Can end-to-end anastomosis reduce the risks of anastomotic leak compared to side-to-end anastomosis? A comparative study of 518 consecutive patients undergoing laparoscopic total mesorectal excision for low- or mid-rectal cancer.

BACKGROUND: After laparoscopic total mesorectal excision (TME) for low or mid-rectal cancer, we observed several cases of anastomotic leakage (AL) in patients with side-to-end anastomosis (STE). Thus, from December 2018, we routinely performed end-to-end anastomosis (ETE). The aim of this study was to assess if this new strategy changed AL and chronic pelvic sepsis rates in our department. METHODS: A retrospective study was conducted on all the patients who underwent a laparoscopic rectal resection with TME and sphincter-saving surgery for mid- and low-rectal adenocarcinoma from January 2006 to December 2019. A comparative study between STE and routine ETE was performed. The primary outcome was the assessment of postoperative AL rate. The secondary outcomes were: (a) overall morbidity rate; (c) severe morbidity rate defined by a Clavien-Dindo score > 3; (c) chronic leak rate. RESULTS: Five hundred eighteen patients underwent TME: STE was performed in 394 cases (76%) and ETE in 124 but for the first 66 cases only if STE was impossible (i.e., too short colon, obese patients). AL rates for STE were 57/204 (23%) after stapled colorectal anastomosis (CRA) and 34/190 (18%) after manual coloanal anastomosis (CAA). Since December 2018, routine ETE was performed in 58 cases. The AL rate for routine ETE was 3/24 (12%) for CRA, and 2/34 (6%) for CAA: thus, The AL rate dropped from 23% (91/394) after STE to 9% (5/58) after routine ETE (p = 0.0005). After a mean follow-up of 43 months (6-156), incidence of chronic AL was 68/394 (17%) after STE and 15/117 (13%) after ETE (p = 0.32). In the group of ETE with chronic AL, 11 patients (73%) spontaneously healed and stoma reversal was possible, whereas this happened in only 20 patients (29%) after STE (p = 0.0025). CONCLUSIONS: ETE seems to be associated with a significantly lower rate of AL and higher rate of spontaneous healing after chronic AL than STE.

NEW DEVELOPMENTS AND APPLICATIONS OF SUPERHEATED EMULSIONS: WARHEAD VERIFICATION AND SPECIAL NUCLEAR MATERIAL INTERDICTION.

In recent years, neutron detection with superheated emulsions has received renewed attention thanks to improved detector manufacturing and read-out techniques, and thanks to successful applications in warhead verification and special nuclear material (SNM) interdiction. Detectors are currently manufactured with methods allowing high uniformity of the drop sizes, which in turn allows the use of optical read-out techniques based on dynamic light scattering. Small detector cartridges arranged in 2D matrices are developed for the verification of a declared warhead without revealing its design. For this application, the enabling features of the emulsions are that bubbles formed at different times cannot be distinguished from each other, while the passive nature of the detectors avoids the susceptibility to electronic snooping and tampering. Large modules of emulsions are developed to detect the presence of shielded special nuclear materials hidden in cargo containers 'interrogated' with high energy X-rays. In this case, the enabling features of the emulsions are photon discrimination, a neutron detection threshold close to 3 MeV and a rate-insensitive read-out.

Holmium Intraductal Laser Lithotripsy of Biliary Stones in Liver Grafts.

BACKGROUND: Biliary stones after liver transplantation (LT) rarely occur but a focus on those complications and their treatment is needed. PATIENTS AND METHODS: In total, 390 adult patients who underwent an LT from July 2004 to July 2014 entered the study. Biliary complications and notably biliary stones after LT were identified. RESULTS: In total, 365 LT were analyzed. Biliary stones were identified in 14 patients (3.8%). Predictive factors for the onset of biliary stones after LT were hepatocellular diseases (P = .038; OR = 9.7) and biliary stenosis (P = .000; OR = 11.9). Treatments consisted of percutaneous transhepatic procedures (4 patients), endoscopic retrograde procedures (9 patients), and in open surgery (1 case); in 2 cases, due to a failure of previous treatments, holmium intraductal laser lithotripsy (HILL) was used: the first patient, a 35-year-old woman developed multiple intrahepatic biliary stones after LT. Percutaneous transhepatic cholangiography (PTC) was ineffective and a HILL was performed, clearing the right common bile duct but leaving residual stones in the left duct. The patient underwent a retransplantation due to recurrent hepatitis C virus infection but died 3 months later because of graft failure. The second patient, a 42-year-old 14 years after retransplantation, developed biliary sludge and stones; after several attempts with PTC and endoscopic retrograde cholangiopancreatography, a HILL was performed. All stones except one big one were treated. The patient is alive and well. CONCLUSIONS: When usual treatments are unsuccessful and biliary stones are large, their fragmentation and treatment could be done with HILL, a promising procedure after LT.