Anastomotic leak (AL) is a feared complication of colorectal surgery, associated with high morbidity, mortality and adverse oncologic outcomes. Despite advances in perioperative care, its incidence remains significant, and prevention is a central challenge in modern colorectal practice. This review summarizes the current evidence on AL with a focus on risk factors, diagnostic considerations and preventive strategies. Patient-related risks include malnutrition, comorbidities, lifestyle factors and, more recently, alterations in the gut microbiota. Intraoperative contributors involve technical aspects of anastomosis construction, adequacy of vascular perfusion and procedure complexity, while postoperative risks relate primarily to delayed recognition and insufficient recovery pathways. Preventive measures span the entire perioperative continuum. Nutritional optimization, risk stratification and modulation of the microbiota represent key preoperative interventions. Intraoperatively, strategies emphasize meticulous technique, assessment of perfusion with emerging technologies and selective use of protective measures such as diverting stomas or transanal tubes. Postoperatively, standardized surveillance and adherence to enhanced recovery protocols are critical for early detection and mitigation of complications. Taken together, the evidence underscores that AL is a multifactorial complication requiring a multimodal prevention strategy. This review provides a structured overview of established knowledge and highlights evolving concepts, with the goal of informing both clinical decision-making and future research.
Small bowel obstruction (SBO) without a congenital aetiology is an urgent surgical condition in children. It can result from a variety of causes, including foreign body ingestion and food impaction. This report presents the case of an 11-year-old male patient who was admitted with SBO due to the ingestion of a pickled pepper, to discuss the diagnostic challenges and therapeutic management of this condition. The patient presented with abdominal distention, bilious vomiting, and progressive abdominal pain. His past medical history was unremarkable. Abdominal x-ray and computed tomography (CT) scan revealed air-fluid levels suggestive of SBO but were not diagnostic for the underlying aetiology. Surgical exploration identified an intraluminal obstructing lesion approximately 80 cm proximal to the ileocecal valve. An enterotomy was performed, and a hot pickled pepper was extracted. The enterotomy site was primarily repaired. The patient was discharged uneventfully. SBO secondary to indigestible food material presents a significant diagnostic challenge and should be considered in the differential diagnosis for previously healthy patients presenting with intestinal obstruction. A careful and detailed history, including dietary intake, is critical for diagnosis. Surgical removal of the impacted material is an effective treatment option for children.
Chylous ascites is a rare but significant complication following extended pelvic lymph node dissection (ePLND) during radical prostatectomy. No universal treatment guideline currently exists. Herein, we present the case of a 74-year-old patient with prostate cancer who developed chylous ascites after radical prostatectomy with bilateral ePLND. Persistent ascites continued despite a medium-chain triglyceride diet, octreotide, and percutaneous drainage. Lymphoscintigraphy confirmed lymphatic leakage but failed to localise the source. Ultimately, intranodal lymphangiography with Lipiodol was performed, which identified and sealed the leakage site, sparing the patient from surgical intervention. Follow-up imaging showed only a small, resolving lymphocele, and the patient remained asymptomatic at 3 months. This case highlights the diagnostic and therapeutic value of intranodal lymphangiography with Lipiodol in managing post-operative chylous ascites.
Background Surgical intervention for pilonidal sinus is associated with an increased risk of wound complications and recurrence. The therapeutic method of pilonidal abscess with delayed closure surgery was compared with initial cyst excision in patients with acute pilonidal cysts. Methods This randomised, double-blind clinical trial included 202 patients with acute pilonidal abscess. Demographic data, age, gender, and body mass index, and patient symptoms were recorded. Participants were then randomly assigned to either Group A or Group B. Group A underwent drainage and cyst excision during a single surgical procedure. Group B underwent incision and drainage of the abscess, followed by discharge with an antibiotic prescription; delayed cyst excision was performed 1 month later. Post-operative outcomes assessed included hematoma, cellulitis, seroma, infection, wound dehiscence, and treatment cost. Results No significant differences were observed between the two surgical groups with respect to age, gender, body mass index, wound characteristics, or post-operative discharge (P > .05). Seroma formation was not observed in any patient in either group. Moreover, there were no significant differences between the two groups in the incidence of cellulitis, infection, or hematoma after surgery (P > .05). However, wound dehiscence occurred significantly more frequently in Group A than in Group B (13% vs 3%, P = .009). The cost of treatment was similar between the two groups (P = .100). Conclusion Given the higher incidence of wound dehiscence and longer operative time observed with initial surgery, delayed closure surgery appears to be the preferable approach for the treatment of acute pilonidal abscess.
BackgroundTranscatheter aortic valve replacement (TAVR) has emerged as an acceptable and often preferred alternative to surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis. However, the mid- and long-term efficacy of TAVR in patients with bicuspid aortic valves (BAVs) remains unclear. This study aims to compare the mid-term outcomes of patients with BAV undergoing either procedure.MethodsWe retrospectively reviewed all patients who underwent AVR at our institution between 2011 and 2022. Of 278 patients identified, 217 underwent SAVR and 61 underwent TAVR. Propensity score matching was used to create comparable groups. Outcomes were compared using Kaplan-Meier survival analyses and chi-square tests (alpha = 0.05). Sensitivity analyses using multiple calliper widths assessed the robustness of our findings.ResultsIn both unmatched and propensity score-matched cohorts, Kaplan-Meier survival analysis demonstrated a significant survival advantage for SAVR over TAVR. TAVR patients experienced significantly higher rates of combined post-operative complications-including stroke/transient ischaemic attack, bleeding, and dialysis-and showed a trend towards increased pacemaker implantation. However, TAVR was associated with significantly shorter hospital stays. Notably, sensitivity analyses consistently favoured SAVR across all calliper widths. Similar findings were observed within the low-risk subgroup.ConclusionDespite longer hospital stays, SAVR was associated with improved mid-term survival and fewer complications compared with TAVR in patients with BAV. These differences were particularly pronounced in the low-risk cohort. Our findings support the continued consideration of SAVR for patients with BAV who are suitable surgical candidates and underscore the need for comprehensive, multicentre prospective studies.
Background: Peritoneal adhesions are an important complication of abdominal surgeries, causing chronic pain, bowel obstruction, and infertility. Despite advances in surgical techniques, pharmacological prevention remains a challenge. This study aimed to evaluate the effectiveness of sirolimus, prednisolone, and their combination in preventing post-operative adhesions in a rat model. Methods: This was a randomised, controlled experimental study. Thirty-three female Wistar rats were divided into five groups: control, vehicle carrier, sirolimus (0.1 mg/kg/day), prednisolone (1 mg/kg/day), and a sirolimus-prednisolone combination. Adhesions were induced by laparotomy and caecal abrasion. Adhesion severity was evaluated by macroscopic analysis (Nair classification) and microscopic analysis (Z & uuml;hlke grading). Statistical analyses were performed using the chi-square and Mann-Whitney tests, with a significance level of 5% (P < .05). Results: The combination group was the only one with no macroscopic or microscopic adhesions (P < .05). Both the sirolimus and prednisolone groups showed reduced adhesion severity compared with the control group. The control and vehicle carrier groups exhibited the highest incidence and severity of adhesions (P < .05). Conclusions: The combination of sirolimus and prednisolone significantly prevents post-operative adhesions, suggesting a potential pharmacological approach to reducing adhesion-related morbidity. Further studies are needed to confirm these findings in clinical settings and to evaluate long-term outcomes. Clinical application should be approached with caution due to the potential immunosuppressive and wound-healing effects of the drugs involved.
Background: We aimed to develop a Russian version of the Patient and Observer Scar Assessment Scale (POSAS 3.0; POSAS-R), evaluate its psychometric properties, and test its applicability in patients undergoing thyroid surgery. Methods: POSAS-R was developed in accordance with international guidelines. Its feasibility, reliability, validity, and sensitivity to change were then evaluated. Results: The POSAS-R was tested in a group of 115 patients (mean age 39.2 years) who underwent thyroid surgery. Both subscales, the Russian version of the Patient Scar Assessment Scale and the Russian version of the Observer Scar Assessment Scale, demonstrated acceptable internal consistency (Cronbach alpha = 0.82-0.86), reproducibility (intraclass correlation coefficient = 0.97 and 0.88; P < .001), and strong correlations with the Visual Analog Scale (Spearman r = -0.807 and -0.712; P < .001). Sensitivity to change was moderate (effect size = 0.50 and 0.52). Conclusion: The developed Russian version of the POSAS is a valid and reliable tool for evaluating post-operative scars after thyroid surgery. The sensitivity and applicability of the POSAS-R to monitor scar changes in patients following thyroid surgery were demonstrated.
Laparoscopic pancreaticoduodenectomy (LPD) is an alternative to the open surgical approach. Several authors have investigated the advantages of LPD over open PD (OPD); this study aims to evaluate the effectiveness of LPD compared with OPD. This study conducted a meta-analysis following the Cochrane Handbook for Systematic Reviews and adhering to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Multiple databases—including PubMed, the Cochrane Trial Register, and Google Scholar—were searched for relevant literature up to April 20, 2024. Studies comparing OPD with LPD were included. A total of 4 randomized controlled trials and 41 non-randomized comparative trials were analysed. No significant difference in post-operative mortality was found ( P = .42). However, there was a significant reduction in overall post-operative complications in the LPD group ( P < .002). The length of hospital stay was also significantly shorter in the LPD group ( P < .00001). No significant differences were observed between LPD and OPD regarding post-operative pancreatic fistula ( P = .93) and post-pancreatectomy haemorrhage (post-pancreatectomy haemorrhage; P = .19). However, the rate of post-operative bile leaks was higher in the LPD group compared with the OPD group ( P = .02). This study concluded that LPD is a safer approach with less post-operative complications, longer operative time, less estimated blood loss, and shorter hospital stays when compared with OPD.
Objective: The latest trend in the surgical management of low-risk differentiated thyroid carcinomas is de-escalation, with lobectomy performed for low-risk cases due to their excellent prognosis. Thyroidectomy for selected nodules under local anaesthesia (LA) is generally safe. This study was undertaken to investigate whether LA thyroidectomy is equally effective for selected cases of papillary thyroid carcinoma (PTC). Methods: Twenty-five patients with histopathologically verified PTC who underwent LA hemithyroidectomy as initial definite therapy were retrieved from the in-house thyroid cancer registry. Their clinicopathologic data, operation status (day vs inpatient), surgical complications (vocal cord palsy, post-operative haematoma, and wound complications), and oncologic outcomes (tumour recurrence and survival) were evaluated. Post-operative thyroglobulin monitoring and radioactive iodine ablation were not practised after hemithyroidectomy. Propensity score matching was utilised to compare operation outcomes with the general anaesthesia counterpart (N = 112). ResultsThe median follow-up was 87.0 months, and the median tumour diameter was 6.0 mm (range 1.0-40.0 mm). Twelve (48%) tumours were incidental, while 13 (52%) were non-incidental. Most patients (84%) were discharged as day cases. Regarding surgical complications, only one case of permanent vocal cord palsy occurred, with no incidence of transient cord palsy, wound swelling, unplanned readmission, or wound infection. Three patients underwent completion thyroidectomy in due course. There was no tumour recurrence or cancer-specific mortality in this series. Length of stay (P = .0002), unplanned readmission (P < .0001), and overall thyroidectomy complications (P < .0001) were significantly lower in the LA arm by propensity score matching analysis. Conclusions: For low- and selected intermediate-risk PTC, LA hemithyroidectomy appears to be safe in the long run. Its benefits include early recovery, a short hospital stay, the feasibility of day surgery, and simplified post-operative care by eliminating thyroglobulin monitoring and long-term thyroxine usage.
Gastrointestinal duplications (GID) are rare congenital anomalies that can occur anywhere along the gastrointestinal tract. Herein, we report an association of oesophageal and ileal duplications to discuss the occurrence of multiple GIDs with different presentations in children. A 9‐month‐old male patient, who had undergone surgery for an oesophageal duplication cyst (DC) in the neonatal period, was admitted with rectal bleeding. During laparoscopy, a 40 cm length tubular duplication was noted. The duplication was resected along with the neighbouring ileal segment, followed by ileo‐ileal anastomosis of the remaining segments. Although almost all GIDs reported in the literature were structurally cystic and diagnosed simultaneously, the association of a neonatal foregut DC with a late‐presenting midgut tubular duplication has not been previously reported. In conclusion, multiple GIDs are very rare in children. Depending on their localization in the gastrointestinal tract, they may present with different clinical symptoms and become symptomatic at varying time points throughout life.
IntroductionSince the 1970s, the surgical treatment of renal tumors with caval thrombosis has been a complex challenge. The advent of robot-assisted nephrectomy with tumor thrombectomy has revolutionized this field. This case series aims to report the outcomes of an unselected population of Renal Cell Carcinoma (RCC) with complex caval thrombosis treated robotically at our center.MethodsWe established a database for RCC cases with inferior vena cava (IVC) thrombectomy, including five patients treated between October 2022 and October 2023. A notable aspect of our methodology was the incorporation of the AngioVac system for the management of a level IV thrombus facilitating a minimally invasive approach without the need for a thoracic approach.ResultsAll patients underwent successful robotic surgery without conversion to open surgery. There were one pT3a, 3 pT3b and one pT3c tumors, 3 on the right side and 2 on the left, the upper level of the thrombus was II in one patient, III in 3 and IV in one. The average surgery duration was 414 +/- 120.95 minutes, and the average blood loss was 400 +/- 393, 70 cc. The mean IVC occlusion time was 20.6 +/- 6.50 minutes. We did not observe any statistically significant differences between the preoperative hemoglobin values (12.14 +/- 1.39) and the postoperative values (9.88 +/- 0.96), nor between preoperative creatinine levels (2.00 +/- 2.11) and postoperative levels (2.20 +/- 2.00). The average length of hospital stay was 7 +/- 2 days. We observed only 2 Clavien-Dindo grade 2 events. The follow-up period, updated for the last patient, is 12 months.ConclusionsThis case series demonstrates the viability and safety of robotic surgery in treating RCC with complex caval thrombosis. While the study is limited by the small number of cases, these results contribute to the growing body of evidence supporting robotic surgery in complex renal tumors.
Aim: This multicentre randomised controlled trial aimed to compare post-operative complications and recovery outcomes between these two approaches. Patients and methods: Eighty patients with symptomatic choledocholithiasis were randomly assigned to undergo either laparoscopic transcystic (LTCBDE; n = 40) or traditional (LCBDE; n = 40) common bile duct exploration. The primary outcome measures were post-operative complications within 3 months, while the secondary outcomes included operative time, intraoperative blood loss, recurrence of bile duct stones, and time to return to activities of daily living (ADLs). Logistic regression models were used to identify predictors of complications and recurrence. Results: The LTCBDE group had significantly shorter operative times (117.55 vs 136.05 min, P < .001) and reduced intraoperative blood loss (51.25 vs 61.45 mL, P < .001). Both groups had a 20% rate of post-operative complications (P = .614). Septic complications were higher in LCBDE compared with LTCBDE (20% vs 7.5%, P = .105). Time to return to ADL was shorter in the LTCBDE group (33.4 vs 39.75 days, P = .007). Diabetes mellitus independently predicted post-operative complications (adjusted odds ratio 4.397, P = .014) and revision surgery (adjusted odds ratio 22.592, P = .006). Recurrence rates were similar between groups (P = .363). Conclusion: LTCBDE is associated with shorter operative times, reduced blood loss, and faster recovery than LCBDE, without an increase in post-operative complications. LTCBDE may be the preferred option for the treatment of choledocholithiasis.
The use of diced cartilage has become increasingly popular in rhinoplasty; however, the viability of the graft can vary. This study aimed to investigate the use of fillers for diced cartilage, evaluate their morphology and viability, and provide a foundation for their clinical use. Six rabbits were used in this experiment. Ear cartilage was excised and diced into pieces and mixed with different fillers, including collagen (COLD), hyaluronic acid (HAD), and normal saline (NSD), or used alone (COND) as a control. They were embedded in the backs of rabbits. After 3 months, the weight and volume of grafts were measured. The cellular viability and morphology were assessed. The HAD group showed the most significant volume change, followed by the NSD group. There was no significant weight change between the COLD and COND groups. Grossly, the COLD group appeared as a smooth block, while the COND and NSD groups appeared rough. Microscopically, fibrous tissue and collagen were arranged regularly in the COLD and HAD groups, and chondrocytes were arranged neatly. By contrast, collagen was less and arranged messily in the NSD and COND groups. There was better cell viability and angiogenesis around cartilage in the COLD group than in the HAD and NSD groups. When mixed with collagen, diced cartilage can maintain its basic shape and smooth appearance, and there is better cell viability and angiogenesis than when mixed with hyaluronic acid or normal saline, or used alone. These findings may provide implications for the clinical use of diced cartilage as injectable implants.
BackgroundAlthough endometriosis is a relatively common condition affecting women, pancreatic endometriosis remains rare, with only a few cases reported in the literature. The primary challenges this condition poses today are its inability to be diagnosed radiologically and the difficulty in distinguishing it from other cystic lesions of the pancreas preoperatively.MethodsThis report presents a case of a 53-year-old female patient with 3 months long left upper quadrant pain and no previous medical history. Imaging revealed an enlarging cyst in the tail of the pancreas, with findings suggestive of a mucinous neoplasm.ResultsThe patient underwent a distal pancreatectomy and splenectomy. Histopathological analysis confirmed the presence of endometrial stroma.ConclusionsConsidering the possibility of pancreatic endometriosis may help avoid extensive surgery. However, as the definite diagnosis of endometriosis remains histopathological, surgical resection continues to be the treatment of choice if malignancy is suspected.
ObjectiveStoma education is an essential part of perioperative management in colorectal surgery. Recently, three-dimensional (3D) printed stoma models have been developed as useful adjuncts to conventional stoma teaching. This study aims to evaluate the impact of the introduction of a 3D stoma model education programme on patients undergoing elective robotic total mesorectal excision (TME).MethodologyBetween April 2021 and October 2021, 12 patients who underwent elective robotic TME in Queen Elizabeth Hospital were recruited into the 3D stoma model education programme. They were compared with 30 patients who had robotic TME before the introduction of the programme from January 2020 to December 2020. Their demographics, length of stay, self-stoma care skills, and feedback regarding the programme were reviewed.ResultsThere was a reduction of 2.7 days in the mean length of stay before (10.8 days) and after (8.1 days) the introduction of the 3D stoma model education programme. A statistically significant difference was observed (P = .0236). The programme was well received among participants. All patients agreed that it relieved their anxiety, increased their understanding and confidence in self-stoma care, and enhanced their self-stoma care ability. This was supported by their excellent performance in the first post-operative stoma care session, where their stoma care skills were assessed by a stoma nurse specialist.ConclusionsPreliminary results from our 3D stoma model education programme for patients undergoing elective robotic TME are promising. The use of 3D stoma models may contribute to a shorter length of hospital stay and self-stoma care proficiency, and are well accepted by patients.
