Enfrentamiento ante filtraciones de la esófagoyeyuno anastomosis

La filtración de la esófagoyeyuno anastomosis (FEYA) es una de las complicaciones más graves tras una gastrectomía total, ya que se asocia a un aumento de la morbimortalidad quirúrgica. El manejo óptimo de la FEYA aún es controversial, existiendo cada vez más opciones mínimamente invasivas, especialmente endoscópicas. El objetivo de la presente revisión es comparar la evidencia científica publicada y actualizada referente al tratamiento médico, endoscópico y quirúrgico de una FEYA y sus resultados a corto y largo plazo además de proponer un algoritmo de manejo que permita orientar la práctica clínica. Finalmente se presenta la experiencia nacional en relación a los avances presentados en los últimos años en torno manejo clínico de FEYA.

Leakage of the esophagojejunostomy (LEY) is one of the most serious complications after total gastrectomy, as it is associated with increased surgical morbidity and mortality. The optimal management of LEY is still controversial, with increasing minimally invasive options, especially endoscopic ones. The aim of this review is to compare the published and updated scientific evidence regarding the medical, endoscopic and surgical treatment of LEY and its short and long-term results, in addition to propose a management algorithm that allows guiding clinical practice. Finally, the national experience is presented in relation to the advances presented in recent years regarding clinical management of LEY.

Uso de plasma rico en fibrina y leucocitos (PRF-L) para la prevención de fuga anastomótica en anastomosis colorrectal grapada, ensayo clínico aleatorizado

Introducción: La tasa de dehiscencia anastomótica en cirugía colorrectal se estima entre un 4% a 20%. El plasma rico en fibrina y leucocitos (PRF-L) es un concentrado plaquetario de segunda generación y su aplicación en anastomosis colorrectales en animales ha evidenciado interesantes resultados que suponen una menor tasa. El objetivo de este estudio fue evaluar la viabilidad de aplicar L-PRF en cirugía colorrectal y determinar la incidencia de fuga anastomótica después de una anastomosis colorrectal. Materiales y Métodos: El estudio tuvo lugar en el Hospital Clínico Regional de Concepción Chile, en el periodo 2018-2021. Se realizó un ensayo clínico randomizado a 1 ciego. Se incluyeron a 106 pacientes sometidos a anastomosis colorrectal termino-terminal grapada. Se formó un grupo experimental con 53 pacientes y otro control con 53 pacientes. Resultados: A todos se les realizó anastomosis termino-terminal grapada. la indicación de cirugía fue cáncer en 79% y se realizó cirugía video-laparoscópica en 46%. No hubo diferencias estadísticamente significativas en variables socio-demográficas, ni relacionadas con la cirugía. Hubo dehiscencia anastomótica en 5 pacientes (9,4%) del grupo control y 1 (1,9%) en el grupo experimental sin diferencias estadísticamente significativas (p = 0,24). Conclusiones: A pesar de que no hubo diferencias con significación estadística entre los grupos, se apreció una tendencia en favor del PRF-L. Se logró establecer la seguridad de la aplicación de PRF-L en anastomosis colorrectales.

Introduction: Anastomotic leak rate in colorectal surgery is estimated between 4 and 20 percent. Leukocyte and and platelet-rich fibrin plasma (L-PRF) is second generation platelet concentrate whose application in colorectal anastomosis in animals has shown promising results that suppose a lower leakage rate. Aim: The objective of this study was to assess the feasibility of using L-PRF in colorectal surgery and to determine the incidence of anastomotic leak after colorectal anastomosis. Methods: This study took place in Hospital Clínico Regional de Concepción Chile, between years 2018 and 2021. A randomized and one-blinded experimental design was used, that included 106 patients that underwent end-to-end stapled colorectal anastomosis, 53 of them received L-PRF during anastomosis (experimental group). Results: Surgical indication in 79% was cancer and laparoscopic procedure was performed in 46% of patients. There were no statistically significant differences in sociodemographic nor surgery related variables. Anastomotic leak occurred in 5 patients of the control group (9.4%) and 1 patient from de experimental group (1.9%), with no statistically significant differences (p = 0.24). Conclusion: Although we did not detect significant differences among both groups, we observed a tendency favoring L-PRF treatment. We were able to stablish the safety of L-PRF use in colorectal anastomosis.

Manejo de perforaciones, fugas y fístulas del tracto gastrointestinal con clip sobre el endoscopio. Experiencia de un centro oncológico Latinoamericano / Management of perforations, leaks and fistulas of the gastrointestinal tract with over the scope clip. Experience at a Latin American cancer center

Introducción. Las fístulas derivadas de enfermedades neoplásicas del tracto digestivo, así como las fugas posteriores a procedimientos quirúrgicos, no son infrecuentes y ocasionan una morbilidad importante cuando se manejan de forma quirúrgica. También durante los procedimientos endoscópicos se pueden presentar perforaciones y, si se logra un manejo no operatorio, se alcanza una adecuada recuperación. El objetivo de este estudio fue describir las características clínicas y los resultados de los pacientes con perforaciones, fístulas y fugas del tracto gastrointestinal, manejadas endoscópicamente con clip sobre el endoscopio. Métodos. Estudio descriptivo, retrospectivo, de pacientes con perforación, fuga o fístula postoperatoria, llevados a endoscopía digestiva con colocación de clip sobre el endoscopio, en el Instituto Nacional de Cancerología en Bogotá, D.C., Colombia, entre enero de 2016 y abril de 2020. Resultados. Se incluyeron 21 pacientes, 52,4 % de ellos mujeres. La mediana de edad fue de 66 años y del diámetro del defecto fue de 9 mm. En el 95 % se logró éxito técnico. Hubo éxito clínico temprano en el 85,7 % de los casos. El 76,1 % de los pacientes permanecieron sin síntomas a los 3 meses de seguimiento. Conclusiones. El manejo de perforaciones, fugas y fístulas con clip sobre el endoscopio parece ser factible y seguro. En la mayoría de estos pacientes se logró la liberación del clip y la identificación endoscópica del cierre inmediatamente después del procedimiento; sin embargo, en el caso de las fístulas, no se alcanzó el éxito clínico tardío en todos los casos

Introduction. Fistula of the digestive tract derived from neoplastic diseases as well as leaks following surgical procedures are not uncommon and usually cause significant morbidity when are managed surgically. Diagnostic and therapeutic endoscopic procedures may present perforations during their performance; if they are managed non-operatively, an adequate recovery is obtained. The purpose of this study was to describe the clinical characteristics and the short- and long-term outcomes of patients with perforations, fistulas and leaks of the gastrointestinal tract managed endoscopically with over the scope clip (OTSC). Methods. Descriptive, retrospective study of patients brought to digestive endoscopy with OTSC placement with diagnosis of postoperative perforation, leak or fistula at the National Cancer Institute in Bogota, Colombia, between January 2016 and April 2020. Results. Twenty-one patients were taken for OTSC application for the management of perforations, leaks and fistulas of the gastrointestinal tract, 52.4% of them were women. The median age was 66 years. The median diameter of the defect was 9 mm. Technical success was achieved in 95%. Early clinical success was described in 85.7% of the cases; 76.1% of patients remained symptom-free at 3-month follow-up. Conclusions. Management of perforations, leaks and fistulas with OTSC appears to be feasible and safe. In most of these patients, clip release and endoscopic identification of closure was achieved immediately after management; however, in the case of fistulas, late clinical success was not achieved in all cases

Proteína C reactiva y su progresión en el tiempo para la detección de las fugas anastomóticas / C-reactive protein and its progression over time for the detection of anastomotic leaks

Introducción. Las fugas anastomóticas son una complicación común y crítica en cirugía gastrointestinal, por lo que su identificación y tratamiento temprano son necesarios para evitar resultados adversos. El uso convencional con un valor límite de la proteína C reactiva ha demostrado una utilidad limitada. El objetivo de este estudio fue determinar la utilidad de la medición seriada de la proteína C reactiva en la detección de fugas anastomóticas. Métodos. Revisión prospectiva de base de datos retrospectiva de pacientes sometidos a cirugía abdominal mayor con al menos una anastomosis intestinal. Se midió la proteína C reactiva al tercer y quinto día posoperatorio. Las complicaciones se categorizaron según la clasificación de Clavien-Dindo. La precisión diagnóstica fue evaluada por el área bajo la curva. Resultados. Se incluyeron 157 pacientes, el 52 % mujeres. La edad promedio fue de 63,7 años. El mayor número de cirugías correspondió a gastrectomía (36,3 %), resección anterior de recto (15,3 %) y hemicolectomía derecha (13,4 %). El 25,5 % tuvieron alguna complicación postoperatoria y el 32,5 % (n=13) presentaron fuga en la anastomosis. El aumento de la proteína C reactiva tuvo un área bajo la curva de 0,918 con un punto de corte de aumento en 1,3 mg/L, sensibilidad de 92,3 % (IC95% 78 ­ 100) y una especificidad de 92,4 % (IC95% 88 ­ 96). Conclusiones. El aumento de 1,3 mg/L en la proteína C reactiva entre el día de la cirugía y el quinto día fue un predictor preciso de fugas anastomóticas en pacientes con cirugía abdominal mayor

Introduction. Anastomotic leaks are a common and critical complication in gastrointestinal surgery. Their identification and early treatment are necessary to avoid adverse results, and conventional use with a cutoff value of C-reactive protein has shown limited utility. The objective of this study was to determine the usefulness of serial measurement of C-reactive protein in the detection of anastomotic leaks. Methods. Prospective review of a retrospective database of patients undergoing major abdominal surgery with at least one intestinal anastomosis. C-reactive protein was measured on the third and fifth postoperative days. Complications were classified according to the Clavien-Dindo classification. Diagnostic accuracy was evaluated by the area under the curve.Results. 157 patients were included, 52% were females. The average age was 63.7 years. The largest number of surgeries corresponded to gastrectomies (36.3%), anterior resection of the rectum (15.3%) and right hemicolectomies (13.4%). 25.5% had some postoperative complication and 32.5% (n=13) had anastomosis leaks. The increase in C-reactive protein had an area under the curve of 0.918 with an increase cut-off point of 1.3 mg/L, sensitivity of 92.3% (95% CI 78-100) and specificity of 92.4%. (95% CI 88-96). Conclusions. The 1.3 mg/L increase in C-reactive protein between the day of surgery and the fifth day was an accurate predictor of anastomotic leaks in patients with major abdominal surgery

Proteína C reactiva como biomarcador predictivo de fuga anastomótica en cirugía oncológica colorrectal: estudio de cohorte retrospectivo / C-reactive protein as a predictive biomarker of anastomotic leak in colorectal cancer surgery: A retrospective cohort study

Introducción. La fuga anastomótica es la complicación más grave del tratamiento quirúrgico del cáncer de colon por su alta morbimortalidad. El diagnóstico evidente, manifestado por la salida de contenido intestinal por drenajes o la herida quirúrgica, ocurre tardíamente (entre el 6º y 8º día). El objetivo de este trabajo fue estudiar la variación de los valores de la proteína C reactiva postoperatoria para hacer un diagnóstico precoz. Métodos. Estudio observacional, analítico, retrospectivo, de una cohorte de pacientes con neoplasia, en quienes se realizó cirugía oncológica con anastomosis intestinal, entre enero de 2019 y diciembre de 2021. Se midieron los valores en sangre de proteína C reactiva postoperatoria (1°, 3° y 5° días). Resultados. Se compararon 225 casos operados que no presentaron fuga con 45 casos con fuga. En los casos sin fuga, el valor de proteína C reactiva al 3º día fue de 148 mg/l y al 5º día de 71 mg/l, mientras en los casos con fuga, los valores fueron de 228,24 mg/l y 228,04 mg/l, respectivamente (p<0,05). Para un valor de 197 mg/l al 3º día la sensibilidad fue de 77 % y para un valor de 120 mg/l al 5º día la sensibilidad fue de 84 %. Conclusión. El mejor resultado de proteína C reactiva postoperatoria para detectar precozmente la fuga anastomótica se observó al 5º día. El valor de 127 mg/l tuvo la mejor sensibilidad, especificidad y valor predictivo negativo, lo cual permitiría el diagnóstico temprano y manejo oportuno de esta complicación

Introduction. Anastomotic leak is the most serious complication of surgical treatment of colon cancer due to its high morbidity and mortality. The obvious diagnosis manifested by the exit of intestinal content through drains or the operative wound, occurs late (between the 6th and 8th day). The objective of this work was to study the postoperative C-reactive protein values to make an early diagnosis. Methods. Observational, analytical, retrospective study of a cohort of patients undergoing colorectal surgery for neoplasia, between January 2019 and December 2021, who underwent oncological surgery with intestinal anastomosis and measured CRP blood values on 1st, 3rd and 5th post-operative days. Results. Two-hundred-twenty-five operated cases that did not present leaks were compared with 45 cases with leaks, with CRP values on the 3rd and 5th day of 148mg/l and 71mg/l in cases without leakage and CRP values of 228.24mg/l and 228.04 mg/l in cases with leakage on the 3rd and 5th day, respectively (p<0.05), CRP value of 197mg/l on the 3rd day has a sensitivity of 77%; CRP value of 120mg/l on the 5th day, has a sensitivity of 84%. Conclusions. The best result for CPR to early diagnosis of anastomotic leak was observed on the 5th day, having the value of 127 mg/l the best sensitivity, specificity and NPV, which would allow early diagnosis and timely management

Analysis of the causes of long-standing pelvic anterior sacral space infection and discussion of management techniques / 中华肿瘤杂志

Objective: To investigate the causes and management of long-term persistent pelvic presacral space infection. Methods: Clinical data of 10 patients with persistent presacral infection admitted to the Cancer Hospital of Zhengzhou University from October 2015 to October 2020 were collected. Different surgical approaches were used to treat the presacral infection according to the patients' initial surgical procedures. Results: Among the 10 patients, there were 2 cases of presacral recurrent infection due to rectal leak after radiotherapy for cervical cancer, 3 cases of presacral recurrent infection due to rectal leak after radiotherapy for rectal cancer Dixons, and 5 cases of presacral recurrent infection of sinus tract after adjuvant radiotherapy for rectal cancer Miles. Of the 5 patients with leaky bowel, 4 had complete resection of the ruptured nonfunctional bowel and complete debridement of the presacral infection using an anterior transverse sacral incision with a large tipped omentum filling the presacral space; 1 had continuous drainage of the anal canal and complete debridement of the presacral infection using an anterior transverse sacral incision. 5 post-Miles patients all had debridement of the presacral infection using an anterior transverse sacral incision combined with an abdominal incision. The nine patients with healed presacral infection recovered from surgery in 26 to 210 days, with a median time of 55 days. Conclusions: Anterior sacral infections in patients with leaky gut are caused by residual bowel secretion of intestinal fluid into the anterior sacral space, and in post-Miles patients by residual anterior sacral foreign bodies. An anterior sacral caudal transverse arc incision combined with an abdominal incision is an effective surgical approach for complete debridement of anterior sacral recalcitrant infections.

Endoscopic negative pressure therapy for the closure of an esophagojejunal anastomosis fistula. Case report / Terapia endoscópica de presión negativa para cierre de fístula de la anastomosis esófago-yeyunal. Reporte de caso

Abstract Introduction: Post-surgical esophagojejunal anastomosis fistulas can be life-threatening. Currently, there are several treatment alternatives. In recent years, endoscopic negative pressure therapy has emerged as an innovative treatment for these fistulas, offering numerous benefits. Case presentation: A 72-year-old man diagnosed with gastric adenocarcinoma of the body and fundus underwent total gastrectomy with D2 lymphadenectomy and Roux-en-Y anastomosis with curative intent in a quaternary care hospital in Popayán, Colombia. However, in the postoperative period, he presented systemic inflammatory response syndrome and acute abdomen due to an esophagojejunal fistula. Initial management included a laparotomy, two peritoneal washings, and an abdominal drainage. Then the patient developed frozen abdomen, so it was not possible to access the esophagojejunal anastomosis. Fistula closure was attempted by inserting a self-expandable metallic stent, yet the procedure was not successful. Salvage therapy was started using an endoscopic vacuum-assisted closure (VAC) system. After 5 replacements of the VAC system, complete drainage of the intra-abdominal collection, complete closure of the peritoneal cavity, and closure of the esophagojejunal leak, with a small residual diverticular formation, were achieved. The patient's condition improved progressively, resuming oral intake 20 days after initiation of VAC therapy. In addition, no new abdominal complications were reported during the follow-up period (17 months). Conclusions: Endoscopic VAC therapy is a new safe and effective alternative to treat complex post-surgical fistulas caused by esophagojejunal anastomosis.

Resumen Introducción. Las fístulas de las anastomosis esófago-yeyunales postquirúrgicas pueden llegar a ser mortales. En la actualidad, existen varias alternativas de tratamiento, y en los últimos años la terapia endoscópica de presión negativa se ha convertido en un método innovador y con grandes ventajas para el manejo de estas fístulas. Presentación del caso. Hombre de 72 años diagnosticado con adenocarcinoma gástrico de cuerpo y fondo a quien se le realizó una gastrectomía total con linfadenectomía D2 y una anastomosis en Y de Roux con intención curativa en un hospital de cuarto nivel en Popayán, Colombia. Sin embargo, en el posoperatorio presentó síndrome de respuesta inflamatoria sistémica y abdomen agudo producto de fístula esófago-yeyunal. Se realizó manejo inicial con laparotomía, dos lavados de cavidad peritoneal y drenaje abdominal. Posteriormente, el paciente desarrolló abdomen congelado, por lo que no fue posible acceder a la anastomosis esófago-yeyunal. Se intentó cierre de fístula mediante la inserción de prótesis metálica autoexpandible, pero el procedimiento no fue exitoso. Se inició terapia de rescate mediante sistema de cierre asistido por vacío (VAC) por vía endoscópica. Luego de 5 recambios del sistema VAC, se logró el drenaje completo de la colección intraabdominal encontrada, el cierre completo de la cavidad peritoneal y el cierre de la fuga esófago-yeyunal, con una pequeña formación diverticular residual. La condición del paciente mejoró progresivamente, con reinicio de la vía oral a los 20 días del inicio de la terapia VAC. Además, no se reportaron nuevas complicaciones abdominales en el periodo de seguimiento (17 meses). Conclusión. La terapia endoscópica de VAC es una nueva alternativa segura y efectiva para el tratamiento de fístulas postquirúrgicas complejas producto de anastomosis esófago-yeyunales.

Estudio comparativo en pacientes sometidos a cirugía colorrectal con preparación mecánica exclusiva y preparación mecánica con antibióticos orales

Objetivo: Evaluar las complicaciones posoperatorias y la evolución clínica en pacientes sometidos a colectomías y anastomosis con dos estrategias preoperatorias, preparación mecánica (PMC) y preparación mecánica con antibióticos orales (PMC+AO). Materiales y Método: Estudio retrospectivo, con un total de 216 pacientes, 149 fueron del grupo PMC y 67 del PMC+AO. Variables estudiadas: características demográficas, intervención quirúrgica, localización anastomótica, fuga anastomótica (FA), infección del sitio operatorio (ISO), tránsito intestinal posoperatorio, infección por Clostridium difficile (CD) y estadía hospitalaria. Para el análisis estadístico se realizaron modelos bivariados y multivariados. Resultados: La FA fue más frecuente en el grupo PMC (7,38% vs. 0%, p = 0,011). En colectomías del lado izquierdo, la diferencia más marcada en las FA de ambos grupos fue en anastomosis del recto medio, sin casos en el grupo PMC+AO (0% vs. 50%, p = 0,019). En colectomías derechas, la FA fue similar para ambos grupos. Hubo más ISO en el grupo PMC (4,7% vs. 0%, p = 0,037). La recuperación del tránsito intestinal fue más rápida para el grupo PMC+AO, determinando menor estadía hospitalaria (3,98 días vs. 6,39 días, p = 0,001). El grupo PMC+AO se asoció a mayor tasa de colitis por CD (4,48% vs. 0,67%, p = 0,008). Discusión y Conclusión: El uso de la preparación intestinal con antibióticos orales podría ayudar a prevenir la FA en las colectomías izquierdas y evitar las ISO, favoreciendo la recuperación del tránsito intestinal, reduciendo la estadía hospitalaria. La asociación a CD debe examinarse en estudios más amplios.

Aim: To evaluate postoperative complications and clinical evolution in patients undergoing colectomies and anastomosis with two preoperative strategies, mechanical bowel preparation alone (MBP) and mechanical bowel preparation with oral antibiotics (MBP+OA). Materials and Method: Retrospective study, with defined inclusion and exclusion criteria. Variables studied: preoperative demographic characteristics, surgical intervention, anastomotic location, anastomotic leakage (AL), surgical site infection (SSI), postoperative intestinal transit, Clostridium difficile (CD) infection and hospital stay. Statistical analysis, bivariate and multivariate models were performed. Results: 216 patients studied, 149 were MBP group and 67 MBP+OA group. The group MBP had higher rates of AL (7.38% vs. 0%, p = 0.011). For left-sided colectomies, AL rate in both groups had a higher difference in the middle rectum, with no cases in the MBP+OA group (0% vs. 50%, p = 0.019). For right colectomies, the AL rates were similar in both groups. SSI was higher in MBP group (4.7% vs. 0%, p = 0.037). The bowel transit recovery was faster for MBP+OA group, determining less hospital stay (3.98 days vs. 6.39 days, p = 0.001). The group MBP+OA had a higher rate of CD colitis, 4.48% (p = 0.008). Discussion and Conclusion: These results suggest that preoperative oral antibiotic with mechanical bowel preparation could help to prevent anastomotic leaks in left-sided colectomies, also avoid surgical site infection, favoring the recovery of postoperative bowel transit, reducing hospital stay. The association to CD should be examined in larger studies.

Progress of biomarkers for predicting postoperative anastomotic leakage of colorectal cancer / 肿瘤研究与临床

Anastomotic leakage is one of the common and serious complications after colorectal cancer surgery, and it should be detected, prevented and treated as soon as possible. In recent years, the causes, diagnosis and treatment of postoperative anastomotic leakage of colorectal cancer have always been the focus of clinical attention, and relevant reports and prediction indicators continue to emerge. This article reviews the current situation and progress of biomarkers for predicting postoperative anastomotic leakage of colorectal cancer, in order to provide theoretical basis for early clinical detection and treatment of anastomotic leakage.

Safety and prognosis analysis of transanal total mesorectal excision versus laparoscopic mesorectal excision for mid-low rectal cancer / 中华胃肠外科杂志

Objective: To compare the short-term and long-term outcomes between transanal total mesorectal excision (taTME) and laparoscopic total mesorectal excision (laTME) for mid-to-low rectal cancer and to evaluate the learning curve of taTME. Methods: This study was a retrospective cohort study. Firstly, consecutive patients undergoing total mesorectal excision who were registered in the prospective established database of Division of Colorectal Diseases, Department of General Surgery, Peking Union Medical College Hospital during July 2014 to June 2020 were recruited. The enrolled patients were divided into taTME and laTME group. The demographic data, clinical characteristics, neoadjuvant treatment, intraoperative and postoperative complications, pathological results and follow-up data were extracted from the database. The primary endpoint was the incidence of anastomotic leakage and the secondary endpoints included the 3-year disease-free survival (DFS) and the 3-year local recurrence rate. Independent t-test for comparison between groups of normally distributed measures; skewed measures were expressed as M (range). Categorical variables were expressed as examples (%) and the χ(2) or Fisher exact probability was used for comparison between groups. When comparing the incidence of anastomotic leakage, 5 variables including sex, BMI, clinical stage evaluated by MRI, distance from tumor to anal margin evaluated by MRI, and whether receiving neoadjuvant treatment were balanced by propensity score matching (PSM) to adjust confounders. Kaplan-Meier curve and Log-rank test were used to compare the DFS of two groups. Cox proportional hazard model was used to analyze and determine the independent risk factors affecting the DFS of patients with mid-low rectal cancer. Secondly, the data of consecutive patients undergoing taTME performed by the same surgical team (the trananal procedures were performed by the same main surgeon) from February 2017 to March 2021 were separately extracted and analyzed. The multidimensional cumulative sum (CUSUM) control chart was used to draw the learning curve of taTME. The outcomes of 'mature' taTME cases through learning curve were compared with laTME cases and the independent risk factors of DFS of 'mature' cases were also analyzed. Results: Two hundred and forty-three patients were eventually enrolled, including 182 undergoing laTME and 61 undergoing taTME. After PSM, both fifty-two patients were in laTME group and taTME group respectively, and patients of these two groups had comparable characteristics in sex, age, BMI, clinical tumor stage, distance from tumor to anal margin by MRI, mesorectal fasciae (MRF) and extramural vascular invasion (EMVI) by MRI and proportion of receiving neoadjuvant treatment. After PSM, as compared to laTME group, taTME group showed significantly longer operation time [(198.4±58.3) min vs. (147.9±47.3) min, t=-4.321, P<0.001], higher ratio of blood loss >100 ml during surgery [17.3% (9/52) vs. 0, P=0.003], higher incidence of anastomotic leakage [26.9% (14/52) vs. 3.8% (2/52), χ(2)=10.636, P=0.001] and higher morbidity of overall postoperative complications [55.8%(29/52) vs. 19.2% (10/52), χ(2)=14.810, P<0.001]. Total harvested lymph nodes and circumferential resection margin involvement were comparable between two groups (both P>0.05). The median follow-up for the whole group was 24 (1 to 72) months, with 4 cases lost, giving a follow-up rate of 98.4% (239/243). The laTME group had significantly better 3-year DFS than taTME group (83.9% vs. 73.0%, P=0.019), while the 3-year local recurrence rate was similar in two groups (1.7% vs. 3.6%, P=0.420). Multivariate analysis showed that and taTME surgery (HR=3.202, 95%CI: 1.592-6.441, P=0.001) the postoperative pathological staging of UICC stage II (HR=13.862, 95%CI:1.810-106.150, P=0.011), stage III (HR=8.705, 95%CI: 1.104-68.670, P=0.040) were independent risk factors for 3-year DFS. Analysis of taTME learning curve revealed that surgeons would cross over the learning stage after performing 28 cases. To compare the two groups excluding the cases within the learning stage, there was no significant difference between two groups after PSM no matter in the incidence of anastomotic leakage [taTME: 6.7%(1/15); laTME: 5.3% (2/38), P=1.000] or overall complications [taTME: 33.3%(5/15), laTME: 26.3%(10/38), P=0.737]. The taTME was still an independent risk factor of 3-year DFS only analyzing patients crossing over the learning stage (HR=5.351, 95%CI:1.666-17.192, P=0.005), and whether crossing over the learning stage was not the independent risk factor of 3-year DFS for mid-low rectal cancer patients undergoing taTME (HR=0.954, 95%CI:0.227-4.017, P=0.949). Conclusions: Compared with conventional laTME, taTME may increase the risk of anastomotic leakage and compromise the oncological outcomes. Performing taTME within the learning stage may significantly increase the risk of postoperative anastomotic leakage.

Preoperative computed tomography angiography in multidisciplinary personalized assessment of patient with right-sided colon cancer: surgeon and radiologist point of view / Angiografia por tomografia computadorizada pré-operatória na avaliação personalizada multidisciplinar de paciente com câncer de cólon direito: visão do cirurgião e do radiologista

ABSTRACT BACKGROUND: 3D-CT angiography has made it possible to reach a qualitatively new level in the determination of treatment tactics for patients with colorectal cancer. AIMS: This study aimed to analyze the clinical and radiological aspects that need to be discussed before surgery by a multidisciplinary team in patients with right-sided colon cancer. METHODS This study involved 103 patients with colorectal cancer who underwent preoperative 3D-CT angiography from 2016 to 2021 RESULTS: All patients underwent radical D3 right hemicolectomy. The median quantity of removal lymph nodes were 24.71±10.04. Anastomotic leakage was diagnosed in one patient. We have identified eight most common types of superior mesenteric artery. The ileocolic artery crossed the superior mesenteric vein on the anterior surface in 64 (62.1%) patients and on the posterior surface in 39 (37.9%). In 58 (56.3%) patients, the right colic artery was either absent or was a nonindependent branch of superior mesenteric artery. The distance from the root of the superior mesenteric artery to the root of the middle colic artery was 37.8±12.8 mm and that from the root of the middle colic artery to the root of the ileocolic artery was 29.5±15.7 mm. The trunk of Henle was above the root of the middle colic artery in 66 (64.1%) patients, at the same level with the middle colic artery in 16 (15.5%), and below the middle colic artery in 18 (17.5%) patients. CONCLUSIONS: Preoperative analysis of 3D-CT angiography is a key pattern in assessment of vascular anatomy and can potentially show the complexity of future lymphadenectomy and reduce the risk of anastomotic leakage.

RESUMO RACIONAL: A angiografia 3D-TC permitiu alcançar um nível qualitativamente novo na determinação de táticas de tratamento para pacientes com câncer colorretal. OBJETIVO: Analisar os aspectos clínicos e radiológicos que precisam ser discutidos antes da cirurgia por uma equipe multidisciplinar em pacientes com câncer de cólon direito. MÉTODOS: Analisar 103 pacientes com câncer colorretal submetidos à angiotomografia 3D pré-operatória entre 2016 e 2021. RESULTADOS: Todos os pacientes foram submetidos à hemicolectomia direita radical D3. A quantidade mediana de linfonodos removidos foi de 24,71±10,04. Deiscência de anastomose foi diagnosticada em 1 paciente. Identificamos 8 tipos mais comuns de artéria mesentérica superior. Em 64 pacientes (62,1%) a artéria ileocólica cruzou a veia mesentérica superior na face anterior e em 39 (37,9%), na face posterior. Em 58 pacientes (56,3%) a artéria cólica direita estava ausente ou era um ramo não independente da artéria mesentérica superior. A distância da raiz da artéria mesentérica superior à raiz da artéria cólica média foi de 37,8±12,8 mm e a distância da raiz da artéria cólica média até a raiz da artéria ileocólica foi de 29,5±15,7 mm. Em 66 pacientes (64,1%) o tronco de Henle estava acima da raiz da artéria cólica média, em 16 (15,5%) o tronco de Henle estava no mesmo nível da artéria cólica média e em 18 pacientes (17,5%) o tronco de Henle estava abaixo da artéria cólica média. CONCLUSÕES: A angiografia 3D-CT pré-operatória é um padrão chave na avaliação da anatomia vascular e pode potencialmente mostrar a complexidade de uma futura linfadenectomia e reduzir o risco de deiscência da anastomose.

Tratamento não-cirúrgico de fístula de alto débito pós-"bypass" gástrico em paciente portador de superobesidade: relato de caso / Non-surgical treatment of high-output fistula after gastric bypass in a patient with superobesity: case report

Introdução: A cirurgia bariátrica é atualmente o tratamento indicado para a obesidade mórbida e a técnica do bypass gástrico em Y de Roux (BGYR) largamente utilizada em todo o mundo, mesmo para pacientes superobesos. No Brasil, o BGYR é a técnica de escolha da maioria dos cirurgiões bariátricos. As deiscências de anastomose ou da linha de grampeamento estão entre as complicações cirúrgicas mais temidas. Relato de Caso: Paciente com fístula da anastomose gastrojejunal após bypass gástrico em Y de Roux comunicando com a ferida operatória, foi tratado com sucesso com tratamento endoscópico conservador. Após o diagnóstico, o paciente foi submetido à endoscopia digestiva alta em ambiente de centro cirúrgico com passagem de sonda nasoenteral. Onze dias após, foi realizada uma segunda endoscopia com dilatação da anastomose gastrojejunal com vela de Savary-Gillard. A fístula fechou em 21 contando da data de seu diagnóstico. Conclusão: A partir desse relato, conclui-se que a abordagem conservadora de fístulas pós-BGYR em pacientes estáveis com auxílio endoscópico para o posicionamento da sonda nasoenteral e dilatação com vela pode reservar bons resultados terapêuticos para a condução dessa complicação e evitar intervenções cirúrgicas mais complexas.

Introduction: Bariatric surgery is currently the indicated treatment for morbid obesity and the Roux-en-Y gastric bypass (RYGB) technique is widely used worldwide, even for super obese patients. In Brazil, RYGB is the most chosen technique of bariatric surgeons. Although, anastomosis or stapling line dehiscences are one of the most feared surgical complications. Case Report: A patient with gastrojejunal anastomosis fistula after Rouxen-Y gastric bypass communicating with the surgical wound was successfully treated with conservative endoscopic treatment. After diagnosis, the patient underwent upper digestive endoscopy in operating room with introduction of a nasoenteral tube. Eleven days later, a second endoscopy was performed with dilation of the gastrojejunal anastomosis with a Savary-Gilliard bougie. The fistula closed at the day 21 counting from the date of his diagnosis. Conclusion: From this report, it's concluded that the conservative approach of post-RYGB fistulas in stable patients with endoscopic aid for positioning the nasoenteral tube and dilation with a bougie can reserve good therapeutic results for the management of this complication and avoid more surgical interventions complex.

Caracterización de la fuga anastomótica en operados por cáncer del esófago en Cuba / Characterization of Anastomotic Leak in Patients Operated on for Esophageal Cancer in Cuba

Introducción: La fuga anastomótica es la principal complicación de la cirugía del esófago, con altos índices de incidencia y mortalidad. Objetivo: Identificar los factores involucrados en la aparición de la fuga anastomótica en pacientes operados de cáncer de esófago en Cuba en el periodo de 1988 al 2020. Métodos: Se realizó una investigación observacional clínico epidemiológica multicéntrica, no randomizada, en el periodo de 1988 al 2020. El universo y la muestra quedaron constituidos por 2844 y 595 enfermos de 9 centros hospitalarios. Algunas variables estudiadas incluyeron sexo, edad, variedad histológica, intervención quirúrgica realizada, comorbilidades y su interrelación con la fuga anastomótica. Resultados: La fuga anastomótica predominó en el grupo de mayores de 55 años (17,8 por ciento), en el sexo femenino 65 (10,9 por ciento), en los no fumadores 79 (13,3 por ciento) y en los que no ingerían bebidas alcohólicas con 100 pacientes (16,8 por ciento). En enfermos con niveles de albúmina normales 98 (16,5 por ciento), con proteínas bajas 94 (15,7por ciento) y cifras normales de hemoglobina 105 (17,6 por ciento). En la variedad histológica adenocarcinoma 65 (10,9 por ciento), la técnica quirúrgica transhiatal 69 (11,6 por ciento), realizada de forma manual 123 (20,7 por ciento), de localización cervical 111 (18,6 por ciento), en cara anterior 57 (9,6 por ciento), en un plano 78 (13,1 por ciento), en la variante término-lateral 120 (20,2 por ciento). Conclusiones: La fuga anastomótica predominó en mujeres mayores de 50 años, con adenocarcinoma, operadas con técnicas transhiatales, manuales, en un plano, termino-laterales, en cara anterior y con hipoproteinemia(AU)

Introduction: Anastomotic leak is the main complication of esophageal surgery, with high incidence and mortality rates. Objective: To identify the factors involved in the appearance of anastomotic leak in patients operated on for esophageal cancer in Cuba in the period from 1988 to 2020. Methods: A nonrandomized, multicenter, clinical-epidemiological and observational investigation was carried out in the period from 1988 to 2020. The universe and the sample consisted of 2844 and 595 patients from nine hospital centers. Some of the variables studied included sex, age, histological variety, surgical intervention performed, comorbidities, and their interrelation with anastomotic leak. Results: Anastomotic leak prevailed in the group aged over 55 years (17.8 percent), in the female sex (65; 10.9 percent)), in nonsmokers (79; 13.3 percent)) and in those who did not ingest alcoholic beverages (100, 16.8; as well as in patients with normal albumin levels (98; 16.5), with low proteins (94; 15.7 percent) and with normal levels of hemoglobin (105; 17.6 percent). In the histological variety of adenocarcinoma (65; 10.9 percent), there was a predominance of the transhiatal surgical technique (69; 11.6 percent), performed manually (123; 20.7 percent), of cervical location (111; 18.6 percent), in the anterior face (57; 9.6 percent), in one plane (78; 13.1 percent), and in the termino-lateral variant (120; 20.2 percent). Conclusions: Anastomotic leak prevailed in women aged over 50 years, with adenocarcinoma, operated on through transhiatal techniques, manually, in one plane, using the termino-lateral variant, in the anterior face and with hypoproteinemia(AU)

Abordaje endoscópico en el manejo de la fuga post manga gástrica / Endoscopic approach in the management of post gastric sleeve leakage

INTRODUCCIÓN. La fuga post manga gástrica es una complicación de los proce-dimientos bariátricos quirúrgicos, con prevalencia del 2,1%, en el que se emplea el abordaje endoscópico, describir su seguridad y éxito es relevante. OBJETIVO. Describir el abordaje endoscópico en el manejo de la fuga post manga gástrica. MATERIALES Y MÉTODOS. Revisión bibliográfica y análisis sistemático de artículos científicos. De un total de 384 artículos, 11 publicaciones de texto completo fueron seleccionados; 9 artículos fueron estudios retrospectivos y 2 revisiones sistemáticas. Los términos de búsqueda sobre el tratamiento endoscópico en fuga post manga gástrica se basaron en datos PubMed que cumplieron los criterios: leak, fístula, par-tial gastrectomy, gastrointestinal endoscopy. RESULTADOS. La literatura reportó se-guridad con cero mortalidad y tasa de éxito para sutura endoscópica del 80,0%, over the scope clip 86,3%, drenaje interno endoscópico 83,41%, septotomía endoscópica 100,0%, stents endoscópicos hasta del 95,0% y terapia vacuum endoscópica 87,5%. CONCLUSIÓN. Se evidenció que el abordaje endoscópico en el manejo de la fuga post manga gástrica fue seguro y exitoso; se necesita personal experto en las dife-rentes modalidades terapéuticas reportadas.

INTRODUCTION. Post gastric sleeve leakage is a complication of surgical bariatric procedures, with a prevalence of 2,1%, in which the endoscopic approach is used, describing its safety and success is relevant. OBJECTIVE. To describe the endos-copic approach in the management of post gastric sleeve leak. MATERIALS AND METHODS. Bibliographic review and systematic analysis of scientific articles. From a total of 384 articles, 11 full-text publications were selected; 9 articles were retrospective studies and 2 systematic reviews. Search terms on endoscopic treatment in postgastric sleeve leak were based on PubMed data that met the criteria: leak, fistula, partial gastrectomy, gastrointestinal endoscopy. RESULTS. The literature re-ported safety with zero mortality and success rate for endoscopic suture 80,0%, over the scope clip 86,3%, endoscopic internal drainage 83,41%, endoscopic septotomy 100,0%, endoscopic stents up to 95,0% and endoscopic vacuum therapy 87,5%. CONCLUSION. It was evidenced that the endoscopic approach in the management of post gastric sleeve leak was safe and successful; expert personnel are needed in the different therapeutic modalities reported

Role of covering Ileostomy in causation of anastomotic strictures in low anterior resections for rectum carcinoma / O papel da ileostomia de proteção como causa das estenoses anastomóticas nas ressecções anteriores de reto

Abstract Background Colorectal resection anastomosis is the commonest cause of rectal strictures. Anastomotic site ischemia, incomplete doughnuts from stapled anastomosis and pelvic infection, are some of the risk factors that play a role in the development of postoperative rectal strictures. However, the role of diverting stoma in the development of rectal strictures has not been studied extensively. Objectives To study the difference in the occurrence of anastomotic strictures (AS) in patients submitted to low anterior resection (LAR) with covering ileostomy (CI), and to LAR without CI for carcinoma rectum. Methods This was a prospective, comparative case control study carried out at a tertiary care referral center. Low anterior resection with covering ileostomy was performed in patients with rectum carcinoma in the study group, while LAR without covering ileostomy was performed in the control group. The study group had 29 patients, while the control group had 33 patients with rectum carcinoma. Results During themean follow-up period of 9.1months, 8 (28%) patients in the study group and 2 (6%) patients in the control group developed AS (p =0.019). Out of these 8 patients with AS in the study group, 50% had Grade-I AS, 25% had Grade-II AS, while 25% of the patients had Grade-III (severe) AS. However, both patients who developed AS in the control group had a mild type (Grade I) of AS. Conclusion Covering ileostomy increases the chances of AS formation after LAR for rectum carcinoma. Also, the SKIMS Clinical Grading of Rectal Strictures is a simple and

Resumo Introdução A anastomose de ressecção colorretal é a causa mais comum de estenoses retais. A isquemia do local da anastomose, donuts (anéis) incompletos de anastomose grampeada e infecção pélvica são alguns dos fatores de risco que desempenham um papel no desenvolvimento de estenoses retais pós-operatórias. No entanto, o papel do estoma de desvio no desenvolvimento de estenoses retais não foi estudado extensivamente. Objetivos Estudar a diferença na ocorrência de estenoses anastomóticas (EA) em pacientes submetidos à ressecção anterior baixa (LAR) com ileostomia de proteção e a LAR sem ileostomia de proteção para carcinoma de reto. Métodos Este foi um estudo prospectivo e comparativo de caso-controle realizado em um centro de referência de atenção terciária. A ressecção anterior baixa com ileostomia de proteção foi realizada em pacientes com carcinoma de reto no grupo de estudo, enquanto LAR sem ileostomia de proteção foi realizada no grupo controle. O grupo de estudo tinha 29 pacientes, enquanto o grupo controle tinha 33 pacientes com carcinoma de reto. Resultados Durante o período de acompanhamento médio de 9, 1 meses, 8 (28%) pacientes no grupo de estudo e 2 (6%) pacientes no grupo controle desenvolveram EA (p=0,019). Destes 8 pacientes com EA no grupo de estudo, 50% tinham EA de Grau I, 25% tinhamEA de Grau II, enquanto 25% dos pacientes tinham EA de Grau III (grave). No entanto, ambos os pacientes que desenvolveram EA no grupo de controle tinham um tipo leve (Grau I) de EA. Conclusão A ileostomia de proteção aumenta as chances de formação de AS após LAR para carcinoma de reto. Além disso, o SKIMS Clinical Grading of Rectal Strictures é uma ferramenta simples e útil disponível para cada cirurgião para graduar, classificar e monitorar as estenoses retais pós-operatórias.

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent? / Cirugía de control de daños en lesiones combinadas de intestino delgado y colon en trauma penetrante: ¿Es pertinente el uso de ostomías?

Abstract Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Resumen El trauma de las vísceras huecas representa una gran proporción de las lesiones asociadas al trauma penetrante. Actualmente, las lesiones aisladas de intestino delgado o colon se manejan a través de anastomosis primaria en pacientes sometidos a laparotomía definitiva o anastomosis diferida en pacientes que requieran cirugía de control de daños. El dogma quirúrgico tradicional de la ostomía se ha probado que es innecesario y en muchos casos puede aumentar la morbilidad. El objetivo de este artículo es describir la experiencia obtenida en el manejo de lesiones combinadas de vísceras huecas de pacientes con trauma penetrante. Se determinó que el manejo primario o diferido del intestino a través de anastomosis es el abordaje quirúrgico preferido en pacientes que presentan lesiones penetrantes combinadas de intestino delgado y colon. Se ha reportado que el 90% de lesiones combinadas penetrantes intestinales pueden ser manejadas a través de anastomosis primaria o diferida incluso en los casos más severos requieren la aplicación de los principios de control de daños. Aplicando esta estrategia, la tasa general para ostomía (primaria o diferida) puede ser reducida a menos del 10%.

Comparación de la anastomosis cervical manual versus mecánica en una serie prospectiva de pacientes con esofagectomía por cáncer

Objetivos : La escasa literatura existente sugiere haber una menor tasa de fugas anastomóticas y una menor formación tardía de estenosis después de la anastomosis esofagogástrica con grapas comparada con la técnica de anastomosis manual. El objetivo del presente estudio es comparar los resultados quirúrgicos de la anastomosis cervical manual termino-lateral versus la anastomosis mecánica por grapado laterolateral luego de una esofagectomía transhiatal por cáncer. Materiales y métodos : Se realizó una revisión retrospectiva de los pacientes sometidos a esofagectomía transhiatal con anastomosis manual o mecánica por neoplasia en tres instituciones de Medellín, entre 2011 y 2018. Los criterios de valoración incluyeron la tasa de fuga anastomótica, la morbilidad, la mortalidad, la estancia hospitalaria y anastomóticas identificadas las estenosis por endoscopia que requirieran dilatación. Resultados : se evaluaron 68 pacientes (40 hombres, 59%), 37 con anastomosis manual y 31 con anastomosis mecánica con características demográficas similares. Se produjeron fugas anastomóticas en 13 pacientes (19,1%), sin encontrarse una diferencia entre la anastomosis manual y mecánica (18,9 frente a 19,3%; p = 0,93). La morbilidad global (61%), la mortalidad intrahospitalaria (3%) y la duración de la estancia hospitalaria (mediana de 12 días) no se vieron afectadas por la técnica anastomótica. Se dispuso de una evaluación endoscópica de seguimiento en todos los pacientes y se detectó una estenosis anastomótica asociada o no a fugas de la anastomosis en 18 pacientes (22%), los casos de estenosis sin fuga fueron más frecuente con la técnica de anastomosis manual que la mecánica (21,6 vs 6,4%; p=0,07) con una duración mayor del procedimiento quirúrgico en caso de la anastomosis manual (p=0,05). Conclusiones : Nuestro estudio no aleatorizado sugiere que la técnica de anastomosis mecánica cursa con un tiempo quirúrgico menor y una menor tasa de estenosis que la anastomosis manual en la reconstrucción esofagogástrica cervical tras la esofagectomía transhiatal, con una tasa de fuga anastomótica, estancia hospitalaria y morbimortalidad similares.

Objectives : The scarce existing literature suggests having a lower rate of anastomotic leakage and less late stricture formation after stapled esophagogastric anastomosis compared to the manual anastomosis technique. The aim of the present study is to compare the surgical outcomes of termino-lateral manual cervical anastomosis versus mechanical anastomosis by later lateral stapling, after transhiatal esophagectomy for cancer. Materials and methods : A retrospective review of patients undergoing transhiatal esophagectomy with manual or mechanical anastomosis for neoplasia was performed at three institutions in Medellin, between 2011 and 2018. Endpoints included leak rate, morbidity, mortality, hospital stay, and endoscopically identified anastomotic strictures requiring dilatation. Results : 68 patients (40 men, 59%) were evaluated, 37 with manual anastomosis and 31 with mechanical anastomosis with similar demographic characteristics. Anastomotic leaks occurred in 13 patients (19.1%), with no difference found between manual and mechanical anastomosis (18.9 vs. 19.3%; p=0.93). Overall morbidity (61%), in-hospital mortality (3%) and length of hospital stay (median 12 days) were not affected by anastomotic technique. Follow-up endoscopic evaluation was available in all patients and anastomotic stricture associated or not with leak was detected in 18 patients (22%), in cases of stricture without leak is more frequent with manual than mechanical anastomosis technique (21.6 vs 6.4%; p=0.07) with longer duration of surgical procedure in case of manual anastomosis (p=0.05). Conclusions : Our non-randomized study suggests that the manual anastomosis technique results in a shorter surgical time and a lower stricture rate than mechanical anastomosis in cervical esophagogastric reconstruction after transhiatal esophagectomy, with a similar rate of leakage, hospital stay and morbidity and mortality.

A study on the correlation between imagingtopographic anatomy and anastomotic leakage after anterior resection for rectal cancer / 中华普通外科杂志

Objective:To study the relation ship between the branch patterns of inferior mesenteric artery (IMA) and imaging pelvic measurement parameters for anastomotic leakage (AL) after anterior resection (AR) of rectal cancer.Methods:Five hundred thirty-four patient were enrolled from Jan 2008 to Dec 2018 at the General Surgery Department of Guizhou Provincial People's Hospital. The AL related imaging risk factors were analyzed by chi-square test or Fisher's exact test.Results:AL was found in 36 (6.7%) patients. AL related mortality rate was 11.1% (4/36) compared to 0.4% (2/498) in those without the complications of no AL cases ( P<0.001). Seven pelvic imaging measurement results were attained in 412 patients including anteroposterior diameter of the inlet of the pelvis, anteroposterior diameter of the outlet of the pelvis, upper edge of the symphysis pubis to the tip of the coccyx, sacrococcygeal distance angle from the lower edge of the pubis to the upper edge of the pubis to the sacral promontory, distance between the ischial spines and that of ischial tuberosity. Univariate analysis showed that there was no significant relationship between the above 7 pelvic measurement parameters and the occurrence of AL (all P>0.05). There was no significant relationship between branch patterns of IMA and AL after rectal cancer surgery ( P=0.712). Conclusion:AL as a severe postoperative complication in rectal cancer patients undergoing AR procedure were caused by multiple factors. Neither IMA branch patters nor pelvic imaging measurement seem to be related to the occurrence of AL after AR for rectal cancer.

Controversy and progress on whether to retain left colonic artery in radical resection of rectal cancer / 中华胃肠外科杂志

Japanese Society for Cancer of the Colon and Rectum (JSCCR) guideline 2019 recommended that lymph node dissection for advanced rectal cancer should include the lymphatic adipose tissue at the root of the inferior mesenteric vessels, but the ligation site of the inferior mesenteric artery (IMA) was not determined, and the NCCN guideline did not indicate clearly whether to retain the left colonic artery (LCA). Controversy over whether to retain LCA is no more than whether it can reduce the incidence of anastomotic complications or postoperative functional damage without affecting the patients' oncological outcome. Focusing on the above problems, this paper reviews the latest research progress. In conclusion, it is believed that the advantages of retaining LCA are supported by most studies, which can improve the blood supply of the proximal anastomosis, and technically can achieve the same range of lymph node dissection as IMA high ligation. However, whether it affects the survival of patients, reduces the incidence of anastomotic leakage, and improves the quality of life of patients, more high-quality evidence-based medical evidence is still needed.

Influencing factors of anastomotic leak after right hemicolon surgery and progress in diagnosis and treatment strategies / 中华胃肠外科杂志

Anastomotic leak is one of the most severe complications following right hemicolectomy but rarely happens, which should be diagnosed based on clinical manifestations, laboratory and radiographic examinations. Influencing factors of anastomotic leak after right hemicolectomy include bowel preparation, emergency surgery, anastomotic procedure (side-to-side anastomosis vs. end-to-side anastomosis, instrument anastomosis vs. manual technigue and intracorporeal vs. extracorporeal anastomosis), surgical resection range and patient's characteristics. The occurrence of anastomotic leak might be avoided by standardized operations and indocyanine green fluorescence imaging. Active treatment is recommended once anastomotic leak is diagnosed. Most patients can be cured by non-surgical treatments such as adequate drainage and anti-infection therapy. When severe sepsis happens or non-surgical treatment fails, surgical treatment should be carried out in time.