Single-anastomosis Sleeve Jejunal: a Mid-term Follow-up Report of a New Surgical Technique.

INTRODUCTION: Single anastomosis sleeve ileal bypass (SASI) is a combined bariatric metabolic technique, in which few studies have shown its outcomes efficacy. However, this technique has a high risk of malnutrition due to long biliopancreatic limb. Single anastomosis sleeve jejunal bypass (SASJ) has a shorter limb. Therefore, it seems to have a lower risk of nutrient deficiency. Furthermore, this technique is relatively new, and little is known about the efficacy and safety of SASJ. We aim to report our mid-term follow-up of SASJ from a high-volume center for bariatric metabolic surgery in the Middle East region. METHODS: For the current study, the 18-month follow-up data of 43 patients with severe obesity who underwent SASJ was collected. The primary outcome measures were demographic data, weight change variables according to ideal body mass index (BMI) of 25 kg/m2 at 6, 12, and 18 months, laboratory assessments, remission of obesity-associated medical problems, and other potential bariatric metabolic complications after the surgery. RESULTS: No patient was lost due to follow-up. After 18 months, patients lost 43.4 ± 11 kg of their weight and 68 ± 14% of their excess weight, and their BMI decreased from 44.9 ± 4.7 to 28.6 ± 3.8 kg/m2 (p < 0.001). The percentage of total weight loss till 18 months was 36.3%. The T2D remission rate at 18 months was 100%. Patients neither faced deficiency in significant markers for nutrition state nor represented major bariatric metabolic surgery complications. CONCLUSION: SASJ bypass achieved satisfactory weight loss and remissions in obesity-associated medical problems within 18 months after surgery without major complications and malnutrition.

Emergency surgical treatment of colonic acute diverticulitis: a multicenter observational study on behalf of the Italian society of colorectal surgery (SICCR) Lombardy committee.

Colonic diverticulitis can be treated conservatively, but some cases require surgery. Patients can undergo Hartmann's procedure (H) or resection with primary anastomosis (RA), with or without diverting stoma. This multicenter observational retrospective study aims to evaluate the adherence to current guidelines by assessing the rate of RA and H in Lombardy, Italy, and to analyze differences in patients' features. This study included data collected from nine surgical units performing emergency surgery in Lombardy, in 2019 and 2021. Data for each year were retrospectively collected through a survey among Italian Society of Colorectal Surgery (SICCR) Lombardy members. Additional data were about: Hinchey's classification, laparoscopic (VLS) or converted procedures, procedures with more than two operators, procedures in which the first operator was older than 40 years, night or weekend procedures, older-than-80 patients, COVID-19 positivity (just 2021). The total number of operations performed was 254, 115 RA and 130 H (45.3% and 51.2%, diff. 12%, p = 0.73), and 9 (3.5%) other procedures. RAs were more frequent for Hinchey 1 and 2 patients, whereas Hs were more frequent for Hinchey 3 and 4. RAs without ileostomy were significantly less than Hs (66 vs. 130, p = 0.04). Laparoscopy was more used for RA compared to H (57 vs. 21, p = 0.03), whereas no difference was found between RA and H with respect to conversion rate, the presence of more than two operators in the team, the presence of a first operator older than 40 years, night or weekend operations, and for older-than-80 patients. This study confirms the adherence to current guidelines for the treatment of acute colonic diverticulitis in Lombardy, Italy. It can be considered as a preliminary survey with interesting results that may open the way to a further prospective observational study to clarify some aspects in the management of this disease.

Microtools: A systematic review of validated assessment tools in microsurgery.

BACKGROUND: Microsurgery is a technically demanding aspect of surgery that is integral to a variety of sub-specialties. Microsurgery is required in high-risk cases where time is limited and pressure is high, so there is increasing demand for skills acquisition beforehand. The aim of this review was to analyse the available literature on validated microsurgical assessment tools. METHODS: Covidence was used to screen papers for inclusion. Keywords included 'microsurgery', 'simulation', 'end-product assessment' and 'competence'. Inclusion criteria specified simulation models which demonstrate training and assessment of skill acquisition simultaneously. Tools which were used for training independently of technical assessment were excluded and so were tools which did not include a microvascular anastomosis. Each assessment tool was evaluated for validity, bias, complexity and fidelity and reliability using PRISMA and SWiM guidelines. RESULTS: Thirteen distinct tools were validated for use in microsurgical assessment. These can be divided into overall assessment and end-product assessment. Ten tools assessed the 'journey' of the operation, and three tools were specifically end-product assessments. All tools achieved construct validity. Criterion validity was only assessed for the UWOMSA1 and GRS.2 Interrater reliability was demonstrated for each tool except the ISSLA3 and SAMS.4 Four of the tools addressed demonstrate predictive validity.4-7 CONCLUSION: Thirteen assessment tools achieve variable validity for use in microsurgery. Interrater reliability is demonstrated for 11 of the 13 tools. The GRS and UWOMSA achieve intrarater reliability. The End Product Intimal Assessment tool and the Imperial College of Surgical Assessment device were valid tools for objective assessment of microsurgical skill.

Video-Based Microsurgical Education versus Stationary Basic Microsurgical Course: A Noninferiority Randomized Controlled Study.

BACKGROUND: Repetitive training is essential for microsurgical performance. This study aimed to compare the improvement in basic microsurgical skills using two learning methods: stationary microsurgical course with tutor supervision and self-learning based on digital instructional materials. We hypothesized that video-based training provides noninferior improvement in basic microsurgical skills. METHODS: In this prospective study, 80 participants with no prior microsurgical experience were randomly divided into two groups: the control group, trained under the supervision of a microsurgical tutor, and the intervention group, where knowledge was based on commonly available online instructional videos without tutor supervision. Three blinded expert microsurgeons evaluated the improvement in basic microsurgical skills in both groups. The evaluation included an end-to-end anastomosis test using the Ten-Point Microsurgical Anastomosis Rating Scale (MARS10) and a six-stitch test on a latex glove. Statistically significant differences between groups were identified using standard noninferiority analysis, chi-square, and t-tests. RESULTS: Seventy-seven participants completed the course. Baseline test scores did not differ significantly between groups. After the 4-day microsurgical course, both groups showed statistically significant improvement in microsurgical skills measured using the MARS10. The performed tests showed that data for self-learning using digital resources provides noninferior data for course with surpervision on the initial stage of microsurgical training (7.84; standard deviation [SD], 1.92; 95% confidence interval [CI], 7.25-8.44) to (7.72; SD, 2.09; 95% CI, 7.07-8.36). CONCLUSION: Video-based microsurgical training on its initial step provides noninferior improvement in microsurgical skills to training with a dedicated instructor.

A rare case report of short bowel anastomosis after acute mesenteric ischaemia in Covid-19 postive patient.

Acute mesenteric ischaemia is one of the serious abdominal surgical emergency, which has got very high morbidity and mortality. During the pandemic of COVID-19, besides respiratory complications, the virus was causing venous and arterial thromboembolism that can lead to acute mesenteric ischaemia in otherwise healthy individuals. Early diagnosis and suitable surgical procedures are the key to the better outcome of this disease. Surgical resection of gangrenous gut, leaving healthy gut is an important step of this operation. Leaving less than 200 cm of small intestine leads to short bowel syndrome which has got its own complication. This case report is on a healthy COVID-19 positive patient who presented with acute mesenteric ischaemia. After surgical resection only 1.5 feet small bowel (60 cm) was left behind and anastomosis was done with healthy transverse colon. He was later managed for complications of small bowel syndrome and was discharged successfully with dietary modifications.

Partial jejunal diversion (PJD) with jejunocolic anastomosis preliminary results of a pilot study.

INTRODUCTION: Bariatric-metabolic surgery is an effective tool in the treatment of severe obesity and related diseases. Its importance has increased even more in the era of the type II diabetes mellitus and COVID 19 pandemics. The aim of our study is to present the initial results of a new operation that minimizes surgical trauma. METHODS: In the prospective study, laparoscopic side-to-side anisoperistaltic jejunocolic anastomosis was constructed in order to derive part of the chyme by the anastomosis. Patients were operated in the period of IV/2018VII/2019; their mean age was 48.43±10.36 years, mean weight 112.3±16.6 kg and mean BMI 41.9±5.2. Patients were examined one month before surgery and then followed at 3, 6 and 12 months after surgery. We evaluated weight loss and changes in carbohydrate metabolism. RESULTS: We did not record any perioperative or postoperative surgical complications. There was a statistically significant weight loss during the study period. There was a significant decrease in absolute weight in kilograms (p.

Post-COVID-19 airway stenosis treated by tracheal resection and anastomosis: a bicentric experience.

Objective: The COVID-19 pandemic was an extraordinary challenge for the global healthcare system not only for the number of patients affected by pulmonary disease, but also for the incidence of long-term sequalae. In this regard, laryngo-tracheal stenosis (LTS) represents one of the most common complications of invasive ventilation. Methods: A case series of patients who underwent tracheal resection and anastomosis (TRA) for post-COVID-19 LTS was collected from June 2020 to September 2021. Results: Among 14 patients included, 50% had diabetes and 64.3% were obese. During intensive care unit stay, mean duration of orotracheal intubation (OTI) was 15.2 days and 10 patients (71.4%) underwent tracheostomy, which was maintained in 7 for an average of 31 days. According to the European Laryngological Society classification, 13 patients (92.9%) had a grade IIIa LTS and one a grade IIIa+. All patients underwent Type A TRA, according to the authors' classification. No major perioperative complications were reported and at the last follow-up all patients were asymptomatic. Conclusions: With the appropriate indications, TRA represents an effective treatment in post-COVID-19 LTS patients. Short OTI times and careful tracheostomy are required in order to reduce the incidence of airway injury.

Early versus delayed ileocolic resection for complicated Crohn's disease: is "cooling off" necessary?

BACKGROUND: Ileal Crohn's disease (CD) complicated by intraabdominal abscess, phlegmon, fistula, and/or microperforation is commonly treated with antibiotics, bowel rest, and percutaneous drainage followed by interval ileocolic resection (ICR). This "cool off" strategy is intended to facilitate the safe completion of a one-stage resection using a minimally invasive approach and minimize perioperative complications. There is limited data evaluating the benefits of delayed versus early resection. METHODS: A retrospective review of a prospectively maintained inflammatory bowel disease (IBD) database at a tertiary center was queried from 2013-2020 to identify patients who underwent ICR for complicated ileal CD confirmed on preoperative imaging. ICR cohorts were classified as early (≤ 7 days) vs delayed (> 7 days) based on the interval from diagnostic imaging to surgery. Operative approach and 30-day postoperative morbidity were analyzed. RESULTS: Out of 474 patients who underwent ICR over the 7-year period, 112 patients had complicated ileal CD including 99 patients (88%) with intraabdominal abscess. Early ICR was performed in 52 patients (46%) at a median of 3 days (IQR 2, 5) from diagnostic imaging. Delayed ICR was performed in 60 patients (54%) following a median "cool off" period of 23 days of non-operative treatment (IQR 14, 44), including preoperative percutaneous abscess drainage in 17 patients (28%). A higher proportion of patients with intraabdominal abscess underwent delayed vs early ICR (57% vs 43%, p = 0.19). Overall, there were no significant differences in the rate of laparoscopy (96% vs 90%), conversion to open surgery (12% vs 17%), rates of extended bowel resection (8% vs 13%), additional concurrent procedures (44% vs 52%), or fecal diversion (10% vs 2%) in the early vs delayed ICR groups. The median postoperative length of stay was 5 days in both groups with an overall 25% vs 17% (p = 0.39) 30-day postoperative complication rate and a 6% vs 5% 30-day readmission rate in early vs delayed ICR groups, respectively. Overall median follow-up time was 14.3 months (IQR 1.2, 24.1) with no difference in the rate of subsequent CD-related intestinal resection (4% vs 5%) between the two groups. CONCLUSIONS: In this contemporary series, at a high-volume tertiary referral center, a "cool off" delayed resectional approach was not found to reduce perioperative complications in patients undergoing ICR for complicated ileal Crohn's disease. Laparoscopic ICR can be performed within one week of diagnosis with low rates of conversion and postoperative complications.

The Use of a Low-Fidelity Simulator to Improve Vascular Anastomosis Skills of Residents during the COVID-19 Pandemic.

BACKGROUND: To evaluate a workshop using a low-fidelity simulator for training vascular surgery residents in vascular anastomosis during the COVID-19 pandemic. DESIGN: Prospective, controlled, single-center. METHODS: Vascular surgery residents at the São Paulo University Medical School were enrolled in the COVID Group (five post graduation year 3 residents) or Control Group (five PGY-4 residents). The COVID Group was trained via a vascular anastomosis workshop. The residents were evaluated using Objective Structured Assessment of Technical Skills (OSATS), Final Product Analysis and time to perform the procedure. The number of anastomoses performed by the residents were calculated. Data were subjected to statistical analysis, and P < 0.05 was considered significant. RESULTS: There was a significant reduction in the number of vascular anastomoses performed by the residents between the COVID group and the control group (mean 22.6 ± 7.76 vs. 35.2 ± 3.9, P = 0.01, Student's t-test). Before the workshop, 80% of the residents from the COVID group failed to perform a vascular anastomosis on the simulator. During the workshop, there was improvement in the Objective Structured Assessment of Technical Skills (OSATS) score (initial: 16.5, interquartile range (IQR) 0, under supervision: 25, IQR 5, and at the end of the workshop: 26.5, IQR 2.5; P = 0.049, Friedman's test) and in the Final Product Analysis (initial: 14.5, IQR 6, under supervision: 26.5, IQR 4.625, end of the workshop: 27, IQR 4, P = 0.049, Friedman's test). Time was not significantly different (initial: 35.6, IQR 2.77; under supervision: 25.8 min, IQR 4.53; P = 0.07, Friedman's test). The residents' technical scores were stable 6 months after the training, and there was no difference between their final scores and those of the control group. The residents from the COVID Group reported an improvement in their knowledge, technical skills and confidence after the workshop. CONCLUSIONS: A workshop using a low-fidelity simulator improved vascular surgery residents' skills and confidence in vascular anastomosis during the pandemic year, when they performed fewer surgical procedures.

How to perform an anastomosis following a low anterior resection by transanal total mesorectal excision surgery: from top to bottom techniques.

AIM: The aim was to describe the range of possibilities and our group's clinical outcomes when performing different types of anastomosis during transanal total mesorectal excision (taTME). METHOD: A retrospective analysis was performed based on four taTME series from 2016 to 2021. Inclusion criteria were patients with rectal cancer in whom a sphincter-saving low anterior resection by taTME was performed. Four different techniques were employed for the anastomosis construction: (A) abdominal view, (B) transanal view, (C) hand-sewn coloanal anastomosis and (D) pull-through. Intra-operative and postoperative data were collected and compared. RESULTS: A total of 161 patients were included. Tumour height was lower in groups C and D (4 [3-5] vs. 7 [6-8] group A vs. 6 [5-7] group B, P = 0.000), requiring a hand-sewn anastomosis. A transanal extraction of the specimen was more commonly performed in groups C and D (over 60% vs. 30% in groups A and B, P = 0.000). The rate of temporary stoma was similar between groups A, B and C (ranging from 84% to 98%) but was significantly lower in group D (P = 0.000). The overall rate of complications was similar between groups; however, group D had longer length of stay (15 days vs. 5-6 in groups A, B and C, P = 0.026). CONCLUSION: Every type of anastomosis construction after a taTME procedure seems to be safe and feasible and should be chosen based on surgeon's experience, tumour height and the length of the rectal cuff after the rectal transection. Colorectal surgeons should be familiar with these techniques in order to choose the one that benefits each patient the most.

Investigation of Objectivity in Scoring and Evaluating Microvascular Anastomosis Simulation Training.

The increase in minimally invasive surgery has led to a decrease in surgical experience. To date, there is only limited research examining whether skills are evaluated objectively and equally in simulation training, especially in microsurgery. The purpose of this study was to analyze the objectivity and equality of simulation evaluation results conducted in a contest format. A nationwide recruitment process was conducted to select study participants. Participants were recruited from a pool of qualified physicians with less than 10 years of experience. In this study, the simulation procedure consisted of incising a 1 mm thick blood vessel and suturing it with a 10-0 thread using a microscope. Initially, we planned to have the neurosurgical supervisors score the simulation procedure by direct observation. However, due to COVID-19, some study participants were unable to attend. Thus requiring some simulation procedures to be scored by video review. A total of 14 trainees participated in the study. The Cronbach's alpha coefficient among the scorers was 0.99, indicating a strong correlation. There was no statistically significant difference between the scores from the video review and direct observation judgments. There was a statistically significant difference (p <0.001) between the scores for some criteria. For the eight criteria, individual scorers assigned scores in a consistent pattern. However, this pattern differed between scorers indicating that some scorers were more lenient than others. The results indicate that both video review and direct observation methods are highly objective techniques evaluate simulation procedures.

Minimally Invasive Ivor-Lewis Esophagectomy for Esophageal Cancer After Gastric Bypass.

The increasing prevalence of morbid obesity in the United States has been accompanied by a concomitant rise in bariatric surgery to help combat the epidemic. The relationship between obesity and certain cancers, such as esophageal adenocarcinoma, is well established. The need for minimally invasive techniques to treat esophageal cancer in patients with previous bariatric surgery is growing and can present a unique surgical challenge. This report presents the case of a 55-year-old woman with a previous Roux-en-Y gastric bypass who was shown by endoscopy to have an invasive adenocarcinoma located in the distal thoracic esophagus. This necessitated an excision of the thoracic esophagus and the gastric pouch. A laparoscopic and thoracoscopic Ivor-Lewis esophagogastrectomy was performed for this complex patient with esophageal adenocarcinoma. The remnant stomach was fashioned into a gastric conduit using a 60-mm linear stapler with a staple height of 4.1 mm (Echelon, Ethicon Endosurgery, Blue Ash, OH). The reconstruction was performed using a 25-mm Orvil (Covidien, Minneapolis, MN, USA) and EEA 25-mm DST XL (Covidien) to create a circular stapled thoracic esophagogastric anastomosis. A feeding jejunostomy was placed in the residual 130-cm Roux limb. The study demonstrated that minimally invasive esophagectomy is safe and technically feasible with appropriate oncologic outcomes for patients with previous gastric bypass. This cohort of patients will undoubtedly continue to grow in the coming years.

Robotic Colostomy Takedown in a Patient with Extensive Ventral Hernias and Adhesive Disease.

STUDY OBJECTIVE: To demonstrate a surgical video wherein a robot-assisted colostomy takedown was performed with anastomosis of the descending colon to the rectum after reduction of ventral hernias and extensive lysis of adhesions. DESIGN: Case report and a step-by-step video demonstration of a robot-assisted colostomy takedown and end-to-side anastomosis. SETTING: Tertiary referral center in New Haven, Connecticut. A 64-year-old female was diagnosed with stage IIIA endometrioid endometrial adenocarcinoma in 2015 when she underwent an optimal cytoreductive surgery. In addition, she required resection of the sigmoid colon and a descending end colostomy with Hartmann's pouch, mainly secondary to extensive diverticulitis. After adjuvant chemoradiation, she remained disease free and desired colostomy reversal. Body mass index at the time was 32 kg/m2. Computed tomography of her abdomen and pelvis did not show any evidence of recurrence but was notable for a large ventral hernia and a parastomal hernia. She then underwent a colonoscopy, which was negative for any pathologic condition, except for some narrowing of the distal rectum above the level of the levator ani. INTERVENTIONS: Enterolysis was extensive and took approximately 2 hours. The splenic flexure of the colon had to be mobilized to provide an adequate proximal limb to the anastomosis site. An anvil was then introduced into the distal descending colon through the colostomy site. A robotic stapler was used to seal the colostomy site and detach it from the anterior abdominal wall. Unfortunately, the 28-mm EEA sizer (Covidien, Dublin, Ireland) perforated through the distal rectum, caudal to the stricture site. A substantial length of the distal rectum had to be sacrificed secondary to the perforation, which mandated further mobilization of the splenic flexure. The rectum was then reapproximated with a 3-0 barbed suture in 2 layers. This provided us with approximately 6- to 8-cm distal rectum. An end-to-side anastomosis of the descending colon to the distal rectum was performed. Anastomotic integrity was confirmed using the bubble test. Because of the lower colorectal anastomosis, a protective diverting loop ileostomy was performed. The patient had an uneventful postoperative course. A hypaque enema performed 3 months after the colostomy takedown showed no evidence of anastomotic leak or stricture. The ileostomy was then reversed without any complications. CONCLUSION: Robot-assisted colostomy takedown and anastomosis of the descending colon to rectum were successfully performed. Although there is a paucity of literature examining this technique within gynecologic surgery, the literature on general surgery has supported laparoscopic Hartmann's reversal and has demonstrated improved rates of postoperative complications and incisional hernia and reduced duration of hospitalization [1]. Minimally invasive technique is a feasible alternative to laparotomy for gynecologic oncology patients who undergo colostomy, as long as the patients are recurrence free.

Ghost Ileostomy in Anterior Resection for Bowel Endometriosis: Technical Description.

OBJECTIVE: To demonstrate our application of the ghost ileostomy in the setting of laparoscopic segmental bowel resection for symptomatic bowel endometriosis nodule. DESIGN: Technical step-by-step surgical video description (educative video) SETTING: University Tertiary Hospital. Institutional Review Board ruled that approval was not required for this study. Endometriosis affects the bowel in 3% to 37% of all cases, and in 90% of these cases, the rectum or sigmoid colon is also involved. Infiltration up to the rectal mucosa and invasion of >50% of the circumference have been suggested as an indication for bowel resection [1]. Apart from general risks (bleeding, infection, direct organ injuries) and bowel and bladder dysfunctions, anastomotic leakage is one of the most severe complications. In women with bowel and vaginal mucosa endometriosis involvement, there is a risk of rectovaginal fistula after concomitant rectum and vagina resections. Hence, for lower colorectal anastomosis, the use of temporary protective ileostomy is usually recommended to prevent these complications but carries on stoma-related risks, such as hernia, retraction, dehydration, prolapse, and necrosis. Ghost ileostomy is a specific technique, first described in 2010, that gives an easy and safe option to prevent anastomotic leakage with maximum preservation of the patient's quality of life [2]. In case of anastomotic leakage, the ghost (or virtual) ileostomy is converted, under local anesthesia, into a loop (real) ileostomy by extracting the isolated loop through an adequate abdominal wall opening. In principle, avoiding readmission for performing the closure of the ileostomy, with all the costs related, means a considerable saving for the hospital management. Also, applying a protective rectal tube in intestinal anastomosis may have a beneficial effect [3]. These options are performed by general surgeons in oncological scenarios, but their use in endometriosis has never been described. INTERVENTIONS: In a 32-year-old woman with intense dysmenorrhea, deep dyspareunia, dyschesia, and cyclic rectal bleeding, a complete laparoscopic approach was performed using blunt and sharp dissection with cold scissors, bipolar dissector and a 5-mm LigaSure Advance (Covidien, Valley lab, Norwalk, Connecticut). An extensive adhesiolysis restoring the pelvic anatomy and endometriosis excision was done. Afterward, the segmental bowel resection was performed using linear and circular endo-anal stapler technique with immediate end-to-end bowel anastomosis and transit reconstitution. Once anastomosis was done, the terminal ileal loop was identified, and a window was made in the adjacent mesentery. Then, an elastic tape (vessel loop) was passed around the ileal loop, brought out of the abdomen through the right iliac fossa 5-mm port site incision and, fixed to the abdominal wall using nonabsorbable stitches. Finally, a trans-anal tube was placed for 5 days. The patient was discharged on the fifth day postoperatively without any complications. The tape was removed 10 days after surgery, and the loop dropped back. Two months after the intervention, the patient remains asymptomatic. CONCLUSION: Ghost ileostomy is a simple, safe, and feasible technique available in the setting of lower colorectal anastomosis following bowel endometriosis resection.

Ileorectal anastomosis in patients with Crohn's disease. Postoperative complications and functional outcome-a systematic review.

AIM: The objective of this systematic review was to investigate the outcomes of ileorectal anastomosis (IRA) in Crohn's disease and to clarify whether there are any time-related trends in outcome measures. The primary outcomes are risk of anastomotic leakage, death, clinical recurrence and subsequent diverting or permanent stoma and/or proctectomy. Secondary end-points are quality of life and functional outcome. METHODS: Systematic searches were conducted using the Cochrane Library, Embase and MEDLINE. The complete search strategy is uploaded online at http://www.crd.york.ac.uk/prospero/. Human studies in English with over five subjects were included and no limit was set regarding the date of publication. All relevant studies were screened by two reviewers. The web-based software platform www.covidence.org was used for primary screening of the title, abstract, full-text review and data extraction. RESULTS: The search identified 2231 unique articles. After the screening process, 37 remained. Key results were an overall anastomotic leak rate of 6.4%; cumulative rates of clinical recurrence of 43% and 67% at 5 and 10 years, respectively; an overall rate of proctectomy of 18.9%; and subsequent ileostomy required in 18.8%. Only one study presented useful data on quality of life. Recurrence rates remained stable over time. A small decline in the anastomotic leak rate was found. CONCLUSIONS: Only minor improvements in the outcomes of IRA in patients with Crohn´s disease have occurred during the past 50 years regarding anastomotic leakage and recurrence, except for a slight increase in the rate of a functioning IRA. These results call for implementation guidelines in patient selection for IRA and postoperative medical treatment and follow-up.

Technical details for a robot-assisted hand-sewn esophago-gastric anastomosis during minimally invasive Ivor Lewis esophagectomy.

BACKGROUND: Minimally invasive Ivor Lewis esophagectomy (MIILE) provides better outcomes than open techniques, particularly in terms of post-operative recovery and pulmonary complications. However, in addition to requiring advanced technical skills, thoracoscopic access makes it hard to perform esophagogastric anastomosis safely, and the reported rates of anastomotic leak vary from 5 to 16%. Several minimally invasive esophago-gastric anastomotic techniques have been described, but to date strong evidence to support one technique over the others is still lacking. We herein report the technical details and preliminary results of a new robot-assisted hand-sewn esophago-gastric anastomosis technique. METHODS: From January 2018 to December 2020, 12 cases of laparoscopic/thoracoscopic Ivor Lewis esophagectomy with robot-assisted hand-sewn esophago-gastric anastomosis were performed. The gastric conduit was prepared and tailored taking care of vascularization with a complete resection of the gastric fundus. The anastomosis consisted of a robot-assisted, hand-sewn four layers of absorbable monofilament running barbed suture (V-lock). The posterior outer layer incorporated the gastric and esophageal staple lines. RESULTS: The post-operative course was uneventful in nine cases. Two patients developed chyloperitoneum, one patient a Sars-Cov-2 infection, and one patient a late anastomotic stricture. In all cases, there were no anastomotic leaks or delayed gastric conduit emptying. The median post-operative stay was 13 days (min 7, max 37 days); the longest in-hospital stay was recorded in patients who developed chyloperitoneum. CONCLUSION: Despite the small series, we believe that our technique looks to be promising, safe, and reproducible. Some key points may be useful to guarantee a low complications rate after MIILE, particularly regarding anastomotic leaks and delayed emptying: the resection of the gastric fundus, the use of robot assistance, the incorporation of the staple lines in the posterior aspect of the anastomosis, and the use of barbed suture. Further cases are needed to validate the preliminary, but very encouraging, results.

Early presentation of post-intubation tracheoesophageal fistula with severe tracheal stenosis in COVID-19 patient.

The current global COVID-19 pandemic is caused by the novel coronavirus severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Currently, acquired tracheoesophageal fistulas are mainly iatrogenic lesions produced by prolonged tracheal intubation. We present a case of tracheoesophageal fistula with severe tracheal stenosis following tracheal intubation in a patient with SARS-CoV-2 infection.

Minimal invasive surgery for left colectomy adapted to the COVID-19 pandemic: laparoscopic intracorporeal resection and anastomosis, a 'don't touch the bowel' technique.

AIM: The COVID-19 pandemic has forced surgeons to adapt their standard procedures. The modifications introduced are designed to favour minimally invasive surgery. The positive results obtained with intracorporeal resection and anastomosis in the right colon and rectum prompt us to adapt these procedures to the left colon. We describe a 'don't touch the bowel' technique and outline the benefits to patients of the use of less surgically aggressive techniques and also to surgeons in terms of the lower emission of aerosols that might transmit the COVID-19 infection. METHODS: This was an observational study of intracorporeal resection and anastomosis in left colectomy. We describe the technical details of intracorporeal resection, end-to-end stapled anastomosis and extraction of the specimen through mini-laparotomy in the ideal location. RESULTS: We present preliminary results of 17 patients with left-sided colonic pathologies, 15 neoplasia and two diverticular disease, who underwent four left hemicolectomies, six sigmoidectomies and seven high anterior resections. Median operating time was 186 min (range 120-280). No patient required conversion to extracorporeal laparoscopy or open surgery. Median hospital stay was 4.7 days (range 3-12 days). There was one case of anastomotic leak managed with conservative treatment. CONCLUSION: Intracorporeal resection and end-to-end anastomosis with the possibility of extraction of the specimen by a mini-laparotomy in the ideal location may present benefits and also adapts well to the conditions imposed by the COVID-19 pandemic. Future comparative studies are needed to demonstrate these benefits with respect to extracorporeal anastomosis.