Tension-free Anastomosis Research Articles

Effectiveness of autologous interposition saphenous graft in the creation of proximal arteriovenous fistula: Our initial experience

Abstract: For the individuals with end-stage renal disease, maintenance hemodialysis is a common treatment. When we compare to dialysis catheters or prosthetic grafts, arteriovenous fistula (AVF) is associated with a greater maturation period but a smaller incidence of infections, central venous stenosis, hospitalizations, and mortality. Fistulas mature by a dynamic process which is known as venous arterialization, where the breakdown of elastin and release of nitric oxide promote the functional and structural remodeling of the venous wall, permitting the expansion of venous outflow. Veins made them exposed to the arterial environment at the time of venous grafts and AVFs creation. Successful adaptation of the vein to the arterial flow is the most demanding part for long-term success, identified by venous dilation followed by wall thickening. Arteriovenous fistulas (AVF) and grafts (AV graft) are the commonest form of vascular access used for maintenance of hemodialysis. In general AVF is superior than AV graft in terms of its durability, patency, complication rate and overall survival of patients. But when the calibre of the vein is not satisfactory or length is not adequate to make tension free anastomosis, interposition graft is used. Most commonly used bridging material is polytetrafluoroethylene (PTFE) polymer. In this case, we used an interposition graft of the saphenous vein for making dialysis access on a 38 year old male patient having renal insufficiency and evaluated its efficacy in maintaining flow.

Artery Grafting for Arterial Anastomoses in Head and Neck Free Tissue Transfer Reconstruction.

Vessel grafting is an important technique in head and neck free tissue transfer (FTT) reconstruction when a tension-free anastomosis is not otherwise feasible. To our knowledge, there are limited data regarding interposition artery grafts for arterial anastomoses in head and neck reconstruction. Here, we present a multi-institutional cohort of arterial interposition grafts for FTT reconstruction for head and neck defects. A retrospective review was conducted at four tertiary care institutions for patients who underwent FTT reconstruction for head and neck defects which utilized an interposition artery graft for the arterial anastomosis. Charts were reviewed for type and length of artery grafts harvested, surgical indication, indication for artery graft, types of flaps harvested, and various preoperative characteristics (including history of radiation or previous FTT reconstruction surgery). Postoperative complications within postoperative day 30 were measured and reported. Nine patients met inclusion criteria. The lateral circumflex femoral artery (either transverse or descending branches) (n = 3) and facial artery (n = 3) were the most commonly harvested arteries. The scalp (n = 5) was the most common primary defect site. Seven grafts were harvested initially and in a planned fashion, while two were harvested as salvage techniques (either for flap salvage or vein graft failure). In planned grafts, arteries were the preferred interposition grafting method due to either size match preferences (n = 4) or similarities in wall thickness (n = 3) between graft and recipient artery. There were no reported cases of unplanned readmission, postoperative hematoma, fistula formation, wound infection, or donor site morbidities. Two patients required unplanned return to the operating room for flap compromise, both of which ultimately resulted in flap failure secondary to clot formation at both arterial and venous anastomoses. When arterial pedicle length is insufficient, interposition artery grafting is both a feasible and viable technique to achieve tension-free arterial anastomoses for select cases of highly complex head and neck free tissue reconstruction.

Swallowing outcomes after tracheal resection and anastomosis: full versus mini infrahyoid laryngeal drop

IntroductionTracheal resection anastomosis has been established as the definitive surgery for high grade postintubation subglottic stenosis. To achieve a relaxed tension-free anastomosis, various laryngeal release techniques were discussed in literature with potential effect on postoperative swallowing dysfunction. This study aims to compare the difference in swallowing outcomes following two methods of infrahyoid laryngeal release: with and without fracture of the superior thyroid horns.MethodsA retrospective cohort study was carried out at our tertiary referral hospitals including cases with grade III and IV subglottic stenosis treated by partial crico-tracheal resection with thyro-tracheal anastomosis. The patients were divided into two groups according to the method used in laryngeal release; mini infrahyoid release (group A) or infrahyoid full release (group B) where full means with fracture of the superior thyroid horn bilaterally while mini means their preservation. Swallowing assessment preoperatively and postoperatively was done by comparing swallowing dysfunction symptoms, Gugging swallowing screen (GUSS) score and fiberoptic endoscopic evaluation of swallowing (FEES) according to penetration aspiration scale (PAS).ResultsA total of 71 patients were included; 46 in Group A and 25 in Group B. Clinical swallowing evaluation one week postoperatively showed statistically significant difference between the two groups being affected in 80.04% and 100% of patients in group A and B, respectively. The mean postoperative GUSS were 18 ± 1.32 in group A patients in comparison to 8.84 ± 5.18 in group B (p-value < 0.001). With FEES assessment, group A had full improvement of their swallowing abilities one month after the surgery while patients in group B had significantly lower PAS scores. Unfavourable scores for both the GUSS test and PAS were associated with increasing patients’ age in group B.ConclusionIn this retrospective cohort study, cases with mini infrahyoid laryngeal release had significantly better swallowing outcomes and full resolution of dysphagia in comparison to full laryngeal release. Also, full laryngeal release is associated with delayed resolution of swallowing difficulty in older patients. This point should be considered during preoperative patient selection and counselling.

Modified Rosi–Cahill technique after left extended colectomy for splenic flexure advanced tumors

Advanced splenic flexure tumors are uncommon and have a higher risk of relapse. To ensure that the resection includes the entire area of lymphatic drainage with a complete mesocolic excision (CME), a left extended colectomy is needed. In peritoneal carcinomatosis, there is often extensive involvement of the sigma and splenic flexure of the colon. In many instances, total colectomies are chosen for these patients, even when a significant portion of the colon could be preserved. The potential impact on quality of life after splenic flexure colon resection is discussed, as well as the importance of anatomical knowledge and expertise in performing this type of surgery. Overall, this work presents a modified technique that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer. Creating a tension-free anastomosis after extended left-sided colorectal resection is challenging. There is a negative impact on quality of life when an ileorectal anastomosis is created. The colorectal anastomosis performed after modified Rosi–Cahill or Deloyers’ technique allows reduced small bowel bacterial overgrowth, achieves better water and sodium absorption, and altogether permits improved stool consistency. There are potential advantages of the Rosi–Cahill technique over other popular options such as Deloyers’ procedure as there is no torsion of the ileocolic vessels and no mesenteric windows. A video was recorded showing a potential pitfall during Deloyers’ technique resulting in the creation of a mesenteric window. The proper rotation of the colon during the modified Rosi–Cahill procedure was also filmed. Overall, this work presents a modified technique for reconstruction after left extended colectomy that aims to improve the outcomes and quality of life for patients with splenic flexure colon cancer.

Laparoscopic ureteroureterostomy for benign non-passable upper ureteric stricture – A case report with review of literature

Ureteral stricture (US) is not a very common condition. The etiology of US could be either benign or malignant. It is mostly due to long-standing ischemia causing inflammation and fibrosis that ultimately leads to stricture formation. In most cases, diagnosis is made incidentally under direct visualization at the time of the ureteroscopic procedure. Surgery for ureteral reconstruction aims to achieve adequate vascular supply, a tension-free anastomosis with mucosal apposition, and to ensure complete excision of stricture-laden ureteral segments. We herein present the case of a 42-year-old male patient who presented with a complaint of acute pain in his left flank, radiating from the loin to the front, for 10 days. The workup investigations revealed a tight stricture in the left upper ureter, a 2-mm calculus in the left upper ureter proximal to the stricture, and left proximal hydroureteronephrosis. The patient was successfully managed by laparoscopic ureteroureterostomy.

Tips and tricks for transluminal specimen extraction and extra-abdominal sigmoid colon resection.

The purpose of this video is to demonstrate how to achieve adequate length and blood supply of the proximal colon for a perineal pull-through procedure, without splenic flexure mobilization during natural orifice specimen extraction. Key steps of the procedure include lateral mobilization of the colon, D3 lymph node dissection, preservation of the left colic artery, low ligation of the inferior mesenteric vein, ligation and washout of the distal bowel lumen, extra-abdominally proximal resection of sigmoid colon, purse-string sutures on the distal sigmoid colon, and an air leak test. Transluminal specimen extraction with extra-abdominal resection was found to be a cost-effective procedure with good cosmetic effects. Tension-free anastomosis was achieved by preservation of the left colic artery and low ligation of the inferior mesenteric vein. The purse-string sutures were placed on the proximal and distal bowel to avoid crossing the staples line. Transluminal specimen extraction with extra-abdominal resection required minimal manipulation intra-abdominally in comparison with other natural orifice specimen extraction techniques.

A novel technique for NO.253 lymph node dissection and left colic artery preservation to avoid potential postoperative internal hernia in laparoscopic radical resection for rectal cancer

BackgroundThe preservation of the left colic artery (LCA) has emerged as a preferred approach in laparoscopic radical resection for rectal cancer. However, preserving the LCA while simultaneously dissecting the NO.253 lymph node can create a mesenteric defect between the inferior mesenteric artery (IMA), the LCA, and the inferior mesenteric vein (IMV). This defect could act as a potential “hernia ring,” increasing the risk of developing an internal hernia after surgery. The objective of this study was to introduce a novel technique designed to mitigate the risk of internal hernia by filling mesenteric defects with autologous tissue.MethodsThis new technique was performed on eighteen patients with rectal cancer between January 2022 and June 2022. First of all, dissected the lymphatic fatty tissue on the main trunk of IMA from its origin until the LCA and sigmoid artery (SA) or superior rectal artery (SRA) were exposed and then NO.253 lymph node was dissected between the IMA, LCA and IMV. Next, the SRA or SRA and IMV were sequentially ligated and cut off at an appropriate location away from the “hernia ring” to preserve the connective tissue between the “hernia ring” and retroperitoneum. Finally, after mobilization of distal sigmoid, on the lateral side of IMV, the descending colon was mobilized cephalad. Patients’preoperative baseline characteristics and intraoperative, postoperative complications were examined.ResultsAll patients’ potential “hernia rings” were closed successfully with our new technique. The median operative time was 195 min, and the median intraoperative blood loss was 55 ml (interquartile range 30–90). The total harvested lymph nodes was 13.0(range12−19). The median times to first flatus and liquid diet intake were both 3.0 days. The median number of postoperative hospital days was 8.0 days. One patient had an injury to marginal arterial arch, and after mobolization of splenic region, tension-free anastomosis was achieved. No other severe postoperative complications such as abdominal infection, anastomotic leakage, or bleeding were observed.ConclusionsThis technique is both safe and effective for filling the mesenteric defect, potentially reducing the risk of internal hernia following laparoscopic NO.253 lymph node dissection and preservation of the left colic artery in rectal cancer surgeries.

Modified Scalp Replantation for Total Scalp Avulsion: Scalp-Shifting Technique.

Scalp replantation is the best treatment for scalp avulsion due to its functional and esthetic benefits. Regular scalp replantation requires only unilateral or bilateral superficial temporal vascular anastomosis. However, shear force always damages vessels in severe scalp avulsions. Short, superficial temporal vessels (STVs) make tension-free anastomosis challenging. The objective of this article is to improve the regular scalp replantation technique. When the STVs are short, tension-free anastomosis, and cosmetic symmetry can be achieved without vein grafts or vascular replacement. This study retrospectively reviewed 18 patients with scalp avulsion, of which 10 underwent scalp-shifting replantation, and 8 underwent regular scalp replantation with direct anastomosis of the STVs. Postoperatively, the authors, assessed whether there was a significant difference in the percentage of scalp survival and in the facial symmetry of patients between the 2 methods. The percentages of scalp survival and facial symmetry were good after surgeries using both methods, and no significant differences were observed. The authors use scalp-shifting replantation to create tension-free anastomoses in cases where scalp avulsion injuries have left the superficial temporal arteries too short. This technique ensures facial symmetry, scalp reimplantation survival, and equally excellent results in function and esthetics.

It is possible to avoid routine splenic flexure mobilization during left hemicolectomy and anterior rectal resection? A single center experience compared to the surgical reality.

Routine splenic flexure mobilization (SFM) during left hemicolectomy and high anterior rectal resection guarantees a well perfused and tension-free anastomosis, respecting current oncological criteria. According to the recent literature, only 70% of laparoscopic colorectal surgeons considered routine SFM mandatory. Because of its difficulty, SFM increases morbidity including surrounding organs injuries. The goal of the study is to report our experience in avoiding routine SFM during colorectal resection compared to the current surgical state of art. Data were collected retrospectively on elective left hemicolectomy without routine SFM performed in our unit between January 2015 to April 2020. Patients were recruited according to diagnosis, histopathology, operative time, ASA score, post-operative morbidity and mortality. Seventy-five oncological patients, underwent to surgery without SFM. The other 13 patients underwent to SFM due to technical issues. The mean operative time was 160.2±44.7 mins, significantly shorter than in patients whose SFM occurred (210.3 min). The morbidity rate was 1%, reintervention occurred in one patient. Eighteen-month median follow-up morbidity was 11% while mortality was 3%. Recurrence rate was of about 5%. As results from study data analysis, left colectomy can be conducted safely in both laparoscopic and laparotomic approach without SFM in selected cases. As reported in a recent meta-analysis, benefits of avoiding SFM concern reduced operative time without compromising postoperative outcome and respecting oncological criteria, as emerged by our results. Colorectal resection without SFM when is feasible, improves surgical approach reducing technical difficulties and avoiding splenic injuries.

Laparoscopic-Assisted Colonic Derotation in Patients With Hirschsprung Disease

BackgroundChildren with Hirschsprung disease (HSCR) proximal to the splenic flexure or those needing a redo pull-through (PT) are at risk for tension and ischemia of the PT which could result in leak, stricture, or loss of ganglionated bowel. Colonic derotation is a technique used to minimize tension and avoid duodenal obstruction. The aim of this study was to describe this technique and outcomes in a series of patients requiring this intervention. MethodsAll patients underwent initial diversion and colonic mapping. The derotation procedure involves mobilization of the remaining colon, counterclockwise rotation via the stoma closure site, placement of the pull through (the right colon) lying on the right of the pelvis, and ligation of the middle colic artery with preservation of the marginal branch running from the ileocolic artery. This maneuver prevents compression of the duodenum by the mesenteric vessels and allows for an isoperistaltic, tension-free anastomosis. Intraoperative indocyanine green fluorescence angiography (ICG-FA) was utilized in many of the cases to map the blood supply of the pull-through colon. We reviewed outcomes for all children with HSCR who underwent colonic derotation from 2014 to 2023. Descriptive statistics were performed. ResultsThere were 37 children included. Most were male (67.5%) with the original transition zone proximal to the rectosigmoid (81.1%). The median age at PT was 9.3 months [6.1–39.7]. Median operative time was 6.6 h [4.9–7.4] and 19 cases (51.4%) used ICG-FA. Most children had no 30-day postoperative complications (67.6%); in those who did develop complications, readmissions for electrolyte imbalance was most common (50.0%).There were zero cases of anastomotic leak at PT anastomosis. At long-term follow up, median 4.4 years [2.3–7.0], three children (8.1%) developed an anastomotic stricture, all were amenable to anal dilation, and five experienced episodes of enterocolitis (14.7%). Most children had between 1 and 4 stools per day (58.8%). ConclusionColonic derotation is a useful strategy to ensure well-perfused colonic length, protect the marginal artery blood supply, avoid duodenal compression, and ensure a tension-free anastomosis with minimal complications. Type of StudyOriginal research, retrospective cohort. Level of EvidenceIII.

Robotic Splenic Flexure Takedown: Single Docking Crossed-Arm Technique.

Splenic flexure mobilization is typically required in the management of left-sided colon and rectal resections to achieve tension-free anastomosis. Although the da Vinci Xi® surgical system (Intuitive Surgical, Sunnyvale, CA, USA) was designed for multi-quadrant operations, robotic mobilization of the splenic flexure continues to be challenging for some surgeons. Re-docking and patient repositioning may be required, which can be time-consuming, especially in centers without motion-activated operating tables. However, there are some tips and tricks to overcome these challenges. Here, we describe our single docking crossed-arm technique, which facilitates splenic flexure mobilization. We demonstrate our technique in a 61-year-old woman with sigmoid colon cancer, and informed consent was obtained. The operation starts in the medial-to-lateral approach by ligating the inferior mesenteric artery and vein. After the left colon mobilization, robotic arm one (tip-up fenestrated grasper) is positioned on the patient's left, while arms two, three, and four are on the patient's right. A tip-up fenestrated grasper, inserted through port #1, retracts the descending colon medial and inferior towards the cecum. Then, we cross the arms from the lateral aspect of arm one and takedown the flexure without the collision of robotic arms. After the lateral side dissection is completed, we change the position of the instruments to mobilize the transverse colon. This time, the tip-up grasping instrument is used to retract the colon through the left lower quadrant, which enables us to work in the medial aspect of the grasping instrument. Dissection can be performed using bipolar forceps, monopolar scissors, or vessel-sealing devices. We achieved complete mobilization of the splenic flexure. With this technique, dissection can be carried medially and cranially beyond the falciform ligament. After the splenic flexure takedown and freeing up the mesocolon above the pancreatic body, tension-free anastomosis can be performed. In this approach, re-docking is not necessary. During robotic left-sided colorectal surgery, the crossed-arm technique with single docking avoids robotic arms collision and restricted mobility of the left upper quadrant instrument (port#1). This technique facilitates robotic splenic flexure mobilization and eliminates re-docking/repositioning, leading to shorter operative time and improved intraoperative flow. See Video Vignette.

Immediate Ansa cervicalis-to-recurrent laryngeal nerve low-tension anastomosis: A new technique for phonation recovery and bilateral anastomoses to avoid tracheotomy

ObjectiveThis case series study investigated the outcomes of an innovative approach, ansa cervicalis nerve (ACN)-to-recurrent laryngeal nerve (RLN) low-tension anastomosis. MethodsPatients who received laryngeal nerve anastomosis between May 2015 and September 2021 at the facility were enrolled. The inclusion criteria were patients with RLN dissection and anastomosis immediately during thyroid surgery. Exclusion criteria were cases with anastomosis other than cervical loop-RLN anastomosis or pronunciation recovery time > 6 months. Patients admitted before January 2020 were assigned to group A which underwent the conventional tension-free anastomosis, and patients admitted after January 2020 were group B and underwent the innovative low-tension anastomosis (Dong's method). ResultsA total of 13 patients were included, 11 patients received unilateral surgery, and 2 underwent bilateral surgery. For patients who underwent unilateral anastomosis, group B had a significantly higher percentage of normal pronunciation via GRBAS scale (83.3 % vs. 0 %, p = 0.015) and voice handicap index (66.7 % vs. 0 %, p = 0.002), and shorter recovery time in pronunciation (median: 1-day vs. 4 months, p = 0.001) than those in group A after surgery. ConclusionsACNs-to-RLN low-tension anastomosis with a laryngeal segment ≤1 cm (Dong's method) significantly improves postoperative pronunciation and recovery time. The results provide clinicians with a new strategy for ACN -to-RLN anastomosis during thyroid surgery.

Retrospective analysis of urethral anastomosis with ancillary maneuvers and intraoperative biaxial defect measurements to achieve a tension free guidance system for redo PFUDD treatment

ObjectivesRedo surgery for pelvic fracture urethral distraction defects (PFUDDs) is still a challenge. the long urethral defect makes it difficult while the high tension increase the recurrence rate. Although certain ancillary maneuvers can relieve tension, there is no consensus or guidelines for the prediction/planning of the selection. In this study, we present our experience with developing an intraoperative guidance system to achieve tension-free urethral anastomosis.Patients and methodsA total of 91 recurrent PFUDD patients managed at our center between 2020 and 2022 were retrospectively analyzed. The patients underwent scar removing and urethral anastomosis. For the long defect and high-tension cases, 6 kinds of tension-relieving maneuvers were used respectively during the process of urethral anastomosis. Preoperative assessment of the urethrogram was done before surgery, while biaxial (vertical and horizontal) defect measurements were performed intraoperatively. The patients were followed-up for 12 months (8.9 ± 4.2), furthermore, recurrence and complications were analyzed.ResultsThe overall success rate was 86.81%. The mean defect in urethrogram was 2.9 ± 1.1 cm. 27 simple anastomosis was performed when the vertical plus horizontal defect was less than 2 cm with 11.11% recurrence. 24 cavernous septum splittings were performed when the horizontal defect was greater than 2 cm with 8.33% recurrence. 21 inferior pubectomies were performed when the horizontal defect was greater than 3 cm with 19.05% recurrence. 15 ancillary distal urethra manipulations (fully distal urethral mobilization, urethral suspension and corpus cavernosa folding) were performed when the vertical defect was 3 to 4 cm with 13.33 recurrence. 4 reroutings were performed when the vertical defect was greater than 4 cm with 25.00% recurrence.ConclusionsAncillary maneuvers are effective for reducing tension in redo urethral anastomosis. Measurement of divergent vertical and horizontal urethral defects could guide the selection of ancillary maneuvers. Combined tension-relieving maneuvers is recommended according to the defect direction and length to achieve a tension-free anastomosis.

Robotic reconstruction of necrosed ileal ureter: Technical challenges, intra-operative difficulty, and learning points.

This video explores the challenges faced during a re-do robotic intra-corporeal ileal ureter reconstruction in a previously operated case. A 24-year-old woman presented with a 12-cm long stricture after robotic ileal ureter replacement surgery. A proper preoperative evaluation in the form of ureteroscopy and a nephrostogram is essential and the key steps include adhesiolysis, identification of the necrotic ileal ureter, and meticulous dissection. A 13-cm long segment of the ileum was isolated and was anastomosed to the renal pelvis and the bladder. The surgery lasted for 420 min with 300 ml of blood loss. Post-operatively, the patient recovered well and had a normal drainage with no complications at 1-year of follow-up. The factors such as a broad mesentery, a tension-free anastomosis, and avoiding the twisting of the pedicle are crucial for success of robotic ileal ureter replacement surgery.

Ventral corporal plication: An additional maneuver for achieving tension-Free anastomosis in repair of failed pelvic fracture urethral injury

Ventral corporal plication: An additional maneuver for achieving tension-Free anastomosis in repair of failed pelvic fracture urethral injury

Tracheal adenoid cystic carcinoma with microscopic positive margin-how we approached with a systematic analysis review of its management.

Adenoid cystic carcinoma (ACC) of the trachea is a rare malignancy. We report a patient with ACC who underwent multimodal management including tracheal resection. A systematic review was also conducted on tracheal resection for ACC. A literature search was conducted on MEDLINE, Embase, and PubMed using the search terms "trachea AND adenoid cystic carcinoma AND (surgery OR resection)" and articles from 2000 to August 2021 were identified. A total of 29 journal articles were included in the review. A total of 403 patients underwent surgery for tracheal ACCs. The mean age was 48.1years and 54.7% were female. The commonest anatomical location was the lower trachea (46.9%). The mean time from symptom onset to diagnosis was 16.6months with the commonest symptom being dyspnoea (52%). Fifty-eight percent of the patients had intraluminal growth. Tracheal resection (46.2%) and access via thoracotomy (41.4%) were the commonest procedures described. The mean length of trachea resected was 39.2mm and the mean tumour size was 31.5mm. 16.8% of lymph nodes were involved and 73.8% of cases had positive resection margins. The overall complication rate was 1.4-5.4% and the in-hospital mortality rate was 9.8%. The overall survival reported was 61.7% at 5years and 54.6% at 10years. Surgical resection followed by adjuvant radiotherapy is the mainstay in the treatment of tracheal ACC, notwithstanding the high rates of involved margins. Achieving tension-free anastomosis should be the first priority given the favourable response of adjuvant therapies in reducing recurrence rate and improving overall survival.

Transmesenteriális colon átvezetéses colorectális anasztomózis.

A crucial element of colorectal surgery is ensuring a safe anastomosis. In order to avoid the most significant complication - anastomotic leakage - two factors are essential: adequate blood supply and a tension-free suture. After extended resections, the mobilised colon sometimes cannot be connected to the rectal stump without tension. In these cases, transmesenteric placement of the transverse colon may facilitate a tension free anastomosis. The results of transmesenteric colorectal anastomoses performed at the Surgical Department of the BAZ County Central Hospital and University Teaching Hospital are reviewed and compared with literature data. Eight patients underwent transmesenteric colorectal anastomosis. No anastomotic insufficiency was observed. Intra-operative blood loss, postoperative intestinal passage induction were similar to those expected with conventional anastomosis. Six cases were completed by laparoscopy, two by laparotomy, and two patients have been converted after laparoscopy. Extended left sided colorectal resections may result in inadequate residual bowel length, which could compromise the anastomosis. When the mobilised left colon does not reach the rectum without tension, transmesenterically placed transverse colon can be used. This surgical technique, which can also be performed laparoscopically, represents a safe alternative of achieving a tension-free anastomosis.

Antiperistaltic Transverse Coloplasty: A Salvage Procedure in Extensive Bowel and Colorectal Resections to Avoid Intestinal Failure

IntroductionAfter extensive small and colon resections, quality of life can be affected. We propose the antiperistaltic transverse coloplasty as a solution that allows for preservation of the transverse colon after both right and left colectomies while achieving a tension-free colorectal anastomosis slowing the transit and increasing the absorption time, resulting in better stool consistency and quality of life compared with an ileorectal anastomosis.MethodsThis technique was performed in a 41-year-old woman with Goblet cell adenocarcinoma of the appendix with peritoneal metastasis. The transverse colon is rotated anticlockwise over the axis of the middle colic vessels toward the left parietocolic flank and relocated to the usual position of the descending colon.ResultsAfter 1 year of follow-up, the patient led a normal life without parenteral nutrition with five bowel movements per day and a weight gain of 15%.ConclusionsThe use of an antiperistaltic transverse coloplasty may be worthwhile to perform in cases of extensive bowel resections during cytoreductive surgery leading to short-bowel syndrome to avoid a permanent stoma or intestinal failure and improve patient outcomes.

Use of tubularized bovine pericardium in left renal vein transposition for nutcracker syndrome

Nutcracker syndrome is an extrinsic compression of the left renal vein by the superior mesenteric artery anteriorly and aorta posteriorly, resulting in hallmark manifestations of hematuria, proteinuria, and flank and/or pelvic pain. This report illustrates the case of a patient with a history of left flank pain and intermittent gross hematuria every 2 weeks. The patient denies any pelvic pain or gastrointestinal or lower extremity symptoms. Urinalysis revealed red blood cells, but no infection was noted. The cystoscopy findings were normal. Computed tomography urography showed left renal vein and duodenal compression between the aorta and superior mesenteric artery with a narrow aortic–superior mesenteric artery angle. The patient underwent left renal vein transposition to the distal inferior vena cava via a transabdominal approach. The left renal vein was transected at the inferior vena cava; however, the length was too short to create a tension-free anastomosis. Thus, a bovine pericardium sheet was tubularized and used as an interposition graft. The patient recovered well and is symptom-free. Left renal vein transposition is a well-described surgical technique in the treatment of nutcracker syndrome. The use of a vein or prosthetic graft has been described. This case demonstrates the use of an alternate conduit for reconstruction.

Operative technique: Tracheal resection and anastomosis in a revision surgery.

Tracheal stenosis is an uncommon pathological condition in which the lumen of the trachea is reduced. Within its management an adequate preoperative workup is crucial to determine the most appropriate procedure for each patient. In this scenario tracheal resection and anastomosis is a viable approach, as a procedure in which part of the trachea is removed and then restored with a tension-free anastomosis. It is usually indicated for extensive and high-grade lesions or when previous endoscopic procedures had failed. The patient here presented had already undergone a balloon dilatation twice and a tracheal resection and referred to our clinic with a residual tracheal stenosis graded Myer-Cotton 3 involving three tracheal rings. We here illustrate step-by-step the surgical procedure and highlight a peculiar way to perform the anastomosis, especially in a revision surgery.