in high-risk situations has not yet been explored. This study compared the incidence of clinically relevant POPF (CR-POPF) between patients with high-risk anastomosis undergoing PG and those undergoing pancreaticojejunostomy (PJ). From 2013 to 2019, 198 consecutive patients with high-risk anastomosis, an updated alternative fistula risk score > 20%, and who underwent pancreatoduodenectomy with the PJ (165) or PG (33) technique were included. Optimal mitigation strategy (external stenting/octreotide omission) was applied for all patients. The primary endpoint was the incidence of CR-POPF. The mean ua-FRS was 33%. CR-POPF (grade B/C) was found in 42 patients (21%) and postoperative hemorrhage in 30 (15%); the mortality rate was 4%. CR-POPF rates were comparable between the PJ (19%) and PG (33%) groups (P = 0.062). The PG group had a higher rate of POPF grade C (24% vs. 10%; P = 0.036), longer operative time (P = 0.019), and a higher transfusion rate (P < 0.001), even after a matching process on ua-FRS. In the multivariate analysis, the type of anastomosis (P = 0.88), body mass index (P = 0.47), or main pancreatic duct diameter (P = 0.7) did not influence CR-POPF occurrence. For patients with high-risk anastomosis, the double purse-string telescoped PG technique was not superior to the PJ technique for preventing CR-POPF.