Stump Leakage Research Articles

Current practice on the use of prophylactic drain after gastrectomy in Italy: the Abdominal Drain in Gastrectomy (ADiGe) survey

Evidence against the use of prophylactic drain after gastrectomy are increasing and ERAS guidelines suggest the benefit of drain avoidance. Nevertheless, it is unclear whether this practice is still widespread. We conducted a survey among Italian surgeons through the Italian Gastric Cancer Research Group and the Polispecialistic Society of Young Surgeons, aiming to understand the current use of prophylactic drain. A 28-item questionnaire-based survey was developed to analyze the current practice and the individual opinion about the use of prophylactic drain after gastrectomy. Groups based on age, experience and unit volume were separately analyzed. Response of 104 surgeons from 73 surgical units were collected. A standardized ERAS protocol for gastrectomy was applied by 42% of the respondents. Most of the surgeons, regardless of age, experience, or unit volume, declared to routinely place one or more drain after gastrectomy. Only 2 (1.9%) and 7 surgeons (6.7%) belonging to high volume units, do not routinely place drains after total and subtotal gastrectomy, respectively. More than 60% of the participants remove the drain on postoperative day 4–6 after performing an assessment of the anastomosis integrity. Interestingly, less than half of the surgeons believe that drain is the main tool for leak management, and this percentage further drops among younger surgeons. On the other hand, drain’s role seems to be more defined for duodenal stump leak treatment, with almost 50% of the surgeons recognizing its importance. Routine use of prophylactic drain after gastrectomy is still a widespread practice even if younger surgeons are more persuaded that it could not be advantageous.

Use of a Bipolar Device (LigaSure) to Seal the Appendiceal Stump in Pediatric Laparoscopic Appendectomy: 10-year Latin-American Experience

BackgroundClosure of the appendiceal stump is a critical step during an appendectomy. There is a lack of knowledge about the feasibility of using electrosurgical devices for the occlusion of the appendix. This study aims to determine the safety of this technique in pediatric patients. MethodsWe performed a cross-sectional analytical study in patients less than 18 years of age treated at Hospital Militar Central Colombia between 2012 and 2021. Our institution's ethics committee approved the study. We analyzed the data using SPSS 22 statistical program. We present frequencies for qualitative variables and measures of central tendency or dispersion for quantitative variables depending on the distribution measured by the Kolmogorov-Smirnov test. In addition, we measured the association of nominal variables with the Chi-square test or Fisher's exact test. For numerical variables, the difference of means with the Student's t-test or the difference of medians with the Mann-Whitney U test. ResultsWe treated 209 patients. One hundred sixteen (55.5%) were boys, and the mean age was 9.7 years (SD 3.2). The median intraoperative time was 60 min, and the hospital stay was 2.8 days on average. There were no cases of stump leakage, and only two patients (1%) had an organ-space surgical site infection, which was unrelated to the closure technique. We found no association between procedural complications and appendicular status (p = 0.450). ConclusionsOur research suggests that using a bipolar sealing device (Ligasure, Medtronic, USA) for appendiceal stump closure in pediatric patients undergoing laparoscopic appendectomy is feasible and should be further studied. Type of StudyTreatment study. Level of evidenceLevel III

Robotic radical distal gastrectomy for gastric cancer using the soft coagulation scissors technique.

We have developed a novel technique for safe and precise lymph-node dissection during robotic gastrectomy for gastric cancer using monopolar curved scissors with soft coagulation. This technique is called the soft coagulation scissors technique. The technical details of this technique are as follows: a long bipolar grasper in the first arm and monopolar curved scissors in the third arm are primarily used for lymph-node dissection, maximizing the use of the robotic arm articulation. The monopolar curved scissors were energized in the soft coagulation mode of the Valleylab™ FT10 energy platform or in the forced coagulation mode of the ERBE VIO®dV with an effect 1/power limit of 15W. This limit was confirmed to be equivalent to the soft coagulation mode in preliminary experiments, and a long bipolar grasper applied adequate tension to the surgical site without strongly grasping the tissue or applying traction. The peak temperatures of our devices were more than 100°C lower than those of the Harmonic ACE and the Maryland bipolar forceps with the forced coagulation mode. Overall, 80 patients with gastric cancer, including 36 (45.0%) with stage III or IV cancers, underwent robotic distal gastrectomy with this technique. The median estimated blood loss was 10g. There were only four surgical complications (5.0%): two paralytic ileus, one intra-abdominal abscess, and one duodenal stump leakage. Robotic distal gastrectomy for gastric cancer is made possible by the soft coagulation scissors technique, which allows for safe and precise lymph-node dissection.

259. COMPARISON OF GREATER CURVATURE AND LESSER CURVATURE CIRCULAR-STAPLED ESOPHAGOGASTROSTOMY AFTER ESOPHAGECTOMY IN ESOPHAGEAL CANCER PATIENTS: A PROSPECTIVE RANDOMIZED CONTROLLED TRIAL

Abstract Using a circular stapler to create an anastomosis for esophagogastrostomy after esophagectomy is well accepted; however, it remains uncertain if the greater curvature (GC) or lesser curvature (LC) of the gastric conduit is better for the anastomosis. We conducted this prospective study to compare the integrity of esophagogastrostomy between the esophagus and the GC or LC side of the gastric conduit. The subjects of this study were 70 patients who underwent esophagectomy and were randomized to a ‘GC’ group and an ‘LC’ group (n = 35 each). The primary and secondary end points were anastomotic leakage (AL) and anastomotic stricture (AS), respectively. The overall AL rate was 22.1%, without a significant difference between the groups. Stump leakage developed in eight of nine patients in the GC group, whereas leakage developed at the esophagogastric anastomosis in five of six patients in the LC group. The rate of stump leakage was significantly higher than that of esophagogastric AL in the GC group. The overall AS rate was 4.4%, with a significant difference between the groups (0% in the GC group vs. 9.1% in the LC group). AL rates were comparable in the two groups, but the sites of leakage were significantly different.

Impact of postoperative NSAIDs (IV-PCA) use on short-term outcomes after laparoscopic gastrectomy for the patients of gastric cancer.

Further data are necessary to evaluate the risk of complications associated with the use of non-steroidal anti-inflammatory drugs (NSAIDs) postoperatively. This study aimed to determine the correlation between the use of NSAIDs in intravenous patient-controlled analgesia (IV-PCA) and postoperative complications after laparoscopic gastrectomy in patients with gastric cancer. This retrospective, single-center study was conducted. The study population comprised 2150 patients who underwent laparoscopic gastrectomy for gastric cancer treatment. They were divided into two groups: non-NSAIDs (n = 1215) and NSAIDs (n = 935) according to their use of the drugs. Clinicopathologic characteristics, operative details, postoperative complications within 30days, risk factors for complications, and survival were analyzed. Of the 2150 patients, 935 (43.49%) used NSAIDs. The overall complication rate showed no significant difference between the NSAIDs and non-NSAIDs groups (22.7% vs. 20.7%, p = 0.280), while the rates of anastomotic leakage and duodenal leakage were higher in the NSAID group (2.4% vs. 0.7%, p = 0.002 and 1.8% vs. 0.6%, p = 0.007, respectively). The rates of intra-abdominal bleeding and intra-abdominal abscess were significantly higher in the NSAID group (2.1% vs. 0.7%, p = 0.005 and 1.5% vs. 0.4%, p = 0.008, respectively). However, postoperative ileus occurred more frequently in the non-NSAID group (3.0% vs. 1.4%, p = 0.015). On multivariate analysis, NSAID use was an independent risk factor for early postoperative complications (1.303 [1.042-1.629], p = 0.020). Meanwhile, the NSAID group showed no differences in overall survival at each pathological stage. Postoperative NSAID use by IV-PCA is associated with anastomotic leakage, duodenal stump leakage, intra-abdominal bleeding, and intra-abdominal abscess in patients who underwent laparoscopic gastrectomy for gastric cancer. Caution is advised when NSAIDs are used peri-operatively.

Acute appendicitis in pregnancy; A single center experience

Objective
 Appendicitis is the most common cause of extrauterine acute abdomen during pregnancy. There are scoring systems, such as Alvarado, based on physical examination and laboratory values developed for the diagnosis of appendicitis in the general population. However, when it comes to pregnant women, the effectiveness of the methods used in daily practice decreases considerably. In our study, we aimed to share the data of our patients who were diagnosed with acute appendicitis during pregnancy in our clinic.
 Material methods
 Pregnant women who were operated for acute appendicitis between April 2008 and May 2021 were included in the study. Demographic data of the patients, gestational week, physical examination and laboratory values at the time of admission, USG findings, type of surgery performed, surgical findings, pathology results and fetal-maternal complications that developed during postoperative follow -up were reviewed retrospectively through the hospital system.
 Results 
 From the clinicopathological features of the patients, only re-operation due to appendiceal stump leakage (p:0.04) and drain placement during operation (p:0.046) were significantly associated with miscarriage. Although complications and abortion rates were higher in patients with perforation and periappendicular abscess, the difference was not statistically significant.
 Conclusion
 Detailed history and physical examination are key for the diagnosis of acute appendicitis in pregnant women. Any patient with right lower quadrant pain, nausea, vomiting and fever, who has tenderness and defensive rebound in the right lower quadrant on physical examination should be considered as appendicitis after obstetric causes are excluded, until proven otherwise.

Effect of duodenal stump reinforcement on postoperative complications in patients undergoing laparoscopic radical gastrectomy

Objective: To evaluate the influence of duodenal stump reinforcing on the short-term complications after laparoscopic radical gastrectomy. Methods: A retrospective cohort study with propensity score matching (PSM) was conducted. Clinical data of 1204 patients with gastric cancer who underwent laparoscopic radical gastrectomy at the First Affiliated Hospital of Army Medical University from April 2009 to December 2018 were collected. The digestive tract reconstruction methods included Billroth II anastomosis, Roux-en-Y anastomosis and un-cut-Roux- en-Y anastomosis. A linear stapler was used to transected the stomach and the duodenum. Among 1204 patients, 838 were males and 366 were females with mean age of (57.0±16.0) years. Duodenal stump was reinforced in 792 cases (reinforcement group) and unreinforced in 412 cases (non-reinforcement group). There were significant differences in resection range and anastomotic methods between the two groups (both P<0.001). The two groups were matched by propensity score according to the ratio of 1∶1, and the reinforcement group was further divided into purse string group and non-purse string group. The primary outcome was short-term postoperative complications (within one month after operation). Complications with Clavien-Dindo grade ≥ III a were defined as severe complications, and the morbidity of complication between the reinforcement group and the non-reinforcement group, as well as between the purse string group and the non-purse string group was compared. Results: After PSM, 411 pairs were included in the reinforcement group and the non-reinforcement group, and there were no significant differences in baseline data between the two groups (all P>0.05). No perioperative death occurred in any patient.The short-term morbidity of postoperative complication was 7.4% (61/822), including 14 cases of anastomotic leakage (23.0%), 11 cases of abdominal hemorrhage (18.0%), 8 cases of duodenal stump leakage (13.1%), 2 cases of incision dehiscence (3.3%), 6 cases of incision infection (9.8%) and 20 cases of abdominal infection (32.8%). Short-term postoperative complications were found in 25 patients (6.1%) and 36 patients (8.8%) in the reinforcement group and the non-reinforcement group, respectively, without significant difference (χ2=2.142, P=0.143). Nineteen patients (2.3%) developed short-term severe complications (Clavien-Dindo grade ≥IIIa), while no significant difference in severe complications was found between the two groups (1.7% vs. 2.9%, χ2=1.347, P=0.246). Sub-group analysis showed that the morbidity of short-term postoperative complication of the purse string group was 2.6% (9/345), which was lower than 24.2% (16/66) of the non-purse string group (χ2=45.388, P<0.001). Conclusion: Conventional reinforcement of duodenal stump does not significantly reduce the incidence of duodenal stump leakage, so it is necessary to choose whether to reinforce the duodenal stump individually, and purse string suture should be the first choice when decided to reinforce.

Comparison of the Electrothermal Bipolar Sealing System (LigaSure) Versus Endoloop in Pediatric Laparoscopic Appendectomy.

Background: Laparoscopic appendectomy has long been in the process of replacing open appendectomy owing to a better wound healing, better cosmetic appearance, less pain, and less postoperative adhesion. Although there are many methods for ligating the appendix stump, studies on energy-based coagulation methods have attracted great interest in recent years. In our study, we aimed to compare the use of LigaSure™ appendiceal sealing and ligation of appendiceal stump by endoloop with regard to duration of surgery, length of hospital stay, and complications in laparoscopic appendectomies. Materials and Methods: A total of 174 consecutive patients under the age of 18 who underwent laparoscopic appendectomy in our clinic between September 2016 and February 2021 were retrospectively analyzed. Patients with perforated appendicitis were excluded from the study. The patients were divided into two groups as the appendix stump was ligated with endoloop (Group 1) and sealed with LigaSure (Group 2). Demographic characteristics of the patients, duration of surgery, length of hospital stay, and complications were recorded. Results: Of the 132 patients who were included in the study, Group 1 consisted of patients using endoloop (n = 39) and Group 2 comprised patients that LigaSure was employed (n = 93). There was no significant difference between Groups 1 and 2 in terms of age and length of hospital stay (P = .126 and P = .784, respectively); however, the operation time was found to be significantly shorter in Group 2 (P < .001). Conclusion: The use of LigaSure is a safe and fast method to seal the mesoappendix and appendix stump in pediatric laparoscopic appendectomy. We think that infection complications due to stump leakage and intra-abdominal spillage will less be encountered.

Is Hartmann's Pouch an Option in the Management of Acute Severe Ulcerative Colitis?

Background: The surgical management of remnant rectosigmoid after subtotal colectomy with end ileostomy for acute severe ulcerative colitis remains controversial with respect to the need to perform sigmoidostomy or Hartmann’s pouch. The aim of this retrospective study was to investigate whether Hartmann’s pouch may be a safe option. Methods: Thirty-eight Hartmann’s pouches were performed between January 2003 and December 2015. We looked at morbidity (with a focus on the occurrence of pelvic sepsis and leakage of the rectal stump) and the rate of restored intestinal continuity. Results: Nineteen patients had surgical complications. Seven had an intra-abdominal collection, only one of which was in the pelvis, and the patient had to be reoperated. Only one patient had a reopening of the rectal stump, which was revealed by rectal bleeding. Twenty-six patients (68.4%) underwent further proctectomy with ileal J-pouch anal anastomosis with no difficulty in localizing or mobilizing the rectal stump and no major surgical complications. Conclusions: Hartmann’s pouch may be considered in patients with acute severe ulcerative colitis, with low rates of morbidity and pelvic sepsis. The restoration of intestinal continuity is possible after this procedure without any special difficulty.

Intra and Postoperative Advantages of Laparoscopy in the Treatment of Complicated Appendicitis.

Aim: To determine and define the advantages of the laparoscopic appendectomy in the treatment of complicated appendicitis by comparing it with the open appendectomy. Material and Methods: In this prospective interventional clinical study we compared the intraoperative data and the postoperative outcome of 77 patients presented with complicated appendicitis, operated with open and laparoscopic appendectomy within a period of 20 months. One surgeon performed all of the laparoscopic procedures and two other senior surgeons performed the open procedures. Results: Operative time was shorter in the laparoscopic group (p = 0.033). Conversion rate was 2.3%. Overall postoperative morbidity was 25.97%. There was one operative revision due to postoperative small bowel obstruction in the laparoscopic group. Appendicular stump leakage occurred in one patient in the open group. One intra-abdominal abscess occurred in the laparoscopic group (p = 0.38). Wound infection occurred only in the open group (p = 0.018). Length of stay was shorter in the laparoscopic group (p = 0.0052). One patient from the laparoscopic group was readmitted. Conclusions: Laparoscopy is a reliable method in the treatment of complicated appendicitis. It offers a shorter operative time, low conversion rate, an acceptable rate of major postoperative complications and a shorter length of stay.

Should We Perform Incidental Appendectomy in Trauma Patients Undergoing Laparotomy?

Incidental appendectomy (IA) is sometimes performed in patients undergoing abdominal operations to prevent subsequent development of appendicitis. Patients who undergo laparotomy for major abdominal trauma are at high risk of developing dense adhesions, increasing the risk of future operations. Therefore, there is a potential benefit to IA for patients undergoing trauma laparotomy. We performed a retrospective review of patients who underwent IA during laparotomy for abdominal trauma at a Level 1 trauma center between January 2010, and June 2020. Twenty-three patients underwent IA; they tended to be young (33.7 ± 18.9years) and male (87%) with 12 penetrating and 11 blunt injuries. Regarding indications, 13 had no documented intra-operative abnormalities of the appendix, 6 patients had a fecalith, and 3 had trauma to the appendix. One patient's appendix was adhered to the peritoneum and one patient had unusual anatomic location. Only one patient developed an appendiceal stump leak after IA.

Spontaneous acalculous gallbladder perforation mimicking duodenal stump leak after gastrectomy for gastric cancer: A case report.

Introduction and importanceSpontaneous gallbladder (GB) perforation is a rare and severe condition. Herein, we present a case of spontaneous acalculous gallbladder perforation mimicking duodenal stump leak after a subtotal gastrectomy for gastric cancer.Case presentationAn 83-year-old woman underwent a radical subtotal gastrectomy for advanced gastric cancer. On postoperative day 5, mild leukocytosis was observed. A computed tomography (CT) scan revealed a slightly distended non-thickened GB with minimal air and fluid collection near the duodenal stump, and fluid collection in the abdominal and pelvic cavities. We considered a duodenal stump leak. The effluent of the Barovac located in the abdominal cavity was serosanguinous and the patient was stable, thus we observed and continued using antibiotics. On day 13, the Barovac stopped functioning properly, so we replaced it with a percutaneous catheter drain (PCD) under ultrasonography guidance, aided by the Barovac tract. The PCD drained over 1000 cc of bile daily. On day 16, a follow-up CT showed an increased fluid collection in the abdominopelvic cavity. After comparing this with the previous CT, we rediagnosed as spontaneous GB perforation. An emergency cholecystectomy was performed. Postoperatively, the patient's condition returned to normal and antibiotic therapy continued until day 14. The patient recovered without other complications and was discharged on day 28.Clinical discussionSpontaneous GB perforation is a rare but serious complication immediately after gastrectomy which should be looked out for.ConclusionWe report a rare case of spontaneous GB perforation mimicking duodenal stump leak after radical subtotal gastrectomy in gastric cancer.

33: A SNAPSHOT OF THE CURRENT PRACTICE ON THE USE OF PROPHYLACTIC DRAIN AFTER GASTRECTOMY IN ITALY: THE ABDOMINAL DRAIN IN GASTRECTOMY (ADIGE) SURVEY

Abstract Background and aim Evidence against the use of prophylactic drain after gastrectomy are increasing. Nevertheless, it is unclear whether this practice is still widespread. We conducted a survey among Italian surgeons through the Italian Gastric Cancer Study Group and the Polispecialistic Society of Young Surgeons, aiming to understand the current use of prophylactic drain. Methods A 23-item questionnaire-based survey was developed to analyze the current practice and the individual opinion about the use of prophylactic drain after gastrectomy. Groups based on age, experience and unit volume were separately analyzed. Results Response of 104 surgeons from 73 surgical units were collected. A standardized ERAS protocol for gastrectomy was applied by 42% of the interviewed surgeons. The large majority of the surgeons, regardless of age, experience or unit volume, declared to routinely place one or more drain after gastrectomy. Only 2 (1.9%) and 7 surgeons (6.7%) belonging to high volume units, do not routinely place drains after total and subtotal gastrectomy, respectively. More than 60% of the interviewed remove the drain on postoperative day 4–6 after performing an assessment of the anastomosis integrity. Interestingly, less than half of the surgeons believe that drain is the main tool for leak management, and this percentage further drops among younger surgeons. On the other hand, drain’s role seems to be more defined for duodenal stump leak treatment, with almost 50% of the surgeons recognizing its importance. Conclusion Routine use of prophylactic drain after gastrectomy is still a widespread practice even if younger surgeons are more persuaded that it could not be advantageous. New and stronger evidence are needed to define the role of prophylactic drain after gastrectomy.

Comparison of endoloop and Hem-o-lok clip for stump closure in laparoscopic appendectomy: which one is more cost-effective. A retrospective study

We aimed to show the effect of closure of the appendix stump with different methods during laparoscopic appendectomy (LA), on postoperative complications, healing process and costs. Patients who underwent LA due to acute appendicitis in the last 5 years in Rize were retrospectively analyzed. Our study includes comparative analysis on two patient groups in which we carried LA. We used endoloop (EL) in Group 1 and hem- o-lok polymeric clip (HC) in Group 2 to close the appendix stump. Patients were compared in terms of demographic characteristics, American Society of Anesthesiologists (ASA) score, preoperative white blood cell and C-reactive protein (CRP) elevation, whether a drain was used, appendix diameter, pathological diagnosis, postoperative complications, duration of surgery and length of stay, and cost. Of 209 patients, 111 (51.2%) were male and 98 (48.8%) were female. The frequency of drain placement was higher in Group 2 (P = 0.005). No stump leakage was observed in either group, but the incidence of other postoperative complications was significantly higher in the EL group (P=0.041). The use of HC is cheaper than the use of EL. There was no significant difference in other parameters. Both EL and HC are used safely in LA. Although both methods do not have obvious advantages over each other, HC stands out one step further due to its more affordable cost and less possibility of postoperative complications.

Laparoscopic vs. Open Gastrectomy for Locally Advanced Gastric Cancer: A Propensity Score-Matched Retrospective Case-Control Study.

Introduction: Minimally invasive surgery has been increasingly used in the treatment of gastric cancer. While laparoscopic gastrectomy has become standard therapy for early-stage gastric cancer, especially in Asian countries, the use of minimally invasive techniques has not attained the same widespread acceptance for the treatment of more advanced tumours, principally due to existing concerns about its feasibility and oncological adequacy. We aimed to examine the safety and oncological effectiveness of laparoscopic technique with radical intent for the treatment of patients with locally advanced gastric cancer by comparing short-term surgical and oncologic outcomes of laparoscopic versus open gastrectomy with D2 lymphadenectomy at two Western regional institutions. Methods: The trial was designed as a retrospective comparative matched case-control study for postoperative pathological diagnoses of locally advanced gastric carcinoma. Between January 2015 and September 2021, 120 consecutive patients who underwent curative-intent laparoscopic gastrectomy with D2 lymph node dissection were retrospectively recruited and compared with 120 patients who received open gastrectomy. In order to obtain a comparison that was as homogeneous as possible, the equal control group of pairing (1:1) patients submitted to open gastrectomy who matched those of the laparoscopic group was statistically generated by using a propensity matched score method. The following potential confounder factors were aligned: age, gender, Body Mass Index (BMI), comorbidity, ASA, adjuvant therapy, tumour location, type of gastrectomy, and pT stage. Patient demographics, operative findings, pathologic characteristics, and short-term outcomes were analyzed. Results: In the case-control study, the two groups were clearly comparable with respect to matched variables, as was expected given the intentional primary selective criteria. No statistically significant differences were revealed in overall complications (16.7% vs. 20.8%, p = 0.489), rate of reoperation (3.3% vs. 2.5%, p = 0.714), and mortality (4.2% vs. 3.3%, p = 0.987) within 30 days. Pulmonary infection and wound complications were observed more frequently in the OG group (0.8% vs. 4.2%, p < 0.01, for each of these two categories). Anastomotic and duodenal stump leakage occurred in 5.8% of the patients after laparoscopic gastrectomy and in 3.3% after open procedure (p = 0.072). The laparoscopic approach was associated with a significantly longer operative time (212 vs. 192 min, p < 0.05) but shorter postoperative length of stay (9.1 vs. 11.6 days, p < 0.001). The mean number of resected lymph nodes after D2 dissection (31.4 vs. 33.3, p = 0.134) and clearance of surgical margins (97.5% vs. 95.8%, p = 0.432) were equivalent between the groups. Conclusion: Laparoscopic gastrectomy with D2 nodal dissection appears to be safe and feasible in terms of perioperative morbidity for locally advanced gastric cancer, with comparable oncological equivalency with respect to traditional open surgery.

Manual loop in laparoscopic appendectomy: A retrospective cohort study and literature review.

To determine the incidence of complications [Surgical site infection (SSI), intra-abdominal abscess (IAA), stump leak] related to stump ligation with manual loop of sliding extracorporeal suture knot in laparoscopic appendectomy. This cohort study was conducted on patients who underwent laparoscopic appendectomy from June 2014 to November 2020 performed by the same surgeon with almost similar technique. Stump was ligated with manual loops, applied by the surgeon or trainee or both (one by surgeon and other by trainee). SSI and IAA were classified according to Centers for Disease Control and Prevention (CDC) criteria. Total 120 patients were included with median (Interquartile range, IQR) age of 24 (19-35) years and male predominance i.e. 81 (67.5%). Median (IQR) for the duration of symptoms, time from presentation to surgery and duration of surgery was 2(1-4) days, 10 (4-15) hours and 60 (44-70) minutes, respectively. SSI was documented in 9(7.5%) patients, managed by wound hygiene and antibiotics. IAA was observed in one(0.8%) patient who required readmission for antibiotics and radiology guided drain placement. No stump leak was observed. Manual endo-loop is a safe, reliable and cost effective technique for stump ligation in LA, and can safely be incorporated into teaching of surgical trainees.

ХИРУРГИЧЕСКОЕ ЛЕЧЕНИЕ ОСТРОГО АППЕНДИЦИТА: ЛАПАРОСКОПИЧЕСКАЯ ИЛИ ОТКРЫТАЯ АППЕНДЭКТОМИЯ?

The results of laparoscopic and "traditional" open appendectomy for acute appendicitis were studied, and postoperative complications were analyzed. The retrospective analysis of surgical treatment of 518 patients with acute appendicitis was carried out. In 433 (83.6%) cases laparoscopic appendectomy was performed, in 84 (16.2%) – open appendectomy. In laparoscopic surgery the ligature method of appendectomy was used, in open surgery invagination method was used. Indications for drainage of the abdominal cavity during laparoscopic and open appendectomy did not fundamentally differ. According to the results of a morphological study phlegmonous appendicitis was observed in 463 (89.4%) cases, gangrenous – in 55 (10.6%). After open appendectomies complications were detected in 11 patients, the overall incidence of postoperative complications was 13.1%. After laparoscopic appendectomies complications were detected in 4 patients, the overall incidence of postoperative complications was 0.9%. The rate of postoperative complications after laparoscopic appendectomy was statistically significantly lower than after open appendectomy. The nature of complications in laparoscopic and open appendectomy differs. In open appendectomy infectious complications of the surgical wound are observed, which do not require surgical treatment. In laparoscopic appendectomy intra-abdominal complications are observed, which in some cases require repeated surgical interventions. During laparoscopic appendectomy, there were such complications as stump leaks with peritonitis and inflammatory infiltrates of the abdominal cavity.

Managements of Subvesical Bile Duct (Duct of Luschka) Leakage after Laparoscopic Cholecystectomy

Laparoscopic cholecystectomy(LC) is the most common operation for gallbladder disease. Bile leakage is a serious complication in LC. Subvesical bile duct (Duct of Luschka) injury is 2nd frequent reasons after cystic duct stump leakage.

Risk Factors for Reoperation Following Radical Gastrectomy in Gastric Cancer Patients.

Reoperation due to elective surgery complications is very mentally, physically, and economically detrimental to patients. This study investigated the potential risk factors associated with early reoperation after radical gastrectomy in gastric cancer patients and included an in-depth analysis of these risk factors. This retrospective study reviewed 1568 patients with gastric cancer. Grade 3 or greater complications were defined as severe. Any factors related to reoperation after radical gastrectomy were analyzed in patients with severe local complications. Among 1537 patients undergoing radical gastrectomy, 115 (7.5%) patients had severe postoperative complications, 98 (6.38%) of whom experienced severe local complications. The most common local complication was anastomotic leakage (31, 2.02%), followed by intra-abdominal abscess (30, 1.95%), pancreatic leakage (22, 1.43%), duodenal stump leakage (18, 1.17%), intra-abdominal bleeding (12, .78%), intraluminal bleeding (8, .52%), small bowel obstruction (5, .32%), and chyle leakage (3, .19%). Of these patients, 26 (1.69%) underwent reoperation, and 6 (.39%) died. In the univariate analysis of clinical factors related to reoperation, intra-abdominal bleeding and small bowel obstruction were risk factors for reoperation, and intra-abdominal bleeding (odds ratio [OR] = 9.57, confidence interval [CI] = 2.65-40.20, P < .001) and small bowel obstruction (OR = 19.14, CI = 2.60-390.13, P = .011) were independent risk factors associated with reoperation in the multivariate analysis. Intra-abdominal bleeding and small bowel obstruction are independent risk factors for reoperation following radical gastrectomy. Patients with postoperative intra-abdominal bleeding and small bowel obstruction need to be warned about reoperation.

How to optimize your set-up for a VATS right upper lobectomy

A 77-year-old woman with multiple ground-glass opacities, the largest of which measured 21 mm, has a biopsy-proven primary lung adenocarcinoma in her right upper lobe. We performed a 3-port right-sided VATS using the Copenhagen approach. There was no pleural effusion or evidence of pleural metastatic spread. A tumor was identified in the upper lobe. The surrounding lung tissue appeared normal. We performed a multilevel intercostal block using 0.25% levobupivacaine. The inferior pulmonary ligament was divided. The superior pulmonary vein and 2 branches of the pulmonary artery to the right upper lobe were dissected, encircled, and divided using tan reloads of the Endo GIA stapler. The right upper lobe bronchus was dissected, encircled, and divided in a similar fashion using a purple reload of the Endo GIA stapler following a successful test inflation of the lower and middle lobes. The horizontal fissure was completed with further firings of the stapler. Lymph nodes from stations 2, 4, 7, 8, 9, 10, and 11 were sampled and sent separately for histological analysis. There was no parenchymal or stump leak to 20 cm H20 on the test inflation. Hemostasis and pneumostasis were checked and ensured. A single 24 Fr drain was placed in the apex. Hemostasis was complete. The incision was closed in layers.