Surgical considerations for the "perfect" colorectal anastomosis.

A technically sound colorectal anastomosis is paramount in optimising outcomes and reducing complications such as anastomotic leak which can lead to prolonged hospital stay, repeated operations, stoma formation, anastomotic stricture formation and even mortality in patients. Therefore, thorough consideration should be given to all aspects of its construct, from its basic mechanical configuration to subsequent evaluation of anastomosis integrity and perfusion. Risk factors for anastomotic leakage are well established and are usually classified into modifiable and non-modifiable risk factors. In this review article, we will focus on and discuss the modifiable surgical risk factors and how the authors incorporate latest evidence and surgical principles in creating a "perfect" colorectal anastomosis. We review the latest evidence on the proper mechanical construct of a colorectal anastomosis, enhanced recovery after surgery (ERAS), high versus low ligation of inferior mesenteric artery (IMA), routine splenic flexure mobilisation (SFM), the use of indocyanine green (ICG), as well as methods used for the evaluation of the anastomosis integrity. New adjuncts described in the literature to reinforce anastomoses are also discussed. In summary, meticulous technique with nuanced refinements based on our understanding of surgical principles, together with the adoption of relevant new technologies, are essential in our strive towards the "perfect" colorectal anastomosis.

Laparoscopic versus open resection of hepatocellular carcinoma in patients with cirrhosis: meta-analysis.

BACKGROUND: The exact role of laparoscopic liver resection (LLR) in patients with hepatocellular carcinoma (HCC) and underlying liver cirrhosis (LC) is not well defined. In this meta-analysis, both long- and short-term outcomes following LLR versus open liver resection (OLR) were analysed. METHODS: PubMed, EMBASE, Scopus and Web of Science databases were searched systematically for randomised controlled trials (RCTs) and propensity-score matched (PSM) studies reporting outcomes of LLR versus OLR of HCC in patients with cirrhosis. Primary outcome was overall survival (OS). This was analysed using one-stage (individual participant data meta-analysis) and two-stage (aggregate data meta-analysis) approaches. Secondary outcomes were operation duration, blood loss, blood transfusion, Pringle manoeuvre utilization, overall and major complications, length of hospital stay (LOHS), 90-day mortality and R0 resection rates. RESULTS: Eleven studies comprising 1618 patients (690 LLR versus 928 OLR) were included for analysis. In the one-stage meta-analysis, an approximately 18.7 per cent lower hazard rate (HR) of death in the LLR group (random effects: HR 0.81, 95 per cent confidence interval [C.I.] 0.68 to 0.96; P = 0.018) was observed. Two-stage meta-analysis resulted in a pooled HR of 0.84 (95 per cent C.I. 0.74 to 0.96; P = 0.01) in the overall LLR cohort. This indicated a 16-26 per cent reduction in the HR of death for patients with HCC and cirrhosis who underwent LLR. For secondary outcomes, LLR was associated with less blood loss (mean difference [MD] -99 ml, 95 per cent C.I. -182 to -16 ml), reduced overall complications (odds ratio 0.49, 95 per cent C.I. 0.37 to 0.66) and major complications (odds ratio 0.45, 95 per cent C.I. 0.26 to 0.79), and shorter LOHS (MD -3.22 days, 95 per cent C.I. -4.38 to -2.06 days). CONCLUSION: Laparoscopic resection of HCC in patients with cirrhosis is associated with improved survival and perioperative outcomes.

Predictors of post-operative complications after surgical resection of hepatocellular carcinoma and their prognostic effects on outcome and survival: A propensity-score matched and structural equation modelling study.

INTRODUCTION: Although hepatectomy is the mainstay of curative therapy for hepatocellular carcinoma (HCC), post-operative complications remain high. Presently there is conflicting data on the impact of morbidity on oncologic outcomes. We sought to identify predictors for the occurrence of post-hepatectomy complications, as well as to analyse the impact on overall survival (OS) and recurrence-free survival (RFS). MATERIALS AND METHODS: We performed a retrospective review of 888 patients who underwent resection for HCC from 2001 to 2016 in our institution. RESULTS: A total of 237 patients (26.7%) developed 254 complications of Clavien-Dindo Grade ≥2. Hepatitis B (p = 0.0397), elevated ASA score (p = 0.0002), higher platelet counts (p = 0.0277), raised pre-operative APRI scores (p = 0.0105) and bloodloss (p < 0.0001) were independently associated with the development of complications. After propensity-score matching, 458 patients were compared in a 1:1 ratio (229 with complications versus 229 without). Patients with complications had significantly longer median length of stay (9 days [IQR 7-15] versus 6 days [IQR 5-8], p < 0.0001), higher 90-day mortality rates as well as inferior OS (p = 0.0139), but there was no difference in RFS (p = 0.4577). Age (p = 0.0006), elevated Child Pugh points (p < 0.0001), microvascular invasion (p = 0.0002), multifocal tumours (p = 0.0002), R1 resection (p = 0.0443) and development of complications (p = 0.0091) were independent predictors of inferior OS. CONCLUSION: Post-operative morbidity affected both short-term and OS outcomes after hepatectomy for HCC. Hepatitis B, higher ASA scores, elevated preoperative APRI and increased blood loss were found to predict a higher likelihood of developing complications. This may potentially be mitigated by careful patient selection and adopting strict measures to minimise intraoperative bleeding.

Use of the Gastroduodenal Artery in Hepatic Artery Reconstruction for Iatrogenic Hepatic Artery Injury During Laparoscopic Total Gastrectomy: Case Report and Review of the Literature.

Iatrogenic injury of the hepatic artery is a potential hazard of hepatopancreatobiliary and gastric surgery. Prompt recognition and specialist management is paramount to limit morbidity for the patient. Several reconstruction options have been reported in the literature, but the optimum approach should be tailored to the individual patient bearing in mind variations in anatomy, clinical conditions, and other concurrent operative interventions. We report the case of a successful hepatic artery reconstruction using the gastroduodenal artery as a transposition graft for inadvertent transection of the common hepatic artery during laparoscopic total gastrectomy. In expert hands, the use of the gastroduodenal artery for extra-anatomic reconstruction of the hepatic artery is a safe, feasible, and effective option.

Early experience with laparoscopic liver resection for spontaneously ruptured hepatocellular carcinoma.

INTRODUCTION: There are limited data to date regarding laparoscopic liver resection (LLR) for spontaneously ruptured hepatocellular carcinoma (srHCC). We performed this study to determine the safety and feasibility of LLR for srHCC. MATERIALS AND METHODS: We conducted a retrospective review of all patients who underwent liver resection for srHCC from 2000 to 2018. A total of five patients underwent LLR for srHCC, and they were matched to 10 patients who underwent open liver resection (OLR) for srHCC to perform a 1:2 comparison. A separate cohort of patients who underwent LLR for non-ruptured HCC (nrHCC) was also compared against the laparoscopic group. RESULTS: The comparison between LLR versus OLR for srHCC demonstrated no significant differences in baseline characteristics between both groups. There was also no significant difference in perioperative outcomes such as median operating time, estimated blood loss (EBL), rate of blood transfusion, post-operative median length of stay (LOS), overall complication rates, major morbidity rates and 90-day mortality rates. Comparison between LLR for srHCC and LLR for nrHCC demonstrated no significant differences in baseline characteristics between both groups. There was also no significant difference in key perioperative outcomes such as median operating time, EBL, rate and volume of blood transfusion, median post-operative LOS, morbidity rates or mortality rates. CONCLUSION: LLR may be performed safely in selected cases of srHCC. These patients have comparable perioperative outcomes as those who undergo OLR for srHCC and LLR for nrHCC.

Identification and characterization of new mutations in mitochondrial cytochrome b that confer resistance to bifenazate and acequinocyl in the spider mite Tetranychus urticae.

BACKGROUND: In spider mites, mutations in the mitochondrial cytochrome b Qo pocket have been reported to confer resistance to the Qo inhibitors bifenazate and acequinocyl. In this study, we surveyed populations of the two-spotted spider mite Tetranychus urticae for mutations in cytochrome b, linked newly discovered mutations with resistance and assessed potential pleiotropic fitness costs. RESULTS: We identified two novel mutations in the Qo site: G132A (equivalent to G143A in fungi resistant to strobilurins) and G126S + A133T (previously reported to cause bifenazate and acequinocyl resistance in Panonychus citri). Two T. urticae strains carrying G132A were highly resistant to bifenazate but not acequinocyl, whereas a strain with G126S + A133T displayed high levels of acequinocyl resistance, but only moderate levels of bifenazate resistance. Bifenazate and acequinocyl resistance were inherited maternally, providing strong evidence for the involvement of these mutations in the resistance phenotype. Near isogenic lines carrying G132A revealed several fitness penalties in T. urticae; a lower net reproductive rate (R0 ), intrinsic rate of increase (rm) and finite rate of increase (LM); a higher doubling time (DT); and a more male-biased sex ratio. CONCLUSIONS: Several lines of evidence were provided to support the causal role of newly discovered cytochrome b mutations in bifenazate and acequinocyl resistance. Because of the fitness costs associated with the G132A mutation, resistant T. urticae populations might be less competitive in a bifenazate-free environment, offering opportunities for resistance management. © 2019 Society of Chemical Industry.

Minimally-invasive versus open enucleation for pancreatic tumours: A propensity-score adjusted analysis.

BACKGROUNDS/AIMS: This study aims to evaluate the perioperative outcomes of minimally-invasive enucleation (MIEn) of the pancreas versus open enucleation (OEn). METHODS: This is a retrospective review of 20 consecutive patients who underwent pancreatic enucleation at a single institution. RESULTS: Seven patients underwent MIEn, of which 3 were robotic and 4 were laparoscopic. After propensity-adjusted analysis, the only significant difference was a reduced rate of readmissions within 30 days in the MIEn group versus the OEn group [0 vs 4 (30.8%), p=0.0464]. There were no conversions to open in the MIEn group, and median operation time was similar in both groups. There was no difference in median EBL in both groups, and none of the patients in our series required blood transfusions. The overall morbidity rate was 45.0% and the major complication (Clavien-Dindo>2) rate was 15%; which was similar between both groups. Seven (35%) patients had a Grade B/C POPF, and there was no significant difference between the two groups for this. The MIEn group had a shorter median length of stay compared to OEn [5 days (range, 3-24) vs 8.5 days (range, 5-42)] this was not significant on propensity-adjusted analysis (p=0.3195). There was no post-operative 90-day/in-hospital mortality in all 20 patients. CONCLUSIONS: Our experience demonstrates that MIEn was associated with similar perioperative outcomes and fewer readmissions compared to OEn.