Incidence Of Anastomotic Stricture Research Articles

Study on the application of self-fixing and self-detachable drainage stent in pancreaticojejunostomy

Objectives: To evaluate the efficacy and safety of the self-fixing and self-detachable drainage stent in pancreaticojejunostomy and to provide supportive data for the follow clinical trials. Methods: This is an experimental research in animals which completed from February 2022 to September 2022. A self-fixing and self-detachable pancreaticojejunostomy drainage stent was designed for Hong's pancreaticojejunostomy technique based on the theory of "fistula healing" in pancreaticojejunostomy. Ten biocompatibility tests were completed in vitro before this study. Twenty-five Bama minipigs were selected and double-ligated in the neck of the pancreas to dilate the distal main pancreatic duct. Twenty-three of them were successfully modelled and divided into three groups by a stratified random method: pancreaticojejunostomy drainage stent group (referred to as stent group) with 11 pigs, pancreatic duct to jejunal mucosa anastomosis group (referred to as manual suture group) with 8 pigs, sham operation group with 4 pigs. The anastomic time,amylase content in postoperative abdominal drainage fluid and the tolerable pressure value of pancreaticojejunostomy were compared between the stent group and the manual suture. An abdominal X-ray fluoroscopy examination was adopted to detect the detach time of the stent. A postoperative pathological examination was performed to verify the healing time,the type of treatment and the stricture rate of pancreaticojejunostomy. Quantitative data was analyzed by independent sample t-test. The classified data were analyzed by Pearson χ2 test. Results: There were no significant differences in the diameter of the pancreatic duct and pancreatic texture,the time of pancreaticojejunostomy,the amylase content in postoperative peritoneal drainage fluid,and the tolerable pressure value of the pancreaticojejunostomy between the stent group and the manual suture group(all P>0.05). Abdominal X-ray fluoroscopy showed that the stents gradually detached and were removed from the body 21 days after operation,and all stents were detached in the follow 3 months after operation. Pancreaticojejunostomy healed 7 days after operation based on fistula formation in the stent group,and 14 days in the manual suture group. The incidence of anastomotic stricture within 35 days after operation was 2/8 in the stent group and 6/8 in the manual suture group (χ2=4.000,P=0.046). Conclusion: The stent method is safer and simpler than the manual suture method in pancreaticojejunostomy of Bama minipigs, with shorter anastomotic healing time and lower stricture rate.

435. CIRCULAR-STAPLED ESOPHAGOGASTROSTOMY USING THE KEYHOLE PROCEDURE: TECHNICAL ASPECTS AND CLINICAL OUTCOMES

Abstract Background The optimal reconstruction method after radical esophagectomy for esophageal cancer has been under debate. For avoiding an anastomotic stricture, we developed a novel method of circular-stapled esophagogastrostomy by employing the keyhole procedure, which uses a linear stapler (LS) to enlarge the anastomotic opening made with a circular stapler (CS). We report the technique and the clinical outcomes. Methods We retrospectively reviewed 70 patients with esophageal cancer who underwent transthoracic esophagectomy and reconstruction via cervical CS-mediated anastomosis with or without the keyhole procedure between 2018 and 2020. The primary outcome was postoperative anastomotic stricture incidence within 180 days after surgery. Surgical procedures: After a 3.5 cm-wide gastric conduit was created, the blood supply was examined via indocyanine green fluorescence imaging. Usually, anastomosis was made at the site which was dominated by the last branch of the right epiploic artery owing to Kocher’s maneuver. The CS was inserted through the anterior wall of the gastric conduit, and the end-to-side anastomosis was established on the greater curvature side of the gastric conduit. Then, a 45-mm long LS was used to create a keyhole over the circular staples, and the entry hole was closed with a 60-mm long LS. Results Among 70 patients, 22 underwent the keyhole procedure (CS + K group) and the remaining did not (CS group). A smaller CS was used in the CS + K group (p < 0.001). The incidence of anastomotic stricture was significantly different (CS vs. CS + K, 18.8 vs. 0%, p = 0.049), especially when a 21 or 23 mm CS was used (CS vs. CS + K, 50.0 vs. 0%, p = 0.005). The univariate analysis confirmed that CS ≤ 23 without a keyhole was a significant risk factor (p = 0.001). Conclusions The keyhole procedure could be a simple and useful alternative technique that reduces the risk of stricture formation in the cervical esophagogastric anastomosis, especially when using the smaller-sized CS.

Mixed-methods feasibility study to inform a randomised controlled trial of proton pump inhibitors to reduce strictures following neonatal surgery for oesophageal atresia

ObjectivesThis mixed-methods feasibility study aimed to explore parents’ and medical practitioners’ views on the acceptability and design of a clinical trial to determine whether routine prophylactic proton pump inhibitors (PPI)...

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.

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.

Circular-stapled esophagogastrostomy using the keyhole procedure after radical esophagectomy for esophageal cancer.

Anastomotic leakage of cervical esophagogastrostomy following radical esophagectomy for esophageal cancer has reduced over time; however, postoperative anastomotic stricture still occurs at a considerably high rate. We developed a novel method of circular-stapled esophagogastrostomy by employing the keyhole procedure, which uses a linear stapler to enlarge the anastomotic opening made with a circular stapler (CS). We retrospectively reviewed 70 patients with esophageal cancer who underwent transthoracic esophagectomy and reconstruction via cervical CS-mediated anastomosis with or without the keyhole procedure between 2018 and 2020. The primary outcome was postoperative anastomotic stricture incidence within 180days after surgery. Among 70 patients, 22 underwent the keyhole procedure (CS + K group) and the remaining did not (CS group). No differences were observed in patients' age, sex, body mass index, performance status, American Society of Anesthesiologists physical status, Charlson's comorbidity index, tumor histological type, tumor location, clinical stage, or preoperative treatment. A smaller stapler was used in the CS + K group (p < 0.001). Incidence of anastomotic stricture was significantly different (CS vs. CS + K, 18.8 vs. 0%, p = 0.049), especially when a 21 or 23mm CS was used (CS vs. CS + K, 50.0 vs. 0%, p = 0.005). Univariate analysis confirmed that CS ≤ 23 without keyhole was a significant risk factor (p = 0.001). The keyhole procedure could be a simple and useful alternative technique that reduces the risk of stricture formation in cervical esophagogastric anastomosis, especially when using the smaller-sized CS.

Modification of the anastomotic technique in completely laparoscopic resection rectopexy with NOSE — a case report

Introduction. We have come a long way from the era of conventional rectal surgery, with most high-volume centres now practising various degrees of laparoscopy assisted colorectal surgeries, via extracorporeal suturing, ex vivo anastomoses, hand-assisted laparoscopic resection anastomoses to robotic rectal resections. However, the limitation to most such techniques remains the fact that these are not ‘completely’ laparoscopic, with varying degrees of open assistance being required, from mobilization, suturing and anastomoses to specimen extraction via separate abdominal incisions or port-site enlargements. These ‘large’ incisions negate some of the advantages of minimal access surgery and lead to complications at such sites, such as wound breakdown, infections, and incisional herniae. This led to the origin of NOTES (Natural Orifice Translumenal Endoscopic Surgery) and the still fairly new concept of NOSE (Natural Orifice Specimen Extraction).Aim. We aim to describe our application of this new frontier in laparoscopic colorectal surgery, doing away with large scars prone to complications.Materials and methods. We describe a case of completely laparoscopic resection rectopexy and trans-rectal extraction of the specimen, with a modified technique of anvil insertion, enabling the faster creation of a larger anastomosis with probably lower anastomotic morbidity.Results and discussion. The patient underwent a ‘completely’ laparoscopic resection rectopexy and had an uneventful immediate post-operative recovery. She had no delayed post-operative complications or recurrence of the rectal prolapse and remained free of constipation as well, over a follow-up period of 6 months.Conclusion. We conclude that this modification of the surgical technique reduces operative time, allows use of larger circular staplers, theoretically reducing the incidence of anastomotic stricture, and being easily reproducible, can be widely applied for better cosmetic and functional outcome.

Clinical comparison between thoracoscopic and thoracotomy repair of Gross type C esophageal atresia

BackgroundTo compare the clinical outcomes between thoracoscopic approach and thoracotomy surgery in patients with Gross type C Esophageal atresia (EA) and tracheoesophageal fistula (TEF).MethodsPatients with Gross type C EA/TEF who underwent surgery from January 2007 to January 2020 at Beijing Children’s Hospital were retrospectively analyzed. The patients were divided into two groups according to surgical approaches. The perioperative factors and postoperative complications were compared among the two groups.ResultsOne hundred and ninety patients (132 boys and 58 girls) with a median birth weight of 2975 (2600, 3200) g were included. The primary operations were performed via thoracoscopic (n = 62) and thoracotomy (n = 128) approach. After comparison of clinical characteristics between the two groups, we found that there were statistically significant differences in associated anomalies, method of fistula closure, duration of mechanical ventilation after surgery, feeding option before discharge, management of pneumothorax, and prognosis (all P < 0.05). To a certain extent, thoracoscopic surgery reduced the incidence of anastomotic leakage and increased the incidence of anastomotic stricture in this study. However, there were no statistically significant differences between the two groups in terms of operative time, postoperative pneumothorax, anastomotic leakage, anastomotic stricture, and recurrent tracheoesophageal fistula (all P > 0.05).ConclusionsThoracoscopy surgery for Gross type C EA/TEF is a safe and effective, minimally invasive technique with comparable operative time and incidence of postoperative complications.

Anastomotic Complications Can Be Reduced Using a Linear Stapler After Total Gastrectomy for Gastric Cancer

The purpose of this retrospective study was to compare the anastomotic complications after radical total gastrectomy using circular and linear stapler. A total of 121 consecutive patients who had undergone radical total gastrectomy at our hospital between 2010 and 2020 were enrolled. Postoperative complications were analyzed according to the baseline characteristics, surgical method, and type of anastomosis. The incidence of anastomotic stricture was significantly higher in the circular stapler group. Multivariate analyses showed that only the type of stapler used was significantly associated with anastomotic complications (odds ratio [OR] 0.11; 95% confidence interval [CI] 0.012–0.986; P = 0.049). The incidence of anastomotic complications, particularly stenosis, is reduced using a linear stapler. Therefore, such as stapler is more suitable for anastomosis after total gastrectomy during both laparoscopic and open surgeries.

Ureteral distal ends combined and inserted into the ileum: a novel anastomotic technique for urinary diversion

BackgroundThis study aimed to introduce a novel method for ureteroileal anastomosis, explore its clinical effectiveness, observe the incidence of postoperative anastomotic stricture, and compare the postoperative complications with those of other types of ureteroileal anastomosis reported in the literature.MethodsBoth ureters were first anastomosed at their distal ends and then inserted into the proximal end of the ileal loop. A postoperative follow-up analysis was performed to evaluate major complication indicators, including anastomotic stricture, anastomotic leak, and hydroureteronephrosis.ResultsWe successfully performed ureteral distal ends anastomosis combined with end-to-end insertion into the ileum for 143 patients. The mean postoperative follow-up lasted 37 months (range: 10–68 months). There was no occurrence of an anastomotic leak. The incidence of anastomotic stricture combined with hydronephrosis, ileal conduit stones, urinary tract infection, and renal dysfunction were 2.1%, 0.7%, 2.1%, and 4.2%, respectively.ConclusionUreteral distal ends combined and inserted into the ileum were simple to perform and helped achieve precise anastomosis with fewer postoperative complications.

Feasibility and quality of life assessment of laparoscopic proximal gastrectomy using double-tract reconstruction.

As the frequency of cancer in the proximal stomach or around the esophagogastric junction (EGJ) increases worldwide, the use of laparoscopic proximal gastrectomy (LPG) has expanded. This study evaluated the safety of LPG with double-tract reconstruction (LPG-DT) and the resulting quality of life (QOL) of patients. In this retrospective cohort study, we reviewed the data of patients who underwent LPG-DT via linear-stapled esophagojejunostomy for gastric or EGJ cancer between 2013 and 2019, and outcomes were compared with those of laparoscopic total gastrectomy with Roux-en-Y reconstruction (LTG-RY) peMME000372rformed over the same period. Surgical outcomes, changes of nutritional parameters, and chronological QOL as evaluated using the Postgastrectomy Syndrome Assessment Scale (PGSAS-37) questionnaire were compared in the propensity-matched cohorts. In total, 289 patients (99 LPG-DT and 190 LTG-RY) were eligible and the outcomes were evaluated in the propensity-matched cohorts (n = 75 each). Operative time and the incidence of complications (≥ grade III) were comparable. Reflux esophagitis was more frequent in the LPG-DT group (8.0% vs. 0%), whereas the incidence of anastomotic stricture did not differ. The percentage rates of body weight loss and hemoglobin reduction were lower in the LPG-DT group at any time point within postoperative 2years but show no statistical differences. In PGSAS-37 (n = 26, n = 23), the diarrhea and quality of ingestion scores were slightly better in the LPG-DT group. The present study suggested that our LPG-DT is feasible and safe in appropriately selected patients, and it may provide slightly better outcomes in nutrition and QOL compared with LTG-RY.

Incidence of anastomotic stricture after hepaticojejunostomy with continuous sutures in patients who underwent laparoscopic pancreaticoduodenectomy.

Laparoscopic hepatojejunostomy (HJ) with continuous sutures is commonly performed in laparoscopic pancreaticoduodenectomy (LPD). This study aimed to investigate the long-term surgical outcomes of HJ in LPD. We retrospectively evaluated 103 consecutive patients who underwent pancreaticoduodenectomy via laparoscopic HJ with continuous suturing using multifilament (n = 48) or monofilament-absorbable sutures (n = 47). During follow-up, anastomotic stricture of HJ was identified in 8 (7.8%) patients via balloon enteroscopy-assisted cholangiography. The median time from surgery to confirmation of stricture formation was 7.6months (range 3.6-19.4). The incidence of HJ stricture was significantly higher in patients with a thin bile duct (diameter < 6.0mm) than in those with a thick bile duct (diameter ≥ 6.0mm) [7/27 (25.9%) vs. 1/76 (1.3%), respectively, p < 0.01]. Similarly, it was significantly higher in the monofilament group than in the multifilament group [7/54 (13.0%) vs. 1/49 (2.0%), respectively, p = 0.04]. In the monofilament suture group, 37.5% of patients with thin bile ducts developed stricture after HJ. A multivariate analysis revealed that a thin bile duct was an independent risk factor for HJ stricture (hazard ratio: 25.3, p < 0.01). Stricture after laparoscopic HJ using continuous sutures frequently occurs in patients with thin bile ducts, particularly when monofilament-absorbable suture is used.

Bilary anastomotic strictures after right lobe living donor liver transplantation: a single-center experience

To determine the incidence of AS after right lobe living donor liver transplantation with various biliary reconstructions and to identify the predictors of this complication. A retrospective and prospective analysis included 245 RLLDLTs for the period 2011-2018 at the Burnazjan Federal Medical Biophysical Center. The results of transplantations in 207 patients aged 19-68 years (median 43 years) were assessed. There were 82 men and 125 women. Follow-up period ranged from 10 to 98 months (median 35 months). We analyzed the relationship between surgical characteristics (preoperative data of recipients and donors, graft parameters, technical features of biliary reconstruction and features of post-transplantation period) and incidence of anastomotic strictures. A total of 58 parameters were analyzed. AS occurred in 20 (9.7%) recipients. Median AS-free period was 5 months (range 1-44). In 17 (85%) patients, AC developed within a year after surgery. Cumulative 1-, 2- and 5-year incidence of AS was 8.3%, 8.9%, and 11%, respectively. Significant predictors of AS were impaired arterial blood supply to the graft (HR 7.8, 95% CI 2.3-26.0, p<0.001), biliary leakage ISGLS class B or C (HR 5.0, 95% CI 2.0-12.8, p<0.001), early allograft dysfunction (HR 4.2, 95% CI 1.5-11.6, p=0.006) and female recipient (HR 3.2, 95% CI 1.1-9.9, p=0.04). In our sample, variant biliary anatomy of the graft and recipient liver, as well as technical features of biliary reconstruction did not affect the risk of AS. Variant biliary anatomy of potential donor alone should not be considered as a contraindication for organ donation and right liver lobe transplantation. Precise surgical technique, high transplantation activity, as well as experience of reconstructive interventions on the bile ducts during other operations can significantly reduce the incidence of AS after RLLDLT up to 9.7%.

Magnetic Compression Anastomosis in Laparoscopic Pancreatoduodenectomy: A Preliminary Study

BackgroundLaparoscopic pancreatoduodenectomy (LPD) is a minimally invasive technique widely developed in the last few decades. Although magnetic compression anastomosis (magnamosis) is used during cholangiojejunostomy, its applicability in LPD has not yet been reported. Herein, we evaluated the feasibility and effectiveness of magnamosis in LPD. MethodsBetween January 2018 and December 2019, seven patients who underwent laparoscopic magnetic compression choledochojejunostomy (LMC-CJ) or laparoscopic magnetic compression pancreatojejunostomy (LMC-PJ) in LPD were enrolled. After LPD, a parent magnet with or without a drainage tube was placed in the proximal bile duct and pancreatic duct of each patient. Daughter magnets were introduced to couple with the parent magnets at the desired sites. A close postoperative surveillance of magnet movements was performed. Various relevant data were collected, and all patients were followed up until February 2020. ResultsLPD was successfully completed in all seven patients, of which seven underwent LMC-CJ and two received LMC-PJ. The median time needed for completion of LMC-CJ was 11 min (range, 8-16). The cost time for the two cases of LMC-PJ was 12 and 15 min, respectively. After a median time of 50 d (range, 40-170) postoperation, all magnets were expelled. No leakages of LMC-CJ or LMC-PJ were observed after operation. After a median follow-up period of 11 mo (range, 4-18), there was no incidence of anastomotic stricture.

Uretero-Enteric Anastomotic Stricture Following Radical Cystectomy: A Comparison of Open, Robotic Extracorporeal, and Robotic Intracorporeal Approaches

ObjectivesTo compare the incidence of benign uretero-enteric anastomotic strictures between open cystectomy, robotic cystectomy with extracorporeal urinary diversion, and robotic cystectomy with intracorporeal urinary diversion. The effect of surgeon learning curve on stricture incidence following intracorporeal diversion was investigated as a secondary outcome. Patients and MethodsPatients who underwent radical cystectomy at an academic hospital between 2011 and 2018 were retrospectively reviewed. The primary outcome, incidence of anastomotic stricture over time, was assessed by a multivariable Cox proportional hazards regression. A Cox regression model adjusting for sequential case number in a surgeon's experience was used to assess intracorporeal learning curve. ResultsNine hundred sixty-eight patients were included: 279 open, 382 robotic extracorporeal, and 307 robotic intracorporeal. Benign stricture incidence was 11.3% overall: 26 (9.3%) after open, 43 (11.3%) after robotic extracorporeal, and 40 (13.0%) after robotic intracorporeal. An intracorporeal approach was associated with anastomotic stricture on multivariable analysis (HR 1.66; P = .05). After 75 intracorporeal cases, stricture incidence declined from 17.5% to 4.9%. Higher sequential case volume was independently associated with reduced stricture incidence (Hazard Ratio per 10 cases: 0.90; P = .02). ConclusionAn intracorporeal approach to urinary reconstruction following robotic radical cystectomy was associated with an increased risk of benign uretero-enteric anastomotic stricture. In surgeons’ early experience with intracorporeal diversion the difference in stricture incidence was more pronounced compared to alternative approaches; however, increased intracorporeal case volume was associated with a decline in stricture incidence leading to a modest difference between the 3 surgical approaches overall.

Clinical analysis of surgery for type III esophageal atresia via thoracoscopy: a study of a Chinese single-center experience

PurposeThe purpose of this study was to investigate the effectiveness and safety of the operation for type III esophageal atresia using a thoracoscope.MethodsThe clinical data for 92 patients with type III esophageal atresia in our hospital from January 2015 to December 2018 were analyzed retrospectively. There were 49 patients in group A who underwent thoracoscopic surgery and 43 patients in group B who underwent conventional surgery.ResultsThe mechanical ventilation time (55.7 ± 11.4 h vs 75.6 ± 19.2 h), intensive care time (3.6 ± 1.8d vs 4.7 ± 2.0d), postoperative hospitalization time (13.1 ± 2.2d vs 16.8 ± 4.3d), thoracic drainage volume (62.7 ± 25.5 ml vs 125.4 ± 46.1 ml), blood transfusion volume (30.5 ± 10.4 ml vs 55.3 ± 22.7 ml) and surgical incision length (2.0 ± 0.5 cm vs 8.0 ± 1.8 cm) in group A were lower than those in group B, and the differences were statistically significant (P < 0.05). Among the postoperative complications, the incidences of postoperative severe pneumonia (8.2% vs 23.3%), poor wound healing (2.0% vs 14.0%) and chest wall deformity (0% vs 11.6%) in group A were significantly lower than those in group B (P < 0.05). There was no significant difference in the incidence of anastomotic stricture, tracheomalacia or gastroesophageal reflux between the two groups after surgery and early during follow-up (P > 0.05), and there were no complications such as achalasia signs and esophageal diverticulum in either group.ConclusionSurgery for type III esophageal atresia via thoracoscopy has the same safety and clinical effectiveness as traditional surgery and has the advantages of smaller incision and chest wall deformity.

Clinical Analysis of Azygos Vein Preservation Under Thoracoscope in the Operation of Type III Esophageal Atresia.

Purpose: The aim of this study was to investigate the clinical effectiveness of azygos vein preservation when using a thoracoscope in the operation for type III esophageal atresia for children. Materials and Methods: We retrospectively analyzed the clinical data of 34 patients (group B) who underwent the thoracoscopic operation of type III esophageal atresia with azygos vein preservation from January 2017 to April 2018. The clinical data of 36 patients (group A) who underwent the thoracoscopic operation of type III esophageal atresia with azygos vein mutilation from April 2015 to December 2016 were selected as a control group. Results: All patients were successfully operated on. There was no significant difference in the operation time, amount of bleeding, mechanical ventilation time, and intensive care time between the azygos vein mutilation group and azygos vein preservation group. Compared with the operation severing the azygos vein, preservation of azygos vein has obvious advantages in postoperative hospitalization time, the incidence of anastomotic leakage (P < .05). The follow-up results for 1 year after the operation showed that the incidence of anastomotic stricture with preservation of azygos vein was significantly lower than that with azygos vein transection (P < .05). Conclusions: The thoracoscopic operation of type III esophageal atresia with azygos vein preservation can not only improve the edema of esophageal tissue around the esophagus, but also reduce the occurrence of esophageal anastomotic leakage and accelerate the postoperative recovery of children, and it has the same safety as the operation with azygos vein mutilation.

Incidence of anastomotic stricture after Ivor-Lewis oesophagectomy using a circular stapling device.

BACKGROUNDBenign oesophageal strictures carry a significant level of morbidity, causing burdensome symptoms impacting on quality of life. Post-oesophagectomy anastomotic stricture rates as high as 41% have been reported in the literature. These can require endoscopic dilatation, often multiple times to relieve dysphagia. The aim of the present study was to determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures, and to identify any independent risk factors in their development.AIMTo determine a single surgeons stricture rate in a series of 2-stage Ivor-Lewis procedures, and to identify any independent risk factors in their development.METHODSWe performed a retrospective analysis of a prospectively collected database of Ivor-Lewis oesophagectomy performed from 2004-2018 to determine the stricture rate. The database comprised a single-surgeon series of open, two-stage oesophagectomies with a circular stapled intra-thoracic anastomosis. Tumour location, histology, neoadjuvant chemotherapy, stapler size, T-stage and R-status were analysed to see if they could predict stricture formation. Stricture was defined as dysphagia requiring endoscopic dilatation. Patients with anastomotic leaks were excluded on the basis they would develop an anastomotic stricture.RESULTSOne hundred and seventy patients were collected in the database. Nineteen were excluded on the basis of anastomotic leak, perioperative death and early recurrence. One hundred and fifty-four patients (119 males, 35 females) with a mean age of 64 ± 10 years were eligible for analysis. A total of 15 patients developed strictures a median of 99 d (interquartile range: 84-133) after surgery, giving a Kaplan-Meier estimated stricture rate of 10% at one year. None of the factors considered were found to be significantly associated with strictures.CONCLUSIONIn this study the stricture rate was 10%, with the majority occurring in the first 100 d after surgery. No significant independent factors were found in the development of strictures.

Modified retroperitoneal laparoscopic dismembered pyeloplasty for children

We describe our modified retroperitoneal laparoscopic pyeloplasty (MRLP) and assess the incidence of anastomotic stricture and torsion of the ureter in the mid-term. We reviewed 12 patients with ureteropelvic junction obstruction (UPJO) we treated with MRLP between 2013 and 2018. MRLP involves: identifying the lowest point of the renal pelvis and the lateral aspect of the ureter to ensure correct orientation of the anastomosis; placing the first suture between the lower edge of the incised pelvis and the distal end of the spatulated ureter to avoid crushing tissue that will be anastomosed; and complete excision of the narrow segment. All MRLP were completed successfully without conversion. UPJO was resolved completely, both clinically and radiologically, in all cases. Mean age at surgery was 6.8 years (range: 1.7–8.8 years); mean operative time was 212.1 min (range: 170–333 min); mean estimated blood loss was 4.2 mL (range: 2–8 mL); mean follow-up was 36.7 months (range: 6–65 months); mean post-operative differential renal function on the affected side was 53.1 ± 13.7% (range: 37.0–87.2%), increased from 44.9 ± 16.0% (range: 27.0–84.3%), pre-operatively (p = 0.02). All remain completely cured after mean follow-up of 36.7 ± 19.7 months (range: 6–65). Our MRLP is safe and effective despite limited retroperitoneal space.

Should Proton Pump Inhibitors be Systematically Prescribed in Patients With Esophageal Atresia After Surgical Repair?

To evaluate outcomes of patients with esophageal atresia (EA) on systematic treatment with proton pump inhibitors (PPI) since the neonatal period and to determine factors associated with successful discontinuation of PPI. Longitudinal cohort study with prospective data collection of 73 EA patients, over 11 years systematically treated with PPI. Outcome and predictive factors for discontinuation of PPI treatment were evaluated at study end in February 2017. The incidence of anastomotic strictures was compared with a historical cohort of 134 EA patients followed in the same institution between 1990 and 2005 before the era of systematic PPI treatment. PPI treatment was discontinued definitively in 48% of patients during follow-up. Prematurity, longer initial hospitalization, moderate-to-severe tracheomalacia, anastomotic leak and anastomotic stricture had a significant negative association with PPI discontinuation on univariate analysis (P < 0.05). On adjusted multivariable Cox regression analysis, moderate-to-severe tracheomalacia and anastomotic leak were negatively associated with discontinuation of PPI treatment (hazard ratio 0.26 [95% CI 0.12-0.59]; P = 0.001 and hazard ratio 0.38 [95% CI 0.16-0.93]; P = 0.03, respectively). There was no significant difference in the incidence of anastomotic strictures in the present cohort compared with the historical cohort (44% vs 39%); (P > 0.05). PPI treatment does not prevent the formation of anastomotic strictures and appears to be over-prescribed in children with airway symptoms because of tracheomalacia. This suggests that PPI treatment could be prescribed more selectively. Close monitoring and long-term follow-up, however, of these vulnerable patients in specialized multidisciplinary clinics is imperative.