BACKGROUND: Severe dysphagia or even aphagia can occur after esophagectomy secondary to necrosis of the ascended organ with severe stricture or complete separation of the stumps. Catastrophic esophageal or gastric disruption drives the decision to "disconnect" the esophagus in order to prevent severe septic complications. The operations employed to re-establish esophageal discontinuity are not standardized and reoperations for re-establishment of the upper digestive transit are a real challenge. METHODS: This is retrospective study collecting the authors experience during 17 years including 18 patients, 14 of them previously submitted to esophagectomy and four to esophagogastrectomy. They were operated on in order to re-establish the upper digestive tract. RESULTS: Redo esophago-gastro-anastomosis was possible in 12 patients, 10 through cervical approach and combined with sternotomy in four in order to perform the new anastomosis. In five patients a new esophago-colo anastomosis was performed. Free jejunal graft interposition was performed in one patient. Complications occurred in ten patients (55.5 %): anastomotic leaks in three, strictures in four, sternal condritis in two and cervical abscess in one. No mortality was observed. CONCLUSION: There are different surgical options for the treatment of this difficult and risky clinical situation which must be treated with tailored procedures according to the anatomic segment available to be used, choosing the most conservative procedure.
Several methods have been proposed for the reconstruction of digestive transit after pancreatoduodenectomy. Biliary anastomosis positioned before gastric anastomosis helps reduce postoperative reflux and cholangitis.
The objective of this study was to present the anatomical sequence of gastric and biliary continuity after pancreatoduodenectomy in patients with pancreatic tumor and to evaluate the short- and long-term results in an initial series of cases.
Two techniques were used: one with Roux-en-Y reconstruction and pancreaticojejunostomy and the other with a single jejunal loop and pancreatogastroanastomosis. In both the cases, the gastric anastomosis was placed performed before the biliary one. An analysis of demographic data, Wirsung’s duct and common bile duct dilatation, the use of percutaneous drainage, and postoperative complications was carried out.
A total of seven patients (four men and three women), with a mean age of 62 years, underwent surgery. All cases had Wirsung’s duct and common bile duct dilatation. A percutaneous external biliary drainage was performed in four patients. There were three postoperative complications: one related to delayed gastric emptying and two related to wound infections. During a median follow-up of 12 months, no episode of cholangitis was recorded.
Elevated percentages of cholangitis are reported in different reconstructions after pancreatoduodenectomy, and it is difficult to conclude reflux as the main etiology. The proposed gastric and biliary reconstructions show conforming results, facilitating posterior endoscopic access. Late follow-up and large number of cases may help assess whether the etiology of postoperative cholangitis is reflux or other factors unrelated to the order of the anastomoses.
Although many methods have been defined for colonic anastomosis, anastomotic leak still remains important for sepsis control and successful healing.
The purpose of this study was to compare the effects of conventional suture, polyglactin 910 mesh, and omental flap coverage on healing and anastomotic leak in experimental colonic anastomosis in rats.
This study was conducted on 18 Wistar rats and the animals were divided into three groups as follows: Group 1: primary suture group; Group 2: primary suture plus polyglactin 910 mesh group; and Group 3: primary suture plus omental flap coverage group. Groups were compared in terms of anastomotic bursting pressure, inflammation, fibroblastic activity, neovascularization, and collagen amount.
There was a statistically significant difference in anastomotic bursting pressure between Groups 1 and 2 and between Groups 1 and 3 (p=0.004, p<0.05). There was a significant difference in fibroblastic activity between Groups 1 and 3 (p=0.011, p<0.05) and between Groups 2 and 3 (p=0.030, p<0.05). There was a significant difference in neovascularization and collagen between Groups 1 and 2 and between Groups 1 and 3 (p<0.05).
This experimental study found that polyglactin 910 mesh and omental flap coverage for colocolic anastomoses improved the physical strength and healing of the anastomosis compared to conventional hand-stitched anastomoses. The polyglactin may be a safe alternative to 910 mesh in cases where the omental flap coverage cannot be used in the colonic anastomosis.
At least 12 lymph nodes (LNs) should be examined following surgical resection of colon cancer. As it is difficult to find small LNs, fat clearing fixatives have been proposed, but there is no consensus about the best option.
The objective of this study was to verify if Carnoy’s solution (CS) increases the LN count in left colon cancer specimens.
A prospective randomized trial (clinicaltrials.gov registration: NCT02629315) with 60 patients with left colon adenocarcinoma who underwent rectosigmoidectomy. Specimens were randomized for fixation with CS or 10% neutral buffered formalin (NBF). After dissection, the pericolic fat from the NBF group was immersed in CS and re-dissected (Revision). The primary endpoint was the total number of LNs retrieved.
Mean LN count was 36.6 and 26.8 for CS and NBF groups, respectively (p=0.004). The number of cases with <12 LNs was 0 (CS) and 3 (NBF, p=0.237). The duration of dissection was similar. LNs were retrieved in all cases during the revision (mean: 19, range: 4-37), accounting for nearly 40% of the LNs of this arm of the study. After the revision, no case was found in the NBF arm with <12 LNs. Two patients had metastatic LNs during the revision (no upstaging occurred).
Compared to NBF, CS increases LN count in colon cancer specimens. After conventional pathologic analysis, fixing the pericolic fat with CS and performing a second dissection substantially increased the number of LNs.
The use of measures in colonic anastomoses to prevent dehiscences is of great medical interest. Sugarcane molasses, which has adequate tolerability and compatibility in vivo, has not yet been tested for this purpose.
To analyze the biomechanical parameters of colonic suture in rats undergoing colectomy, using sugarcane molasses polysaccharide as tape or gel.
45 Wistar rats (Rattus norvegicus albinus) were randomized into three groups of 15 animals: irrigation of enteric sutures with 0.9% saline solution; application of sugarcane molasses polysaccharide as tape; and sugarcane molasses polysaccharide as gel. The rats underwent colon ressection, with subsequent reanastomosis using polypropylene suture; they were treated according to their respective groups. Five rats from each group were evaluated at different times after the procedure: 30, 90 and 180 days postoperatively. The following variables were evaluated: maximum rupture force, modulus of elasticity and specific deformation of maximum force.
The biomechanical variables among the scheduled times and treatment groups were statistically calculated. The characteristics of maximum rupture force and modulus of elasticity of the specimens remained identical, regardless of treatment with saline, polysaccharide gel or tape, and treatment time. However, it was found that the specific deformation of maximum force of the intestinal wall was higher after 180 days in the group treated with sugarcane polysaccharide gel (p=0.09).
Compared to control, it was detected greater elasticity of the intestinal wall in mice treated with sugarcane polysaccharide gel, without changing other biomechanical characteristics, regardless of type or time of treatment.
Among the anastomoses of the gastrointestinal tract, those of the esophagus are of special interest due to several anatomical or even general peculiarities.
Evaluate retrospectively the results comparing mechanical vs. manual suture at cervical esophagogastric anastomosis in megaesophagus treatment.
Were included 92 patients diagnosed with advanced megaesophagus with clinical conditions to undergo the surgery. All underwent esophageal mucosectomy, performing anastomosis of the esophagus stump with the gastric tube at the cervical level. In order to make this anastomosis, the patients were divided into two groups: group A (n=53) with circular mechanical suture, lateral end; group B (n=39) with manual suture in two sides, lateral end. In the postoperative period, an early evaluation was performed, analyzing local and systemic complications and late (average 5.6 y) analyzing deglutition.
Early evaluation: a) dehiscence of esophagogastric anastomosis n=5 (9.4%) in group A vs. n=9 (23.0%) in group B (p=0.0418); b) stenosis of esophagogastric anastomosis n=8 (15.1%) in group A vs. n=15 (38.4%) in group B (p=0.0105.); c) pulmonary infection n=5 (9.4%) in group A vs. n=3 (7.6%) in group B (p=1.0000.); d) pleural effusion n=5 (9.4%) in group A vs. n=6 (15.4%) in group B (p<0.518). Late evaluation showed that 86.4-96% of the patients presented the criteria 4 and 5 from SAEED, expressing effective swallowing mechanisms without showing significant differences among the groups.
Cervical esophagogastric anastomosis by means of mechanical suture is more proper than the manual with lower incidence of local complications and, in the long-term evaluation, regular deglutition was acquired in both suture techniques in equal quality.
In high-income countries, morbid obesity is a growing health problem that has already reached epidemic proportions. When performing a laparoscopic gastric bypass several operative methods exist.
To describe the institutional experience using a knotless unidirectional barbed suture (V-Loc 180/Covidien, Mansfield, MA) to create a hand-sewn gastrojejunostomy (GJ) and jejunojejunostomy (JJ) during bariatric surgery.
Evaluation of a case series of 87 morbidly obese patients who underwent laparoscopic gastric bypass with a hand-sewn gastrojejunostomy (GJA) and jejunojejunostomy (JJA) between 01/2015 and 06/2017. The patients were divided into two groups: in group I, GJA und JJA sutures were performed using the knotless unidirectional barbed suture; in group II, GJA and JJA were sutured with resorbable multifilament thread (Vicryl® 3/0 Ethicon, Livingstone, UK). The recorded data on gender, age, BMI, ASA score, operative time, postoperative morbidity, length of hospital stay, and reoperation, were analyzed and compared.
All procedures were completed laparoscopically with no mortality. The mean operative time was 123.23 (±30.631) in group I and 127.57 (±42.772) in group II (p<0.05). The postoperative complications did not differ significantly between the two groups. Early complications were observed for two patients (0.9%) in the barbed suture group and for one patient (0.42%) in the multifilament suture group (p<0.05). In group I two patients (0.9%) required reoperation: on the basis of jejunojejunal stenosis in one patient, and local abscess near the gastrojejunostomy, without a leakage, in the other. In group II one patient (0.42%) required reoperation due to stenosis of the GJA. The duration of hospital admission was similar for both groups: 3.36 (±0.743) days in group I vs. 3.38 (±1.058) days in group II (p<0.05).
The novel anastomotic technique is a safe and effective method and can be applied to gastrojejunal anastomosis and jejunojejunal anastomosis in laparoscopic gastric bypass.
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