Intraoperative endoscopy with immediate suture reinforcement of the defect in colorectal anastomosis: a pilot study.

Colorectal anastomosis is the one at higher risk of complication in alimentary tract surgery. Several techniques have been used to intraoperatively check a colorectal anastomosis, without reaching a clear consensus. The aim of the present study is to evaluate the addition of intraoperative flexible endoscopy to indocyanine green fluorescence in detecting colorectal anastomotic defects in a consecutive series of patients. This was a pilot study conducted over a 15-month period. Patients were scheduled for an elective laparoscopic left colectomy or anterior resection with a planned stapled colorectal anastomosis. Pre-, intra- and postoperative data were collected. Intraoperative endoscopy was routinely performed and the anastomotic defects were classified. A suture reinforcement of the defect encountered was immediately performed either laparoscopically or transanally. The primary endpoint of the study was the rate of postoperative complications. Fitfty-two patients were enrolled. At intraoperative endoscopy, 12 anastomotic defects were detected and corrected with immediate suture reinforcement. Defects were classified as two leaks, two mucosal crash, one simultaneous leak and crash, one mucosal edema and six active bleedings. None of these patients developed any postoperative complication. Moreover, there was no postoperative bleeding complication in the entire cohort. The three patients developing a postoperative leak requiring anastomosis takedown were at high risk due to general status and cancer characteristics. Even though more data and a comparative group are needed, the results of this pilot study are very promising regarding the role of intraoperative endoscopy and suture reinforcement of a colorectal anastomotic defect.

Challenging abdominal incisional hernia repaired with platelet-rich plasma and bone marrow-derived mesenchymal stromal cells. A case report.

INTRODUCTION: The necessity to develop new treatment options for challenging procedures in hernia surgery is becoming even more evident and tissue engineering and biological technologies offer even newer strategies to improve fascial healing. The present case reports a patient-tailored surgical technique performed to repair a grade IV abdominal incisional hernia, with a combined use of platelet-rich plasma and bone marrow-derived mesenchymal stromal cells, implanted on a biological mesh. PRESENTATION OF THE CASE: A 71 year-old female patient complained of an abdominal incisional hernia, complicated by enterocutaneous fistula, four-months following laparostomy. Contrast enhanced computed tomography showed an incisional hernia defect of 15.5×20cm, with a subcutaneous abscess and an intestinal loop adherent to the anterior abdominal wall, with a concomitant enterocutaneous fistula. Surgery involved abdominal wall standardized technique closure, with in addition platelet-rich plasma and bone marrow-derived mesenchymal stromal cells implanted on a biological mesh. Two years follow up showed no recurrences of incisional hernia. DISCUSSION: Coating surgical meshes with patient's own cells may improve biocompatibility, by reducing inflammation and adhesion formation. Moreover, platelet-rich plasma is a good source of growth factors for wound healing, as well as a good medium for bone marrow multinucleate cells introduction into fascial repair. CONCLUSION: This approach is likely to improve abdominal wall repair in high grade (IV) incisional hernia, with the real possibility of improving prosthetic compatibility and reducing future recurrences. The authors agree with the necessity of further studies and trials to assure the safety profile and superiority of this procedure.

A partnership model between high- and low-volume hospitals to improve results in hepatobiliary pancreatic surgery.

OBJECTIVE: To optimize the results of low-volume (LV) centers for hepatopancreaticobiliary (HPB) surgery. BACKGROUND: High-volume (HV) centers for HPB surgery have lower mortality than LV. Strategies for collaboration between HV and LV centers are not well investigated. METHODS: Postoperative outcomes of patients undergoing curative HPB resection were evaluated at an LV hospital before (2006-2008) and during the collaboration (2009-2012) and at 2 hospitals with HV for either liver or pancreatic resection (2009-2012). Itinerant tutor surgeons from the HV centers were involved in the pre-, intra- and postoperative course of HPB patients at the LV hospital. RESULTS: HPB cases at the LV center increased from 18 to 40 patients per year from 2006 to 2012, whereas 6-month postoperative mortality decreased from 17.8% (2006-2008) to 6% (2009-2012), P<0.05 (liver: 10.3% vs 4.7% and pancreas: 29.4% vs 7.9%). During the collaborative study period, outcomes for hepatectomy were similar for LV and HV (85 vs 507 cases): postoperative Clavien-Dindo scores 4 and 5 were 2% and 0.2% for HV versus 2.4% and 1.2% for LV, respectively. Outcomes for pancreatic procedures (LV 63 vs HV 269 cases) showed better postoperative Clavien-Dindo scores 4 and 5 in the HV (0.7% score 4 and 1.5% score 5 for HV vs 3.2% and 6.3%, respectively, for LV) but the difference disappeared in the last 2 years (2011-2012) and matching the cases. CONCLUSIONS: Our partnership model helped improve postoperative outcomes at the LV center. Results at the LV hospital were comparable with the HV centers, although 2 years of partnership were required to achieve this in pancreatic surgery.