Restoration Of Gastrointestinal Continuity Research Articles

Restoration of gastro-intestinal continuity after laparoscopic distal gastrectomy

Restoration of gastro-intestinal continuity after laparoscopic distal gastrectomy

Aortoesophageal fistula: A case report

Introduction: Aortoesophageal fistula (AEF) is a rare and potentially lethal cause of upper gastrointestinal bleeding. Although several causes have been implicated in this condition, a ruptured thoracic aortic aneurysm remains the most common cause. Despite the challenge of differential diagnosis, this is a situation that requires prompt action with immediate hemorrhage control. Case Report: We report a case of a 56-year-old woman who presented with hemorrhagic shock secondary to AEF with no underlying cause identified, treated with Thoracic Endovascular Aortic Repair (TEVAR) after immediate bleeding control with a Sengstaken–Blakemore (SB) tube. Post-operatively the patient developed pneumonia and operative wound infection that were treated conservatively. At 24 months follow-up, the patient is asymptomatic and there is no clinical, analytical, or imagiological evidence of vascular graft infection. Conclusion: Survival outcomes have improved with the advent of endoluminal aortic stent therapies and TEVAR is currently considered a viable approach for AEF bleeding control in the emergency setting for unstable patients. However, long-term concerns remain since TEVAR is not a definitive treatment for AEF defect, leaving the patients at risk for AEF recurrence but also for stent graft infection. Resection of the esophagus with restoration of gastrointestinal continuity and vascular reconstruction can be performed in a one or two stage procedure and is the definitive treatment for AEF.

Surgical Infection Society Guidelines for Total Abdominal Colectomy versus Diverting Loop Ileostomy with Antegrade Intra-Colonic Lavage for the Surgical Management of Severe or Fulminant, Non-Perforated Clostridioides difficile Colitis.

Background: Clostridioides difficile infection (CDI) can result in life-threatening illness requiring surgery. Surgical options for managing severe or fulminant, non-perforated C. difficile colitis include total abdominal colectomy with end ileostomy or creation of a diverting loop ileostomy with antegrade vancomycin lavage. Methods: The Surgical Infection Society's Therapeutics and Guidelines Committee convened to develop guidelines for summarizing the current SIS recommendations for total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for severe or fulminant, non-perforated C. difficile colitis. PubMed, Embase, and the Cochrane database were searched for pertinent studies. Severe infection was defined as laboratory diagnosis of C. difficile infection with leukocytosis (white blood cell count of ≥15,000 cells/mL) or elevated creatinine (serum creatinine level >1.5 mg/dL). Fulminant infection was defined as laboratory diagnosis of C. difficile infection with hypotension or shock, ileus, or megacolon. Perforation was defined as complete disruption of the colon wall. Total abdominal colectomy was defined as resection of the ascending, transverse, descending, and sigmoid colon with end ileostomy. For the purpose of the guideline, the terms subtotal colectomy, total abdominal colectomy, and rectal-sparing total colectomy were used interchangeably. Diverting loop ileostomy with antegrade enema was defined as creation of both a diverting loop ileostomy with intra-operative colonic lavage and post-operative antegrade vancomycin unless otherwise specified. Evaluation of the published evidence was performed using the Grades of Recommendation Assessment, Development and Evaluation (GRADE) system. Using a process of iterative consensus, all committee members voted to accept or reject each recommendation. Results: We recommend that total abdominal colectomy be the procedure of choice for definitive therapy of severe or fulminant, non-perforated C. difficile colitis. In select patients, colon preservation using diverting loop ileostomy with intra-colonic vancomycin may be associated with higher rates of ostomy reversal and restoration of gastrointestinal continuity but may lead to development of recurrent C. difficile colitis. Conclusions: This guideline summarizes the current Surgical Infection Society recommendations regarding use of total abdominal colectomy versus diverting loop ileostomy with antegrade lavage for adults with severe or fulminant, non-perforated C. difficile infection.

Caustic and Toxic Ingestions

Ingestion of caustic substances remains a potentially fatal public health concern with extensive morbidity and the possibility of long-term sequelae. The management strategies of these complex injuries continue to be extensively studied in the literature. Areas of interest include the most efficacious treatment of caustic esophageal stricture to preserve the native esophagus, use of steroids, and use of esophageal stents. Prevention of accidental ingestion through strategies to limit the availability of caustic substances is a key factor in reducing the incidence of injury, but there continues to be a high rate of accidental ingestion in developing countries with less rigorous manufacturing standards. Initial evaluation includes endoscopic evaluation of the esophagus and tracheobronchial tree. Optimal treatment strategies, including the use of proton pump inhibitors to reduce gastroesophageal reflux, steroid use to prevent stricture formation, and use of stents for management of strictures, continue to be debated. Initial surgical management includes esophagectomy for full-thickness injury with abdominal exploration. Multiple surgical options exist for both restoration of gastrointestinal continuity after esophagectomy and the management of strictures refractory to medical management, including reverse gastric tube, colonic interposition, and gastric advancement. Numerous small studies have evaluated the efficacy of these interventions, but there continues to be a need for larger prospective studies to develop a worldwide consensus opinion on best practices. We provide a review of the recent literature and practice recommendations for the management of injuries due to caustic ingestion. This review contains 7 figures, 10 tables, and 51 references. Key words: caustic ingestion, endoscopic management, stricture, surgical management

Caustic and Toxic Ingestions

Ingestion of caustic substances remains a potentially fatal public health concern with extensive morbidity and the possibility of long-term sequelae. The management strategies of these complex injuries continue to be extensively studied in the literature. Areas of interest include the most efficacious treatment of caustic esophageal stricture to preserve the native esophagus, use of steroids, and use of esophageal stents. Prevention of accidental ingestion through strategies to limit the availability of caustic substances is a key factor in reducing the incidence of injury, but there continues to be a high rate of accidental ingestion in developing countries with less rigorous manufacturing standards. Initial evaluation includes endoscopic evaluation of the esophagus and tracheobronchial tree. Optimal treatment strategies, including the use of proton pump inhibitors to reduce gastroesophageal reflux, steroid use to prevent stricture formation, and use of stents for management of strictures, continue to be debated. Initial surgical management includes esophagectomy for full-thickness injury with abdominal exploration. Multiple surgical options exist for both restoration of gastrointestinal continuity after esophagectomy and the management of strictures refractory to medical management, including reverse gastric tube, colonic interposition, and gastric advancement. Numerous small studies have evaluated the efficacy of these interventions, but there continues to be a need for larger prospective studies to develop a worldwide consensus opinion on best practices. We provide a review of the recent literature and practice recommendations for the management of injuries due to caustic ingestion. This review contains 7 figures, 10 tables, and 51 references. Key words: caustic ingestion, endoscopic management, stricture, surgical management

Laparoscopic mechanical latero-lateral esophagojejunostomy after total gastrectomy for cancer in the elderly: technical notes and results

The realization of an esophagojejunostomy is a critical step in total gastrectomy. Several techniques based on a Roux-En-Y restoration of gastrointestinal continuity were described with similar results. We report our laparoscopic experience in intracorporeal esophagojejunostomy. Adults who underwent laparoscopic total gastrectomy for cancer with latero-lateral (functional termino-terminal) Roux en Y intracorporeal esophagojejunostomy with linear stapler from January 2014 to December 2018 were included. Demographics, intra- and postoperative outcomes including 30-day readmissions and mortality were considered. Thirty-two patients were included. Nodal dissection D1 was 16. Median operative time was 280'. Median blood loss was 200 mL. Fluid oral intake is usually resumed on the second postoperative day and soft solid diet is started on the third postoperative day. Three patients had minimal anastomotic leakage and they underwent nonoperative management. Median postoperative stay was 8.5 days. This technique may improve the ergonomics of esophagojejunostomy creation. The procedure is suitable for experienced laparoscopic surgeons.

The Incidence of Low Anterior Resection Syndrome as Assessed in an International Randomized Controlled Trial (MRC/NIHR ROLARR).

To investigate the incidence of LARS in patients undergoing elective anterior resection within the MRC/NIHR ROLARR trial and to explore perioperative variables that might be associated with major LARS. Sphincter-preserving rectal cancer surgery is frequently accompanied by defaecatory dysfunction known as Low anterior resection syndrome (LARS). This is distressing for patients and is an unmet clinical challenge. An international, retrospective cohort study of patients undergoing anterior resection within the ROLARR trial was undertaken. Trial participants with restoration of gastrointestinal continuity and free from disease recurrence completed the validated LARS questionnaire between August 2015 and April 2017. The primary outcome was the incidence of LARS and secondary outcome was severity (minor versus major). LARS questionnaires were received from 132/155 (85%) eligible patients. The median time from surgery to LARS assessment was 1065 days (range 174-1655 d). The incidence of LARS was 82.6% (n = 109/132), which was minor in 26/132 (19.7%) and major in 83/132 (62.9%). The most common symptoms were incontinence to flatus (n = 86/132; 65.2%) and defaecatory clustering (88/132; 66.7%). In a multivariate model, predictors of major LARS were: 1 cm decrease in tumor height above the anal verge (OR = 1.290, 95% CI: 1.101,1.511); and an ASA grade greater than 1 (OR = 2.920, 95% CI: 1.239, 6.883). Treatment allocation (laparoscopic vs robotic) did not predict major LARS. LARS is a common after rectal cancer surgery and patients should be appropriately counselled preoperatively, particularly before surgery for low tumors or in comorbid populations.

Intestinal failure after bariatric surgery: Treatment and outcome at a single-intestinal rehabilitation and transplant center

BackgroundThough intestinal failure (IF) after bariatric surgery (BS) is uncommon, its prevalence is increasing. However, data on the outcomes for these patients are limited. ObjectivesTo analyze the outcomes of treatment for patients with IF after BS. SettingUniversity hospital. MethodsA single-center analysis (1991–2016) of outcomes according to treatment arms established by a multidisciplinary team. ResultsTwenty-five IF patients were identified (median age 45 yr). BS was 92% Roux-en-Y gastric bypass. The major cause of IF was volvulus/internal hernia (72%). Median time from BS to IF was 48 months. Treatment arms were intestinal rehabilitation (IR, n = 15), transplantation (TXP, n = 5), and parenteral nutrition (PN, n = 5). For IR, median bowel length was 60 cm. Forty-six percent ultimately discontinued PN. Twenty-seven percent were partially weaned PN and 27% failed IR. Common surgical rehabilitation was Roux-en-Y gastric bypass reversal and restoration of gastrointestinal continuity. The 5-year overall survival was 74%. For TXP, 7 patients were listed for TXP (5 initially and 2 after failed IR). Three underwent TXP, 2 isolated intestine and 1 isolated liver. Three were delisted (1 improvement and 2 death). For PN, 6 patients required long-term PN (5 initially and 1 after failed IR). Four patients are alive currently. ConclusionsIF after BS is an increasing problem facing IR centers. Internal hernia is the major cause. Surgical IR is the first-line therapy and affords the best outcome. TXP is reserved for rescuing patients who failed IR or develop PN complications. Long-term PN is suitable for patients in whom IR or TXP is impractical.

Using intestinal segments during secondary salvage procedures after failed reconstructions of the cervical oesophagus

The free anterolateral thigh (ALT) flap is commonly used for the reconstruction of the cervical oesophagus with satisfactory results. Its convenience and popularity make it a popular flap for reconstructive surgeons. The use of intestinal flaps, however, carries a higher level of technical difficulty and is normally performed as a primary reconstructive procedure. This report investigates the feasibility of intestinal flaps for the reconstruction of the cervical oesophagus and strategies to optimize its success when used as a secondary flap after primary ALT flap failure. We retrospectively reviewed 22 patients (age 39-72 years) who were men, between April 2013 and January 2015, with intestinal segments (free and pedicled ileocolon, jejunal and colon flaps) that were used secondarily to salvage failed primary free ALT flap reconstructions after hypopharyngeal cancer resection. Ten patients presented with leakage and 2 with tracheo-oesophageal fistulae as complications from the primary flap failure. Oral intake commenced around 1-month postoperatively. One case of flap failure was observed. The majority had no major postoperative complications. Patients were followed up (6-27 months), and 21 cases of a secondary intestinal flap were successful with the restoration of oesophageal continuity and oral intake. Intestinal flaps, free or pedicled, can be used secondarily after failed ALT flap reconstructions with minimal complications or morbidity. Intestinal flaps successfully allow restoration of gastrointestinal continuity with early commencement of oral intake and swallowing function.

Current concepts in the management of enterocutaneous fistula

Enterocutaneous fistula is an abnormal connection between the intra-abdominal gastrointestinal tract and skin. It causes considerable morbidity and mortality. The goals of management are restoration of gastrointestinal continuity and allowance of enteral nutrition with minimal morbidity and mortality. A multidisciplinary approach is essential in the successful management and this has led to closure rates ranging from 5-20% following conservative management and 75-85% with operative treatment. This article seeks to review the current concepts in the management of enterocutaneous fistula. A systematic search of literature on enterocutaneous fistula was conducted. Relevant materials were selected and selected references from relevant books, journal articles and abstracts using Medline, Google scholar and Pubmed databases were critically reviewed. Enterocutaneous fistulas can be classified by the anatomy, aetiology or physiology. Anatomically, enterocutaneous fistula has been classified based on the organ of origin and this is useful in the consideration of management options: type l (abdominal oesophageal and gastroduodenal fistula), type ll (small bowel fistula), type lll (large bowel fistula) and type IV (enteroatmospheric, regardless of origin. The anatomy also depends on the presence or absence of associated abscess cavity and the length and characteristics of the fistula tract. Aetiologically, the majority of enterocutaneous fistulas are iatrogenic (75-85%) while between 15 and 25% occur spontaneously. The physiological classification is based on the volume of its output. High output fistulas drain more than 500mls in 24 hours, moderate output between 200 and 500mls in 24 hours and low output less than 200mls in 24 hours. Successful management requires a multidisciplinary approach and would consist of initial resuscitaion with fluids and electrolytes, control of sepsis, good and adequate nutrition, wound care and skin protection and definitive management. The treatment of enterocutaneous fistula is multidisciplinary and remains a challenge despite the recent improvement in supportive care. Once enterocutaneous fistula occurs, adequate stabilization of the patient and non-operative management should be commenced. If surgery is required, careful planning, meticulous dissection, restoration of bowel continuity and reconstruction of abdominal wall are critical.

Colonic Histological Criteria Predict Development of Pouchitis after Ileal Pouch: Anal Anastomosis for Patients with Ulcerative Colitis

Background/Aims: Pouchitis is one of the main complications after ileal pouch-anal anastomosis in patients with ulcerative colitis. The aim of this study was to determine whether the use of colonic histological criteria can predict the development of pouchitis. Methodology: We retrospectively reviewed 147 patients' clinical data and performed a histological evaluation of the resected total colon using Tanaka's criteria, which comprise the following 6 factors: ulceration (H₁), crypt abscesses (H₂), degree of mononuclear cell infiltration (MNCI) (H₃), segmental distribution of MNCI (H₄), eosinophil infiltration (H₅), and extent of disease of resected colon (H₆). Results: The development of pouchitis and chronic pouchitis within 3 years after restoration of gastrointestinal continuity was recognized in 52 (35.4%) and 26 (17.7%) of the 147 patients, respectively. Using various combinations of each score, the H₃ + H₄ - H₅ scores of patients with pouchitis or chronic pouchitis were significantly higher than those of patients without. A H₃ + H₄ - H₅ score of >0.4 was a statistically significant risk factor for the development of both pouchitis and chronic pouchitis. Conclusions: The combination of the degree of MNCI, segmental distribution of MNCI, and eosinophil infiltration from histological criteria has utility in predicting the future development of pouchitis, especially chronic pouchitis.

Management of low colorectal anastomotic leak: Preserving the anastomosis.

Anastomotic leak continues to be a dreaded complication after colorectal surgery, especially in the low colorectal or coloanal anastomosis. However, there has been no consensus on the management of the low colorectal anastomotic leak. Currently operative procedures are reserved for patients with frank purulent or feculent peritonitis and unstable vital signs, and vary from simple fecal diversion with drainage to resection of the anastomosis and closure of the rectal stump with end colostomy (Hartmann's procedure). However, if the patient is stable, and the leak is identified days or even weeks postoperatively, less aggressive therapeutic measures may result in healing of the leak and salvage of the anastomosis. Advances in diagnosis and treatment of pelvic collections with percutaneous treatments, and newer methods of endoscopic therapies for the acutely leaking anastomosis, such as use of the endosponge, stents or clips, have greatly reduced the need for surgical intervention in selected cases. Diverting ileostomy, if not already in place, may be considered to reduce fecal contamination. For subclinical leaks or those that persist after the initial surgery, endoluminal approaches such as injection of fibrin sealant, use of endoscopic clips, or transanal closure of the very low anastomosis may be utilized. These newer techniques have variable success rates and must be individualized to the patient, with the goal of treatment being restoration of gastrointestinal continuity and healing of the anastomosis. A review of the treatment of low colorectal anastomotic leaks is presented.

405. The use of the ileocecal segment of bowel for reconstruction after combined gastrectomy

Background: Gastrectomy remains the radical treatment of gastric cancer. The choice of method of restoration of gastrointestinal continuity after gastrectomy is a major factor in the incidence of various organic and functional disorders of the digestive system, especially esophagitises. Tumor invasion to the transverse colon requires transversectomy. Recovery phase of this operation using the ileocecal segment reduces the risk of insolvency of colonic anastomoses and prevent the development of reflux esophagitis. Materials and methods: The study is based on an analysis of the results of treatment 338 patients with locally advanced gastric cancer who were treated at the Institute of General and Urgent Surgery of Academy of Medical Sciences from 1998 till 2013, aged from 29 to 86 years. Mean age was 62.9 years. 208 were males (61.5%), 130 were females (38.5%). All patients showed tumor spread to nearby organs: the pancreas e in 81 (32.9%), colon and mesocolon e in 62 (25.2%), liver e 46 (12.2%), esophagus e in 38 (10, 6%), spleen e 21 (5.0%), diaphragm e 16 (4.3%), hepatoduodenal ligament e 19 (4.0%), duodenum (duodenum) e 9 (3.6%) and invasion in several organs e in 46 (18.2%) patients. Results: Gastrectomy with combined resection of the transverse colon, good intraoperative conditions, we used esophagogastroplasty by ileocecal segment of the intestine (18 patients). The essence of the method is to separate the ileocecal segmentwith the supplying vessel (a. ileocolica),move it to the position of the stomach and the formation of esophago-ileoanastomosis ’end to side’ or ’end to end’ and ceco-duodenoanastomosis. It should be stressed that in such a reconstruction the ileocecal valve is present, which replaces a Gubarev valve and warns gastro e and duodeno-esophagal reflux. Availability of isoperistaltic reconstruction, with the inclusion of duodenum into digestion, and presence of ileocecal valve creates good conditions for the functioning of graft displaced into stomach position, preventing duodeno-esophageal reflux. Among patients undergoing gastro-esophagoplasty by ileocecal segment early postoperative deathswere not reported. On examination in a period of 3 to 9 months, no symptoms of reflux esophagitis were found in patients with ileocecal segment gastroplasty. Radical surgery was performed in 131 (38.7%) patients, palliative and symptomatic in 207 (61.3%). Postoperative complications occurred in 128 (37.9%) patients. Postoperative mortality was 18.3% (62 patients), general mortality e 22.8% (77 patients). The average follow up from radical surgery group and palliative surgery group was 28 months and 16 months respectively. Median survival rate in groups was 16.3 and 9.3 months. Conclusions: Use of the ileocecal segment of colon after combined gastrectomy and traversectomy provides good results, is the prevention of reflux esophagitis development. No conflict of interest.

Sphincter Saving Surgeries for Locally Advanced Low Rectal Cancer after Neoadjuvant Chemoradiation

Background: Rectal cancer accounts for the largest distribution within one anatomical region of the large bowel, with approximately one third of all CRC located within the rectum. The Golden standard treatment of primary rectal cancer is curative surgical resection; however, a fine balance remains between disease cure and restoration of gastrointestinal continuity. Combined modality has proven efficacy in many malignant tumors with advantage of organ preservation. Methods: Forty nine (49) patients with low rectal carcinoma were included in a prospective study, between Jan 2007 and Jan 2012. Preoperative chemoradiation was administrated to all patients and subjected to different techniques of sphincter saving surgery. Stage I and Stage IV disease at diagnosis were excluded from the study. Results: Forty nine patients were included in the study. 27 (55%) patients were male and 22 (45%) were female; the age ranges from 23 years to 70 years with the median age 46 years. The main presenting symptoms were bleeding per rectum and tenesmus, Stage II 18 patients (36.7%), stage III 31 patients (63.3%). Complete clinical and pathological response in 3 patients (6%), and complete clinical response with only microscopically residual carcinoma in 20 patients (41%), partial response in 18 patients (36.7%), and no significant response in 8 patients (16%) 7 from 8 were mucoid carcinoma. Low anterior resection (LAR) in 22 patients (44.9%), Hartman’s procedure in 4 patients (8.1%), Coloanal pull-through (COP) was done in 19 patients (38.9%) and perineal colostomy in 4 patients (8.1%). For patients with colo-anal pull-through technique complete dehiscent and retraction observed in 2 cases, Major leakage in one case, stenosis in 4 cases. Conclusion: There is tendency of colorectal cancers to affect younger groups. Most patients presented in advanced stage. Neadjuvant chemo radiation is an excellent tool in sphincter saving surgery. Coloanal pull-through technique is not a widely spread technique for low rectal cancer with good oncological safety and acceptable functional outcome.

P-0290 Sphincter Saving Surgeries For low Rectal Cancer After Neoadjuvant Chemoradiation

ABSTRACT Introduction Rectal cancer accounts for the largest distribution within one anatomical region of the large bowel, with approximately one third of all CRC located within the rectum. The gold standard treatment of primary rectal cancer is curative surgical resection; however, a fine balance remains between disease cure and restoration of gastrointestinal continuity. Combined modality has proven efficacy in many malignant tumors with advantage of organ preservation. In this study we assess different surgical techniques after chemoradiation to preserve anal sphincter Methods Forty nine patients (49) patients with low rectal carcinoma were included in a prospective study, between Jan. 2007 and Jan. 2011. Preoperative chemo radiation was administrated to all patients and subjected different techniques of sphincter saving surgery. Stage IV disease at diagnosis were excluded from study. Results Forty nine patients (49) patients were included in the study. 27 (55%) patients were male and 22 (45%) were female, the age range from 23 years to 70 years with the mean age 38 years. The main presenting symptoms were bleeding per rectum and Tenesmus. Stage I 4 patients (8.1%), stage II 15patients (30.6%), Stage III 30 patients (61.2. Complete clinical and pathological response in 3 patients (6%), complete clinical response in 11 patients (22%), partial response in 27 patients (55%), no significant response in 8 patients (16%). low anterior resection (LAR) in 22 patients (44.9%), Hartman's procedure in 4 patients (8.1%), coloanal pull through ( COP) was done in 19 patients (38.9%) and perineal colostomy was done in 4 patients(8.1). For patients with coloanal pull-through technique complete dehiscent and retraction in one case, major leakage in one case, stenosis in 4 cases. Conclusion There is tendency of colorectal cancers to affect younger groups. Most patients presented in advanced stage due to lack of awareness. Neoadjuvant chemo-radiation is an excellent tool in sphincter saving surgery. Coloanal pull-through operation is new technique for very low rectal cancer with good oncological safety and functional outcome.

Eastern Association for the Surgery of Trauma: A Review of the Management of the Open Abdomen—Part 2 “Management of the Open Abdomen”

During the course of the last 30 years, several authors have contributed their clinical experience to the literature in an effort to describe the various management strategies for the appropriate use of the open abdomen technique. There remains a great degree of heterogeneity in the patient population, and the surgical techniques described. The open abdomen technique has been used in both military and civilian trauma and vascular and general surgery emergencies. Given the lack of consistent practice, the Eastern Association for the Surgery of Trauma (EAST) Practice Management Guidelines Committee convened a study group to establish recommendations for the use of open abdomen techniques in both trauma and nontrauma surgery. This has been a major undertaking and has been divided into two parts. The EAST practice management guidelines for the open abdomen part 1 “Damage Control” have been published.1 During the development of the open abdomen part II “Management of the Open Abdomen,” the current literature remains contentious at best, current methods of treatment continue to change rapidly, and patient populations are so heterogeneous that clear recommendations could not be provided. What follows is a thorough review of the current literature for the management of the open abdomen: part 2 “Management of the Open Abdomen” and provides clinical direction regarding the following specific topics.

Minimally invasive esophagectomy with two-field lymphadenectomy

Curative surgical therapy for esophagogastric cancer has three fundamental principles: (1) resection of part or all of the affected organs (esophagus, stomach) with adequate clearance of the primary tumor, (2) removal of local and regional lymph nodes to eliminate potential metastatic disease, and (3) restoration of gastrointestinal continuity with satisfactory function. During the past century, a wide variety of different techniques in pursuit of these principles have been described, but to date no consensus has been reached as to which approach is ideal. Radical resections involving a thoracotomy and laparotomy in theory offer the greatest chance for long-term disease-free survival but are associated with substantial morbidity and significant impairment of postsurgical quality of life [1]. Less invasive techniques, although perhaps better tolerated, may fail to achieve the same oncologic goals. With the advancement of videoscopic technology and its application to surgery from the late 1990s onward, the concept of a minimally invasive resection using thoracoscopic and laparoscopic rather than open approaches has been an attractive aim. The intention is to achieve a curative resection but with substantially less surgical trauma relating to operative access. Initial enthusiasm was, however, dampened when early case series reported only limited success in achieving these aims. Not until the experience described by Luketich et al. [2] did it become apparent that minimally invasive esophagectomy (MIO) might offer a viable alternative to traditional open surgery. The Exeter technique of MIO, based heavily on that described by Luketich et al. [2], offers a thoracoscopic, laparoscopic esophagectomy with two-field, radical lymph node clearance. Our initial experience confirms that this procedure can be performed successfully with low operative mortality and morbidity as well as good short-term outcomes [3].

Factors affecting reversal following Hartmann’s procedure: Experience from two district general hospitals in the UK

Restoration of gastrointestinal continuity following Hartmann's procedure is a challenging task associated with significant morbidity and mortality. New strategies to avoid a stoma are not readily available in general hospitals. Knowledge of the factors related to reversal is required to develop treatment strategies and counsel patients realistically. The present study was conducted to determine the reversal rate and factors affecting Hartmann's reversal in our practice. This study retrospectively reviewed the medical records of patients who underwent Hartmann's procedure and its reversal in two United Kingdom District Hospitals between January 1996 and December 2005. Case notes from 184 patients were reviewed. Hartmann's procedure was reversed in 51 (34.7%) of the surviving patients, with a complication rate of 37.3% and no mortality. Reversal of Hartmann's procedure was significantly related to patient age (P < 0.001), mode of admission (P = 0.003), American Society of Anesthesiologists grading (P = 0.003), Dukes' staging (P = 0.003), benign pathology (P = 0.001), and extracolonic cancer (P = 0.023). Despite the challenging nature of Hartmann's reversal, colostomy closure can be achieved without mortality in a district general hospital. Familiarity with the factors associated with reversal should enable a genuine discussion with patients regarding reversal.

Extended Stent Usage for Persistent Esophageal Leak: Should There Be Limits?

A patient with a spontaneous esophageal perforation was unsuccessfully managed elsewhere by repeated stent placement. Because of inability to remove the stents and persistent empyema, staged procedures of esophagectomy and later restoration of gastrointestinal continuity were necessary.

Laparoscopic subtotal colectomy for medically refractory ulcerative colitis: the time has come

To evaluate laparoscopic versus open subtotal colectomy (STC) in patients with ulcerative colitis (UC) requiring urgent or emergent operative intervention. A retrospective review was performed of 90 patients with medically refractory UC who underwent STC with end ileostomy at The Mount Sinai Medical Center from 2002 to 2007. Patients with toxic megacolon were excluded. Univariate analysis was conducted by unpaired Student t-test and chi-square test. Results are presented as mean +/- 95% confidence interval. Ninety patients underwent STC, 29 by laparoscopic and 61 by open approach. In patients undergoing laparoscopic versus open STC, intraoperative blood loss was decreased (130.4 +/- 38.4 vs. 201.4 +/- 43.2 ml, p < 0.05) and operative time prolonged (216.4 +/- 20.2 vs. 169.9 +/- 14.4 min, p < 0.01). In the absence of postoperative complication, hospital length of stay (4.5 +/- 0.7 vs. 6 +/- 1.3 days, p < 0.001) was shorter in laparoscopic versus open group. No mortalities occurred. Overall morbidity, 30-day readmission, and reoperation were equivalent regardless of operative approach. Wound complications were absent in the laparoscopic group compared with 21.4% in the open group (p < 0.01). Follow-up at a mean of 36 months demonstrated no difference in restoration of gastrointestinal continuity. Laparoscopic STC confers the benefits of improved cosmesis, reduced intraoperative blood loss, negligible wound complications, and shorter hospital stay. Laparoscopy is a feasible and safe alternative to open STC in patients with UC refractory to medical therapy requiring urgent or emergent operation.