Anastomosis Rate Research Articles

Clinical efficacy of ladder neoadjuvant therapy in treatment of advanced mid-low rectal cancer

Objective: To explore the clinical efficacy of ladder neoadjuvant therapy in treatment of advanced mid-low rectal cancer. Methods: We performed a retrospective study of one hundred and eighty mid and low rectal cancer patients who underwent ladder neoadjuvant therapy(neoadjuvant chemotherapy followed by surgery if neoadjuvant chemotherapy was effective; neoadjuvant chemotherapy followed by neoadjuvant chemoradiotherapy if neoadjuvant chemotherapy was ineffective)(n=90) or neoadjuvant chemoradiotherapy (n=90). Results: In the ladder neoadjuvant therapy group, the descent stage rate was 85.6% (77/90), the anastomosis rate was 50.0% (45/90), the pre-sacral infection rate was 4.4% (4/90), the pathological complete remission (pCR) was 13.3%(12/90), R0 resection rate was 85.6% (77/90), the 2-year disease control rate was 76.7% (69/90), and the 2-year survival rate was 90.0% (81/90). In the control group, the descent stage rate was 88.9% (80/90), The anastomosis rate was 45.6% (41/90), the rate of pre-sacral infection was 11.1% (10/90), pCR was 16.7% 15/90), R0 resection rate was 88.9% (80/90), the 2-year disease control rate was 78.9% (71/90), and the 2-year survival rate was 87.8% (79/90). The difference was not statistically significant (P>0.05). The ladder neoadjuvant therapy group had lower prophylactic transverse colostomyrate(10.0% vs 34.4%), lower radiation injury rate (6.7% vs 27.8%), and lower sexual dysfunction rate (38.9% vs 87.8)compared to the control group. Conclusions: The ladder neoadjuvant therapy might reduce side injury caused by radiotherapy, improve compliance of patients, and reduce treatment costs. Moreover, the RO resection rate, 2-year local control rate and 2-year survival rate of ladder neoadjuvant therapy group was comparable with neoadjuvant chemoradiotherapy.

Comparison of Laparoscopic versus Open Surgery after Insertion of Self-Expandable Metallic Stents in Acute Malignant Colorectal Obstruction: A Case-Matched Study

Background: Self-expanding metallic stents (SEMS) have been acknowledged in management of acute colorectal obstruction. The surgical approach after SEMS insertion varies from open approach to laparoscopic-assisted approach. The primary objective of this study was to compare the outcomes of laparoscopic approach and open approach after SEMS insertion. Methods: From January 2007 to December 2010, cross-sectional medical records reviewed a total of 76 patients who underwent colorectal stenting with SEMS. Patients and tumor characteristics, complications, morbidity and mortality were obtained. Results: Forty-three patients underwent SEMS placement as a bridge to surgery. Laparoscopic-assisted surgery (LS) was performed in 24 patients (55.8%), and open surgery (OS) was performed in 19 patients (44.2%). All clinicopathological parameters were matched. The technical success of SEMS was found in 42 patients (97.7%), and the clinical stent success was 100%. LS had a higher chance of primary anastomosis than OS (p=0.012; Odd ratio 2.717; 95%CI: 1.79-4.012). LS had a lower permanent ostomy rate (p=0.031; Odd ratio 0.385; 95%CI: 0.259-0.572) and lower estimated blood loss (p=0.024; Odd ratio 0.23; 95%CI: 0.006-0.086). The post-operative complications, mortality rate, recurrence rate, disease free status, and overall survival rates between the two groups were non-significant. Conclusion: Colonic stent is an effective treatment of acute malignant colonic obstruction. The authors suggest the advantage of laparoscopic approach resection after colonic stenting results in a higher primary anastomosis rate, and lower blood loss than open surgery.

Self-Expanding Metallic Stent as a Bridge to Surgery in the Treatment of Left Colon Cancer Obstruction: Cost–Benefit Analysis and Oncologic Results

IntroductionThe use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost–benefit and long-term oncological outcomes of both therapeutic options. MethodsThis is a prospective, comparative, controlled, non-randomized study (2005–2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n=27) or emergency surgery (n=55) operated with local curative intention. The main outcome measures (postoperative morbi-mortaliy, cost–benefit, stoma rate and long-term oncological outcomes) were compared based on an “intention-to-treat” analysis. ResultsThere were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs 56.4%; P=.05). The mean costs in the emergency surgery group resulted to be €1391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. ConclusionsThe use of self-expanding metallic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis.

Stents metálicos autoexpandibles como puente a la cirugía en el tratamiento del cáncer de colon izquierdo en oclusión. Análisis coste-beneficio y resultados oncológicos

IntroductionThe use of a self-expanding metallic stent as a bridge to surgery in acute malignant left colonic obstruction has been suggested as an alternative treatment to emergency surgery. The aim of the present study was to compare the morbi-mortality, cost-benefit and long-term oncological outcomes of both therapeutic options. MethodsThis is a prospective, comparative, controlled, non-randomized study (2005-2010) performed in a specialized unit. The study included 82 patients with left colon cancer obstruction treated by stent as a bridge to surgery (n=27) or emergency surgery (n=55) operated with local curative intention. The main outcome measures (postoperative morbi-mortaliy, cost-benefit, stoma rate and long-term oncological outcomes) were compared based on an “intention-to-treat” analysis. ResultsThere were no significant statistical differences between the two groups in terms of preoperative data and tumor characteristics. The technically successful stenting rate was 88.9% (11.1% perforation during stent placement) and clinical success was 81.4%. No difference was observed in postoperative morbi-mortality rates. The primary anastomosis rate was higher in the bridge to surgery group compared to the emergency surgery group (77.8% vs. 56.4%; P=.05). The mean costs in the emergency surgery group resulted to be €1,391.9 more expensive per patient than in the bridge to surgery group. There was no significant statistical difference in oncological long-term outcomes. ConclusionsThe use of self-expanding metalllic stents as a bridge to surgery is a safe option in the urgent treatment of obstructive left colon cancer, with similar short and long-term results compared to direct surgery, inferior mean costs and a higher rate of primary anastomosis.

Venous anastomosis in free flap reconstruction after radical neck dissection: is the external jugular vein a feasible option?

Free microvascular tissue transfer has become a reliable and wellestablished technique in reconstructive surgery. Success rates greater than 95% are constantly reported in the literature. End-to-end anastomosis to the external jugular vein (EJ) is supposed to be equally successful as anastomosis to the internal jugular vein (IJ) in patients treated with selective neck dissection. No data has been published so far when the IJ had to be resected during neck dissection. The purpose of this study was to evaluate the success rate and complications of end-to-end anastomosis to the EJ in cases of (modified) radical neck dissection with resected IJ. A retrospective mono-center cohort study was performed. All patients with end-to-end anastomosis to either the IJ or EJ-system were reviewed. 423 free-tissue transfers performed between 2009 and 2016 were included. The overall success rate was 97.0% with an anastomotic revision rate due to venous thrombosis of 12.3%. In patients when the IJ had to be resected and the venous anastomosis was performed at the ipsilateral side to the EJ (n = 53), overall flap loss was significantly higher (5/53; 9.4%). The revision rate in these cases was 22.6%. Success rate of anastomosis to the EJ when the ipsilateral IJ was still intact was 100% (n = 20). Success rate when the anastomosis was performed at the contralateral side was 100%. End-to-end anastomosis to the EJ in cases with resected IJ is more likely to result in free flap loss. Furthermore, it is associated with a higher revision rate. Therefore, in cases with resected IJ, we suggest to plan the operation beforehand with anastomosis at the contralateral side whenever possible.

Impact of surgeon laparoscopic training and case volume of laparoscopic surgery on conversion during elective laparoscopic colorectal surgery.

The study aimed to determine whether laparoscopic volume and type of training influence conversion during elective laparoscopic colorectal surgery. An Institutional Review Board-approved prospective database was reviewed for patients who underwent colorectal resection, performed by six colorectal surgeons, for all diagnoses from 2009 to 2014. Surgeons were designated as laparoscopic- or open-trained based on formal laparoscopic colorectal surgery training, and were classified as low laparoscopic volume (LLV) (i.e. had performed <100 laparoscopic procedures) or high laparoscopic volume (HLV) (i.e. had performed ≥100 laparoscopic procedures). Technique was laparoscopic, open or converted (pre-emptive or reactive). Conversion was compared among three groups: LLV, laparoscopic trained (group A); LLV, open trained (group B); and HLV, open trained (group C). In total, 159/567 procedures were open and 408 laparoscopic procedures were attempted. Of the 408 laparoscopic procedures, 73 were converted. Among the 567 patients [meanage: 56±17years (44% male)], the overall conversion rate was 13% (73/567), including 75% pre-emptive and 25% reactive. Conversion rates for groups A, B and C were 17.9%, 42.6% and 14.3%, respectively. Significantly higher conversion was seen in group B compared with group C (P=0.01), but not between group A and group C (P = 0.85) or between group B and group A(P=0.11). Converted patients were older (P<0.001), with lower rates of proctectomy (P=0.007), higher rates of anastomosis (P<0.001) and higher body mass index (BMI) (P<0.001). After adjusting for patient and surgeon factors, training type was not associated with conversion (P=0.15). Compared with successful laparoscopy, converted patients had a significantly higher incidence of ileus (P<0.001), length of stay (P = 0.002), time to flatus (OR = 3.21, P<0.001) and time to solids (P<0.001). Converted patients experienced increased morbidity. Training is not associated with conversion. Rather, HLV surgeons, regardless of training, convert less frequently than do LLV surgeons.

Endoscopic stenting as bridge-to-surgery (BTS) in left-sided obstructing colorectal cancer: Experience with conformable stents

Compared to emergency surgery, self-expandable metallic stents are effective and safe when used as bridge-to-surgery (BTS) in operable patients with acute colorectal cancer obstruction. In this study, we report data on the new conformable colonic stents. To evaluate clinical effectiveness of conformable stents as BTS in patients with acute colorectal cancer obstruction. This was a retrospective study. The study was conducted at six Italian Endoscopic Units. Data about patients with acute malignant colorectal obstruction were collected between 2007 and 2012. All patients were treated with conformable stents as BTS. Technical success, clinical success, rate of primary anastomosis and colostomy, early and late complications were evaluated. Data about 88 patients (62 males) were reviewed in this study. Conformable SEMS were correctly deployed in 86 out of 88 patients, with resolution of obstruction in all treated patients. Tumor resection with primary anastomosis was possible in all patients. A temporary colostomy was performed in 40. Early complications did not occur. Late complications occurred in 11 patients. Stent migration was significantly higher in patients treated with partially-covered stents compared to the uncovered group (35% vs. 0%, P<0.001). Endoscopical re-intervention was required in 12% of patients. One patient with rectal cancer had an anastomotic dehiscence after surgery and he was successfully treated with endoscopic clipping. One year after surgery, all patients were alive and local recurrence have not been documented. This was a retrospective and uncontrolled study. Preliminary data from this large case series are encouraging, with a high rate of technical and clinical success and low rate of clinically relevant complications. Partially-covered SEMS should be avoided in order to reduce the risk of endoscopic re-intervention.

Safety and Efficacy of Sequential Left Internal Thoracic Artery Grafting to Left Circumflex Area

This study investigated short-term and long-term results of coronary artery bypass grafting (CABG) with in situ sequential left internal thoracic artery (LITA) grafting to the left circumflex area. The study divided 452 patients who underwent CABG with bilateral ITA grafting to the left coronary artery into two groups: 191 in the sequential group and 261 in the individual group. The 147 pairs were matched by the propensity score. In the matched pairs, the rates of off-pump, complete revascularization, and hospital death were comparable between the two groups. Early graft evaluation was performed in 78.6%. There was no occlusion of the sequential LITA graft itself, but 5 complications occurred involving the distal segment of the LITA graft (occlusion, 2; string, 2; and competition, 1), and 3 complications (occlusion, 2; and string, 1) developed in the individual group. Event-free anastomosis rates were 97.8% in the sequential group and 97.4% in the individual group (p= 0.847). Diamond anastomosis of proximal sequential grafting showed a better patency of the distal part of sequential anastomosis compared with a parallel anastomosis of proximal sequential grafting (98.4% vs 90.7%, respectively). The freedom from target lesion revascularization and overall survival at 8 years was 94.6% and 96.3% in the sequential and individual groups, respectively (log-rank p= 0.645) and 80.7% and 77.4% (p= 0.300), respectively. In situ sequential LITA grafting provides acceptable early graft patency and freedom from repeat revascularization, resulting in excellent survival. This technique is a useful strategy for multivessel revascularization including the left circumflex area.

Single Center Experience of Biliary Reconstruction in Living Donor Liver Transplantation: Duct-to-Duct Anastomosis

Background: Duct-to-duct anastomosis is the most common biliary reconstruction method in living donor liver transplantation. However, biliary complications can frequently occur. The objective of this study was to examine biliary complications and related risk factors of patients with living donor liver transplantation during the last 12 years in our institution. Methods: Surgical outcomes of 252 consecutive patients with duct-to-duct anastomosis for biliary reconstruction in living donor liver transplantation between December 2000 and July 2012 were analyzed retrospectively. Results: Among the 252 patients, there were 65 cases (25.8%) of biliary complications. Before 2010, the incidence of biliary complications was 30.4% (56 of 184 cases). After 2011, the incidence was significantly (P<0.05) decreased to 13.2% (nine out of 68 cases). The complication rate of anastomosis of two separated bile ducts of graft to recipient two separated bile ducts using cystic duct and common bile duct of recipient was 50% (10 out of 20), which was relatively higher compared to that of single to single duct anastomosis (47 out of 191, 24.6%) or multiple duct to single duct anastomosis (eight out of 41, 19.5%). Conclusions: Duct to duct anastomosis between two separated bile ducts of a graft to two separated bile ducts of a recipient, the most common biliary reconstruction method, was associated with higher rate of biliary complications. Complications related to biliary reconstruction of living donor liver transplantation was gradually decreased. Standardization of bile duct anastomosis might lead to sequential reduction of biliary complications in living donor liver transplantations.

Retrospective clinical analysis of surgical treatment for gastric stump carcinoma

To investigate the clinical feature and surgical procedures of gastric stump carcinoma (GSC) and to identify the prognostic factors which influence survival rate of GSC patients. Clinical data of 167 patients who underwent R0 resection for gastric stump carcinoma at Chinese People's Liberation Army General Hospital between January 1990 and December 2012 was collected. There were 144 male and 23 female cases. The clinicopathological features of GSC patients were compared between those who underwent initial surgery for benign disease (GSC-B group, 78 cases) and for gastric cancer (GSC-M group, 89 cases). The analysis of therapeutic methods and survival time were also performed.t-test was used to compare the quantitative data between two groups. Pearson χ(2) test was used to compare the various clinicopathological characteristics between the two groups. Kaplan-Meier method was used to analyze the survival rate. Multivariate survival analysis was based on the Cox proportional hazard model. Compared with GSC-M group, the interval time between initial gastrectomy and surgery in GSC-B group was longer ( (28.2±10.2) years vs. (10.8±1.0) years, t=15.902, P=0.001). There were 56 patients (71.8%) who received BillrothⅠ reconstruction in GSC-B group, and 49 patients (55.1%) who received BillrothⅡ reconstruction in GSC-M group, the difference of anastomosis method between the two groups was statistically significant (χ(2)=25.770, P=0.001). Compared with GSC-M group, the tumor of GSC-B group was usually located at the anastomotic site (χ(2)=6.975, P=0.031). The overall 1-, 3-, and 5-year survival rates of the 167 patients were 87%, 60%, and 41%. The 5-year survival rates for TNM stagesⅠ, Ⅱ, and Ⅲ were 65%, 43%, and 22%, respectively (P= 0.001). Multivariate analysis showed that small intestinal or esophageal infiltration (HR=1.957, 95%CI: 1.096 to 3.494, P=0.023), tumor location (HR=1.618, 95%CI: 1.104 to 2.372, P=0.014), and TNM stage (HR=2.307, 95%CI: 1.708 to 3.118, P=0.001) have independent effect on survival. The metastasis rates of perigastric lymph nodes, jejunum anastomosis and mesenteric lymph nodes were very high (56.3% and 65.2%, respectively). The GSC appears earlier in patients with gastrectomy for malignant disease than those with benign disease. Appropriate curative resection including residual lymph node dissection is very important to improve the prognosis. Small intestinal or esophageal infiltration, tumor location, and TNM stage have independent effect on survival.

Reevaluation of Self-Expanding Metal Stents as a Bridge to Surgery for Acute Left-Sided Malignant Colonic Obstruction: Six Years Experience

IntroductionSelf-expanding metal stents (SEMS) as a bridge to surgery have been used as an alternative for acute malignant left-sided colonic obstruction. However, the benefits are uncertain. The European Society of Gastrointestinal Endoscopy no longer recommends their use in patients with low surgical risk because of the risk of tumor recurrence. MethodsPatients admitted for acute malignant left-sided colonic obstruction who underwent SEMS as a bridge to elective surgery or urgent surgery were retrospectively evaluated. Postoperative morbidity/mortality, stent complications and survival were recorded. Our aim was to compare the outcome between preoperative SEMS and direct emergent surgery in acute left-sided malignant colonic obstruction. Results42 patients were included (SEMS group: 27 and surgery group: 15). There were no differences between groups in relation to age, ASA classification and tumor stage. The technical success of SEMS was 88.9% and the clinical success was 85.2%. There were three SEMS related perforations. In the surgery group, the stoma rate was higher (86.7% vs 25.9%, p<0.001) and there was a trend for a lower length of hospital stay (18.9 days vs 26.3 days, p=0.051).SEMS verses surgery group: There were no differences in the rate of temporary stoma (57.1% vs 61.5%, p=0.84), definitive stoma (42.8% vs 38.5%, p=0.84), success of primary anastomosis (86.7% vs 66.7%, p=0.22) and Clavien–Dindo classification (≥III: 36% vs 58.2% p=0.24). Overall survival at 1/5 years was identical in the two groups 100%/56% in the SEMS group vs 93%/43% in the surgery group, p=0.14), as well as tumor recurrence at 3/5 years (24%/50% vs 20%/36% respectively, p=0.68). ConclusionsSEMS are associated with a lower overall stoma rate and a higher primary anastomosis rate. However, there are no differences in complications, overall survival and recurrence between the groups.

Stochastic model of tumor-induced angiogenesis: Ensemble averages and deterministic equations.

A recent conceptual model of tumor-driven angiogenesis including branching, elongation, and anastomosis of blood vessels captures some of the intrinsic multiscale structures of this complex system, yet allowing one to extract a deterministic integro-partial-differential description of the vessel tip density [Phys. Rev. E 90, 062716 (2014)]. Here we solve the stochastic model, show that ensemble averages over many realizations correspond to the deterministic equations, and fit the anastomosis rate coefficient so that the total number of vessel tips evolves similarly in the deterministic and ensemble-averaged stochastic descriptions.

Blood Transfusion and Cervical Anastomotic Leakage in Esophageal Reconstructive Surgery

Introduction: Esophageal reconstruction is associated with significant blood loss and blood transfusion rates. Blood transfusion is a quick method of correction of anemia and rapid restoration of intravascular volume. However, concerns exist about the side effects of blood transfusion on the anastomotic complications. This prospective study aimed to report the impact of intraoperative blood transfusion on cervical anastomotic leak rate in esophageal reconstructive surgery Patients and methods: From 2006 to 2014, 85 the left isoperistaltic colon grafts based on the left colonic vessels were performed. There were 71 females and 14 males. The mean age of patients was 25 years. The mean preoperative haemoglobin (Hb) was 11.24 ± 9.23 g/dl. Operative blood loss 500 ml was used as threshold for ABT. The oesophagocolique anastomotic integrity was assessed by barium study. Impact of intraoperative allogeneic blood transfusion on the cervical anastomosis rate was studied. Statistical analyses were performed using Student’s t-test or the chi-square test. The multivariate analysis was performed by SPSS 11.0 for Windows (SPSS, Chicago, IL, USA). Results: The median operative duration was 3 hours. The median hospital stay was 14 days. The mortality rate was 2.4%. Graft necrosis occurred in two patients. Fifty patients received intra-operative allogeneic blood transfusion. Twenty seven patients were developed a cervical leak. There were 23 females and 4 males. Leak was occurred in 22 patients who received intraoperative ABT. The complete spontaneous healing of leak was obtained in all patients after a median delay of 7 days. The result of the univariate and multivariate analysis revealed that the intra-operative allogeneic blood transfusion was a predictive factor of cervical leak. Conclusion: The correction of preoperative anemia, meticulous surgical dissection, good haemostasis and the respect of the guidelines of blood transfusion may reduce intraoperative blood transfusion and related surgical site infection.

Placement of the Decompression Tube as a Bridge to Surgery for Acute Malignant Left-Sided Colonic Obstruction

PurposeThe aim of this study is to investigate the feasibility, safety, and effectiveness of placing the decompression tube as a bridge to surgery for acute malignant left-sided colonic obstruction. MethodsFrom January 2009 to August 2014, consecutive patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery in our center. The technical and clinical success of placing the decompression tube was evaluated. Clinical success was defined as relief of obstructive symptoms within 48 h after placing the decompression tube. Elective tumor resection was performed 7–9 days after colonic decompression. The types of surgery, primary anastomosis rate, and follow-up findings were analyzed. ResultsTwenty patients with acute malignant left-side colonic obstruction underwent placement of the decompression tube as a bridge to surgery. Placement of decompression tube was technically successful in all patients. No procedure-related complication occurred. Clinical success was achieved in 19 patients. Elective tumor resection and primary anastomosis were successfully performed in all 19 patients. The postoperative complications included wound infection (n = 2) and anastomotic stenosis (n = 1). ConclusionDecompression tube can serve as an easy, safe, and effective bridge to subsequent surgery for patients with acute malignant left-sided colonic obstruction.

Emergency left colonic resections on an acute surgical unit: does subspecialization improve outcomes?

Left-sided colonic pathologies requiring emergency resection are commonly encountered on an acute surgical unit. Subspecialist colorectal (CR) management of these patients may result in decreased morbidity, mortality and stoma rates. This study is the first of its kind comparing outcomes between CR surgeons and general surgeons on an acute surgical unit. This is a retrospective review of 196 consecutive patients who underwent emergency left colonic resection on an acute surgical unit between January 2009 and July 2014. Patients were divided into two groups dependent on whether their surgery was managed by a CR specialist or general surgeon. Primary outcome measures were 30-day mortality, rate of primary anastomosis and overall stoma rate. Patients in the two groups were comparable for age, sex, American Society for Anesthesiologists score as well as CR POSSUM scores. Rates of primary anastomosis were significantly higher in the CR group compared with the acute surgical unit group (85.5 versus 28.7%, P ≤ 0.001). Overall stoma rates were significantly lower in the CR group (40.4 versus 88.8%, P = 0.0001). Thirty-day mortality was similar in both groups. Other secondary markers of morbidity including length of stay, return to theatre, anastomotic leak rate, wound problems and systemic complications had no significant difference between the two groups. Subspecialist CR management of patients undergoing emergency left-sided colonic resection on an acute surgical unit is associated with a similar level of morbidity and mortality while safely achieving significantly higher rates of primary anastomosis and lower stoma rates.

Repeat Excision and Primary Anastomotic Urethroplasty for Salvage of Recurrent Bulbar Urethral Stricture

We compared the results of initial excision and primary anastomosis urethroplasty to the excision and primary anastomosis outcomes of other challenging reoperative clinical settings, including secondary cases (prior urethroplasty of any technique other than excision and primary anastomosis) and repeat cases (prior excision and primary anastomosis). We reviewed our database of patients who underwent excision and primary anastomosis urethroplasty for bulbar urethral stricture atour tertiary referral center from 2007 to 2014. Patients without available dataand those with a history of lichen sclerosus, radiation, pelvic fracture urethral injuries, distal strictures and/or hypospadias were excluded from analysis. Patient characteristics and outcomes were compared between those undergoing initial, secondary, and repeat excision and primary anastomosis urethroplasty for bulbar urethral stricture. Among 898 urethroplasties performed during the study period we identified 305 men who underwent excision and primary anastomosis urethroplasty ofthe bulbar urethra, including an initial procedure in 268 of 305 (88%) and reoperation in 37 (12%). Of patients with reoperation 18 of 37 (49%) underwent secondary excision and primary anastomosis following a different type of prior urethroplasty and 19 (51%) underwent repeat excision and primary anastomosis. Repeat excision and primary anastomosis in the bulbar urethra was successful in18 of 19 patients (95%), which was comparable to the success rate of initial bulbar excision and primary anastomosis (251 of 268 or 94%) as well as secondary bulbar excision and primary anastomosis (17 of 18 or 94%, p = 0.975) with a similar mean stricture length. Mean followup for all patients was 41.5 months (range 6 to 90) and mean followup in each group was greater than 30 months. Repeat excision and primary anastomosis urethroplasty has excellent results for short bulbar strictures, comparable to those achieved in the initial and secondary setting.

A retrospective study of end-to-side venous anastomosis for free flap in extremity reconstruction

IntroductionThe success of end-to-side (ETS) venous anastomosis primarily depends on several mandatory factors including recipient vessel selection and reconstruction site. This retrospective study was designed to analyze the success rate of ETS venous anastomosis for free flap extremity reconstruction. MethodsBetween 2009 and 2011, ETS venous anastomosis was performed in 117 patients to reconstruct soft tissue defects of extremity at Nanjing Drum Tower Hospital. The patients were divided into three groups: (1) only one large recipient vein left, (2) two deep venas, (3) one deep vein and one superficial vein. Medical records and the follow-up data were retrospectively reviewed. The success rates of the three groups were compared with Chi-squared test. ResultsTotally, 5, 52, and 60 patients were included in Group 1, Group 2, and Group 3, respectively. The overall surgery success rate was 96.6% (113/117) with four failures: zero in Group 1, two in Group 2 (2/52, 3.8%) and two in Group 3 (2/60, 3.3%), due to venous thrombosis. The re-anastomosis rate in re-exploration in Group 1, 2 and 3 was 0%, 1.9% (1/52), and 1.7% (1/60), respectively. No complication was observed during the operation. DiscussionNo statistical difference was observed in flap failure rate among the three different types of ETS anastomosis. This suggests that differences of the ETS anastomosis surgical site might not affect the surgery success rate. ConclusionThese results confirmed that the success rate of ETS anastomosis was not affected by the local conditions of surgery site.

Colonic perforation either during or after stent insertion as a bridge to surgery for malignant colorectal obstruction increases the risk of peritoneal seeding.

Endoscopic colorectal stenting may be performed as a bridge to surgery in patients with malignant colorectal obstruction, and has been reported to be associated with a high rate of successful primary anastomosis, low rate of stoma formation, and shorter hospital stay. However, the results of recent studies suggest that colorectal stenting could potentially worsen the prognosis. This study aimed to compare outcomes between patients who underwent colorectal stenting as a bridge to surgery and patients who underwent curative surgery only for malignant colorectal obstruction. This study included patients with malignant colorectal obstruction and symptomatic bowel dilatation who were treated by stenting as a bridge to surgery (stent group, n = 27) or surgical resection only (surgery-only group, n = 29) between May 2009 and May 2012. The short-term outcomes evaluated were the primary anastomosis rate, length of hospital stay, and rates of emergency and open surgery. The long-term outcomes evaluated were overall survival (OS) and recurrence-free survival (RFS). The primary outcomes were similar in the two groups. There were no significant differences between the stent and surgery-only groups in 3-year OS (85.2 vs. 82.8%; p = 0.655) or 3-year RFS (80.7 vs. 78.6%; p = 0.916). The odds ratio for seeded metastasis after perforation either during or after stent placement was 46.0 (95% CI, 2.0-1,047.8; p = 0.016). Colorectal stenting as a bridge to surgery showed no significant short- or long-term benefits compared with surgery only, and was associated with peritoneal seeding after perforation. Stenting before surgery should therefore only be considered in patients with a high risk of complications associated with emergency surgery.

Surgical treatment of Crohn's disease - type of ileocolonic anastomosis and anastomotic leak rate

Introduction Although the medical management is the mainstay treatment in Crohn’s disease, about 70% of the patients will require surgery during their lifetime. Aim The aim of this study was to analyse our experience for the period 2004-2012 and to evaluate the influence of the type of the ileocolonic anastomosis on the anastomotic leak rate. Material and methods A retrospective analysis of 41 operated patients due to complicated Crohn’s disease. Results The mean age of the included patients was 29.4 years (17-49), 31 males and 10 females. Sixty eight percent (n=28) of the cases were with ileocecal localisation. The types of operations performed was the following – 2 ileocecal resection, 26 right hemicolectomies, 4 strictureplasties, 4 small bowel resections, 1 sigmoid resection and adhesiolysis in 4. In the cases with ileocolonic localization, the surgery was indicated due to obstruction in 19 patients, high-output fistulas in 6 and abscess in 3. The mean hospital stay was 12.4 days (7-34). In 4 cases laparoscopic-assisted resection was performed with stapled side-to-side anastomosis. In the rest, the continuity of the gastrointestinal tract was performed by hand-sewn end-to-side anastomosis in 22 cases, side-to-side in 2. Anastomotic leak was noted in 1 case with side-to-side anastomosis (3.6%). Conclusions The surgery in Crohn’s disease is indicated only to overcome the related complications. A more conservative approach to preserve sufficient length of the bowels is recommendable. In the case with ileocolonic resections hand-sewn T-L anastomosis can be a safe method, especially when is performed in high-volume centers. Laparoscopic resection is а reliable alternative of the open surgery, but requires considerable experience.

Changes in the Surgical Approach to Colonic Emergencies during a 15-Year Period

Purpose: The present study aims to determine the morbidity and mortality of emergency colonic surgery and the factors associated with adverse outcome, and to evaluate any change in incidence of the different types of pathological conditions and in the surgical approach over the last 15 years. Materials and Methods: A total of 319 patients who underwent emergency colonic surgery between January 1997 and December 2011 were retrospectively analyzed. Patients were divided into two groups according to the date of surgery, namely group 1, between 1997 and 2006, and group 2, between 2006 and 2011. The differences in terms of postoperative outcomes between the groups were analyzed. Results: Overall postoperative morbidity and mortality rates were 25.3 and 17.2%, respectively; no differences were found between the groups. Group 2 showed a significantly increased rate of primary resection and anastomosis (p < 0.001), as well as an increase in laparoscopic approach compared with group 1 (p < 0.001). Conclusions: Emergency colon surgery is today primarily performed for benign diseases, of these the most common is diverticular disease followed by ischemic colitis. Age, comorbidities, and ischemic colon disease are predictors of adverse outcomes, while the surgical procedure per se is not.