Prevention and management of complications after colon interposition for corrosive esophageal burns

SUMMARY. We present our experience in the management of complications after a colon interposition for corrosive esophageal burns. From April 1976 to December 2006, 85 patients with caustic esophageal burns were included in this study. The superior belly median incision with an anterior border incision of the left sternocleidomastoid was used. Anastomosis between the colon and the cervical esophagus was performed in 68 and between the colon and pharyngeal portion in 14 patients. An esophageal scar part resection and gastric‐esophageal anastomosis was performed in one patient who had been given an unsuccessful colon and jejunum interposition at another institute. An anastomotic modeling operation was performed in one patient with anastomotic stricture who had been managed with colon interposition at another institute. Exploratory thoracotomy and gastrostomy was performed in one patient who had an unsuccessful colon interposition at another institute. Seven of 14 patients (8.5% of 17.1%) died with serious complications such as aspirated pneumonia, interposition colon necrosis, abdominal wound dehiscence and degradation of swallowing and concordance function. However, others with such serious complications survived and were discharged for rehabilitation after corresponding treatment. The 25 patients (30.1%) with other mild complications were discharged for rehabilitation and corresponding management. Two patients from other institutes were discharged for rehabilitation and one was lost to follow‐up. The most dangerous complication of this procedure is colon necrosis, and the stomach is the best organ for re‐operation. Otherwise, aspiration in infants due to hypoplasia and degradation of swallowing co‐ordination needs attention. Peri‐operative management is very important, including the control of mediastinal and pulmonary infection and systemic nutritional support to avoid abdominal wound dehiscence. The platysma flap is an excellent method for the treatment of anastomotic stricture.     

Simple antireflux technique for the cologastric anastomosis: complementary step in retrosternal colon interposition procedure

Gastrocolic reflux is a troublesome symptom causing repeated aspiration or chocking in patients underwent retrosternal colon interposition. Various techniques were described to avoid such complication, however, they entail complicated technique that may jeopardize the viability of the graft or cause obstructing symptoms. A simple antireflux procedure is described here alleviating this problem. Over the last 7 years, 87 patients had gastrocolic antireflux procedure for cologastric anastomosis; 75 patients as a primary procedure (group 1) and 12 patients as a secondary procedure treating symptomatic reflux (group 2). The technique entails the creation of cologastric angle after finishing the cologastric anastomosis by applying three stitches between the colon and the stomach, thus tucking the colon to the stomach for 3–4 cm. Gastrocolic reflux was evaluated clinically and radiologically 3 months postoperatively. In group 1, three cases (4%) suffered symptomatic gastrocolic reflux, and seven cases (9.3%) had radiological asymptomatic mild reflux, while all patients in group 2 had complete alleviation of their symptoms with gastrogram showing no reflux. Gastrocolic reflux can be treated simply by creation of cologastric angle; however, controlled trial is needed to confirm its effectiveness in comparison to other described techniques.     

Anterior vs. Posterior Mediastinal Routes in Colon Interposition after Esophagectomy

Background/Aims: Colon interposition is the most commonly used method of esophageal reconstruction when the stomach cannot be used; however, this method may cause surgical complications such as anastomotic leakage and sepsis due to colon necrosis. Therefore, many surgeons use a retrosternal or subcutaneous route because it is easier to manage the subcutaneous drainage when anastomotic leakage occurs. However, some researchers have reported that the posterior mediastinal route provides better long-term functional outcomes after surgery than the anterior mediastinal route. Thus, in this study, we compared these reconstruction routes used for colon interposition, with or without the supercharge technique, in patients with a history of distal gastrectomy, who have undergone colon interposition after esophagectomy. Methodology: We retrospectively studied 30 patients who underwent esophagectomy with colon interposition. These patients were divided into 2 groups based on the reconstruction route: the anterior mediastinal or subcutaneous route (A group), or the posterior mediastinal route (R group). Results: Anastomotic leakages were observed in 4 patients (26.7%) in the A group and in 1 patient (6.7%) in the R group. Conclusions: Ischemia is not always the result of arterial failure, but may also originate from venous blood flow impairment due to injury or distortion of veins.     

Colon interposition in the treatment of esophageal caustic strictures: 40 years of experience

The objective of this article was to analyze 40 years of experience of colon interposition in the surgical treatment of caustic esophageal strictures from the standpoints of our long-term personal experience. Colon interposition has proved to be the most suitable type of reconstruction for esophageal corrosive strictures. The choice of colon graft is based on the pattern of blood supply, while the type of anastomosis is determined by the stricture level and the part of colon used for reconstruction. In the period between 1964 and 2004, colon interposition was performed in 336 patients with a corrosively scared esophagus, using the left colon in 76.78% of the patients. In 87.5% a colon interposition was performed, while in the remaining patients an additional esophagectomy with colon interposition had to be done. Hypopharyngeal strictures were present in 24.10% of the patients. Long-term follow-up results were obtained in the period between 1 to up to 30 years. Early postoperative complications occurred in 26.48% of patients, among which anastomosic leakage was the most common. The operative mortality rate was 4.16% and late postoperative complications were present in 13.99% of the patients. A long-term follow up obtained in 84.82% of the patients found excellent functional results in 75.89% of them. We conclude that a colon graft is an excellent esophageal substitute for patients with esophageal corrosive strictures, and when used by experienced surgical teams it provides a low rate of postoperative morbidity and mortality, and long-term good and functional quality of life.     

Left colonic graft in esophageal reconstruction for caustic stricture: mortality and morbidity

The adequacy of the blood supply to the left colon graft and its ability to transport food effectively from pharynx to stomach made it an esophageal substitute of choice, particularly in esophageal caustic stricture. From 1999 to 2009, 60 patients underwent colon interposition for esophageal caustic stricture (n= 57) and cancer (n= 3). An isoperistaltic colonic graft based on the left colonic artery could be used in all of these patients. The substernal route was used exclusively, and upper thoracic inlet was opened when necessary. The isoperistaltic left colonic graft interposed by substernal route represents the surgical procedure of choice in all operations performed for esophageal substitution during the study period. The operative mortality rate was 3.3%. A cervical fistula occurred in 10 patients (16.6%) and cervical anastomotic stricture in five patients (8.3%). Dilation was required in all the stricture of the esophageal colonic anastomosis with good response. The isoperistaltic left colic transplant supplied by the left colic pedicle is an excellent long‐term replacement organ for the esophageal caustic stenosis. When performed by experienced surgeons, the left isoperistaltic esophagocoloplasty is a satisfactory surgical method for esophageal reconstruction with acceptable early morbidity and good long‐term functional results.     

Differences between right- and left-sided colon cancer in patient characteristics, cancer morphology and histology

Background and Aim: Recently, the clinical and biological differences between right‐ and left‐sided colon cancers have been widely debated. However, close analyses of these clinical differences, based on large‐scale studies, have been scarcely reported. Methods: A total of 3552 consecutive Japanese colorectal cancer cases were examined and the clinical differences between right‐ and left‐sided colon cancer cases were investigated. Results: The proportion of right‐sided colon cancer was relatively high in patients aged less than 40 years (33%) and more than 80 years (43%). The proportion of right‐sided colon cancer in patients aged 40–59 years was relatively low (male 22% and female 29%). In male patients the proportion increased in the 70‐79 years age group (30%), while in female patients the proportion increased in the 60‐69 years age group (39%). Right‐sided colon cancer was more likely to be detected at an advanced stage (T1 stage; left 22%, right 15%) (P < 0.01) with severe symptoms. Polypoid‐type early cancer was dominant in the left colon (left 59%; right 40%) (P < 0.01), while the proportion of flat‐type early cancer in the right colon was significantly higher than that in the left colon (left 25%; right 44%) (P < 0.01). Conclusions: Specific age distribution of right‐sided colon cancer was observed and the difference between male and female patients was highlighted. Other clinical features also differed between right‐ and left‐sided colon cancer, suggesting that different mechanisms may be at work during right and left colon carcinogenesis.     

3D腹腔镜右半结肠癌根治术经阴道取标本的应用体会

目的探讨3D腹腔镜右半结肠癌根治术经阴道取标本的安全性和可行性。 方法回顾性分析2015年10月至2018年2月间在河南大学淮河医院接受经阴道取标本的3D腹腔镜右半结肠癌根治术的13例女性患者的临床资料。中间入路,按全结肠系膜切除原则处理血管、清扫淋巴结,游离右半结肠、结肠肝曲和部分回肠系膜后,在横结肠和回肠末端预切断吻合处打开肠腔,腔内直线切割闭合器行回肠-横结肠侧侧吻合,更换枪钉后闭合切断回肠和横结肠完成标本切除和吻合。切开阴道后穹窿,经阴道置入保护套,将标本通过保护套经阴道后穹窿切口拖出体外,腔镜下缝合阴道后穹窿切口。所有患者于术前和术后3个月分别填写盆底功能障碍问卷（PFDI-20）,对盆底功能障碍中盆腔、直肠和膀胱功能进行评价。 结果13例女性患者中,年龄58~76（中位62）岁,体质指数20.8~34.5（中位31）Kg/m²,肿瘤位于结肠肝曲4例,回盲部7例,升结肠2例,全组患者手术均顺利完成,无一例中转开腹。手术时间164~232（中位176）min,术中出血50~200（中位100）ml,清扫淋巴结13~18（中位14）枚,术后排气时间1.8~5.2（中位2.8）d,术后住院时间6.3~9.2（中位6.8）d,术后无吻合口出血、吻合口漏或腹腔内感染病例。随访4~30个月未见局部复发和远处转移病例。术前与术后3个月患者的盆底功能评分差异均无统计学意义（P>0.05）。 结论经阴道取标本的3D腹腔镜右半结肠癌根治术具有一定优势且不影响患者的盆底功能,是安全可行的。     

利用套袖式吻合技术的低位直肠癌新辅助放化疗后NOSES手术20例临床分析

目的探讨利用套袖式吻合技术的低位直肠癌新辅助放化疗后经自然腔道取标本手术（NOSES）的安全性、可行性及近期疗效。 方法回顾性分析中国医学科学院北京协和医学院肿瘤医院2018年10月至2021年10月20例利用套袖式吻合技术完成NOSES手术的低位直肠癌新辅助放化疗后患者的临床资料,统计并分析患者的临床特征、手术情况、术后恢复、病理特征、围手术期并发症以及术后复发转移等资料,并分别于术后1个月、3个月及6个月采用低位前切除综合征（LARS）评分量表评估肛门功能。 结果20例低位直肠癌新辅助放化疗后患者均成功完成利用套袖式吻合技术的NOSES手术,术前肿瘤距肛缘中位距离为4.0 cm,术中未行预防性造口,中位手术时间为171.5 min,中位吻合时间为17.0 min,中位术中出血量为35.0 mL。患者术后中位下地时间、进食时间、排气时间和住院时间分别为18.5 h、12.0 h、30.0 h和7.0 d,中位住院费用为47 678.0元。术后病理显示中位肿瘤长径为3.3 cm,中位近端切缘长度为10.3 cm,中位远端切缘长度为1.0 cm,中位淋巴结检出数目为14.5枚。随访过程中,结肠残端回缩入盆腔的中位时间为11.5 d,其中1例（5.0%）患者于术后第五天出现吻合口漏,另外有3例（15.0%）患者出现肛周粪水性皮炎伴肛周疼痛,均予对症止处理后好转。1例（5.0%）患者术后1年出现肝转移,其余患者无肿瘤局部复发或转移。12例（60%）患者术后1个月LARS评分较高,但术后3个月15例（75%）患者肛门功能较为满意。 结论利用套袖式吻合技术的低位直肠癌新辅助放化疗后NOSES手术安全可行,避免了预防性造口,经对症指导治疗肛门功能恢复满意,具有较好的近期疗效,其远期疗效待进一步随访观察。     

Prosthetic graft interposition of the brachiocephalic veins or superior vena cava combined with resection of malignant tumours: graft patency and risk factors for graft occlusion

Background

We aimed to assess graft patency in patients undergoing prosthetic graft interposition of the brachiocephalic veins (BCVs) or the superior vena cava (SVC) combined with resection of malignant tumours.

Methods

A retrospective analysis was conducted on 16 patients who underwent prosthetic graft interposition of the BCVs or the SVC between 1998 and 2012.

Results

Among a total of 20 grafts in 16 patients (unilateral graft interposition in 12, bilateral graft interposition in 4), 8 grafts were occluded in 8 patients. Overall graft patency rate was 64.6%, 42.4% at the 2- and 5-year follow-up. Graft patency rate of the left BCV was significantly lower than that of the right BCV or the SVC (2-year patency, 38.1% vs. 81.8%, P=0.024). In univariate analysis, the superior anastomosis site [left BCV vs. right BCV; hazard ratio (HR) =2.312; 95% confidence interval (CI), 1.015–5.265; P=0.046], the inferior anastomosis site (right atrial appendage vs. SVC; HR =2.409; 95% CI, 1.124–5.161; P=0.024), and interruption of warfarin (HR =5.015; 95% CI, 1.106–22.734; P=0.037) were significant risk factors for graft occlusion. Graft occlusive symptoms were identified in 4 patients who underwent unilateral graft interposition.

Conclusions

Prosthetic graft interposition between the left BCV and the right atrial appendage resulted in a significant rate of graft occlusion. Prosthetic graft interposition of the bilateral BCVs and long-term warfarin therapy may be necessary to prevent graft occlusive symptoms.     

Functional Outcome Following Colon Interposition in Total Pharyngoesophagectomy with or without Laryngectomy

Our study compares deglutition between a group who had undergone total esophagopharyngolaryngectomy and a group who had esophagectomy and partial pharyngectomy with preserved larynx, after reconstruction of the upper digestive tract with pedicled colon interposition. In four patients the laryngeal structures could be preserved (three caustic burns and one proximal esophageal tumor). Six patients underwent a total laryngopharyngectomy for large pharyngeal tumors. Swallowing was assessed by a questionnaire, clinical examination, and videofluoroscopy. All patients had normal intake of semisolid foods and fluids. All patients but three experienced some feeling of narrowing of the tract: four at the level of the hypopharynx, two at the oropharyngeal level, one at the oral level. In the laryngectomy group, solid food caused some degree of delayed swallowing in three patients. Dumping occurred in one case out of the nonlaryngectomy group. On clinical examination a tense motility in all laryngectomy patients appeared, food remnants in five and repeated swallowing movements in four. The videofluoroscopy confirmed repeated swallowing movements and presence of residual food in the oral cavity. Temporal stagnation occurred at the anastomosis site in all patients and in two patients at a place of colon redundancy. Colon interposition is a reliable reconstruction and gives the possibility of a good functional outcome. Although preservation of the larynx facilitates swallowing even in this reconstructive procedure, it may be better to perform a total laryngopharyngectomy and colon interposition in oncological cases where the pharyngeal remnant is borderline for primary closure.     

German experience with colon interposition grafting as an esophageal substitute.

Preliminary results of a questionnaire survey showed that gastric transposition is the technique of choice in Germany to restore alimentary continuity after esophageal resection. Experience with colon interposition grafting is low. Only 13% of all centers perform this technique. Despite this limited experience, there appears to be no difference in the complication rate between gastric pull-through procedures and colon interpositions. A modification of established colon interposition techniques is possible when the right colon is used if it is prepared in such a way that the left colonic artery is the blood supplying vessel. This modified technique may be simpler to perform than previous procedures for creating a colon interposition graft and may also facilitate esophageal replacement using colon interposition grafting.     

Surgical and pathological outcomes of laparoscopic surgery for transverse colon cancer

Purpose Several multi-institutional prospective randomized trials have demonstrated short-term benefits using laparoscopy. Now the laparoscopic approach is accepted as an alternative to open surgery for colon cancer. However, in prior trials, the transverse colon was excluded. Therefore, it has not been determined whether laparoscopy can be used in the setting of transverse colon cancer. This study evaluated the peri-operative clinical outcomes and oncological quality by pathologic outcomes of laparoscopic surgery for transverse colon cancer. Materials and methods Analysis of the medical records of patients who underwent laparoscopic colorectal resection from August 2004 to November 2007 was made. Computed tomography, barium enema, and colonoscopy were performed to localize the tumor preoperatively. Extended right hemicolectomy, transverse colectomy, and extended left hemicolectomy were performed for transverse colon cancer. Surgical outcomes and pathologic outcomes were compared between transverse colon cancer (TCC) and other site colon cancer (OSCC). Results Of the 312 colorectal cancer patients, 94 patients underwent laparoscopic surgery for OSCC, and 34 patients underwent laparoscopic surgery for TCC. Patients with TCC were similar to patients with OSCC in age, gender, body mass index, operating time, blood loss, time to pass flatus, start of diet, hospital stay, tumor size, distal resection margin, proximal resection margin, number of lymph nodes, and radial margin. One case in TCC and three cases in OSCC were converted to open surgery. Conclusions Laparoscopic surgery for transverse colon cancer and OSCC had similar peri-operative clinical and acceptable pathological outcomes.     

Ileo-right hemi-colonic cervical pull-up on a non-supercharged ileocolic arterial pedicle: A technical and case report

Esophageal reconstruction can be challenging when stomach and colon are not anatomically intact and their use as esophageal substitutes is therefore limited. Innovative individual approaches are then necessary to restore the intestinal passage. We describe a technique in which a short stump of the right hemicolon and 25 cm of ileum on a long, non-supercharged, fully mobilized ileocolic arterial pedicle were used for esophageal reconstruction to the neck. In this case, a 65 year-old male patient had accidentally indigested hydrochloric acid which caused necrosis of his upper digestive tract. An emergency esophagectomy, gastrectomy, duodenectomy, pancreatectomy and splenectomy had been performed in an outside hospital. A cervical esophagostomy and a biliodigestive anastomosis had been created and a jejunal catheter for enteral feeding had been placed. After the patient had recovered, a reconstruction of his food passage via the left and transverse colon failed for technical reasons due to an intraoperative necrotic demarcation of the colon. Our team then faced the situation that only a short stump of the right hemi-colon was left in situ when the patient was referred to our center. After intensified nutritional therapy, we reconstructed this patient's food passage with the right hemicolonapproach described herein. After treatment of a postoperative pneumonia, the patient was discharged from hospital on the 26 th postoperative day in a good clinical condition on an oral-only diet. In conclusion, individual approaches for long-segment reconstruction of the esophagus can be technically feasible in experienced hands. They do not always require arterial supercharging or free intestinal transplantation.     

An evaluation of results of colon anastomosis in prepared and unprepared bowel

Considerable controversy exists about the wisdom of primary anastomosis after resection of the unprepared right colon. We reviewed the records of 70 patients who had undergone colon resection with primary anastomosis in emergency and elective situations. One group consisted of 50 patients who underwent nonemergent colon resection after standard mechanical and antibiotic bowel preparation (prepared). The second group consisted of 20 patients who underwent resection of the right colon on an emergent basis without benefit of bowel preparation (unprepared). Risk factors (steroid dependence, peritonitis, previous radiation, diabetes mellitus, chronic renal failure) and complications were analyzed for each group. Statistical analysis demonstrated the following: (a) the incidence of total complications was greater in the unprepared group (p = 0.04), (b) there was an increased incidence of anastomotic disruption in the unprepared group (p = 0.02), and (c) a significant relationship existed (p = 0.005) between the presence of one or more risk factors and the development of complications after surgery in the unprepared group, indicating that in the absence of risk factors a successful outcome could be anticipated with primary anastomosis. Based on data from this study, our conclusions are twofold. First, in the presence of one or more risk factors, primary anastomosis after resection of unprepared right colon should not be attempted. Second, in any situation in which there are no risk factors, primary anastomosis of the unprepared right colon would be expected to achieve similar results as with prepared bowel.     

Proximal gastrectomy with jejunal interposition and TGRY anastomosis for proximal gastric cancer

AIM: To compare the short-term outcomes of patients who underwent proximal gastrectomy with jejunal interposition (PGJI) with those undergoing total gastrectomy with Roux-en-Y anastomosis (TGRY).METHODS: From January 2009 to January 2011, thirty-five patients underwent PGJI, and forty-one patients underwent TGRY. The surgical efficacy and short-term follow-up outcomes were compared between the two groups.RESULTS: There were no differences in the demographic and clinicopathological characteristics. The mean operation duration and postoperative hospital stay in the PGJI group were statistically longer than those in the TGRY group (P = 0.00). No anastomosis leakage was observed in two groups. No statistically significant difference was found in endoscopic findings, Visick grade or serum albumin level. The single-meal food intake in the PGJI group was more than that in the TGRY group (P = 0.00). The PG group showed significantly better hemoglobin levels in the second year (P = 0.02). The two-year survival rate was not significantly different (PGJI vs TGRY, 93.55% vs 92.5%, P = 1.0).CONCLUSION: PGJI is a safe, radical surgical method for proximal gastric cancer and leads to better outcomes in terms of the single-meal food intake and hemoglobin level, compared with TGRY in the short term.     

Single-stage procedure with intraoperative colonoscopy and colonic irrigation in patients with obstructing left-sided colonic cancer

Background and aims Recently there has been growing acceptance of the one-stage resection and primary anastomosis with intraoperative antegrade irrigation. This study evaluated the efficacy of a newly developed device for performing a single-stage procedure in patients with obstructing left-sided colon cancer.Patients and methods A series of 151 consecutive patients with obstructing left-sided colonic cancer underwent on-table irrigation, resection, and primary anastomosis with the use of a newly developed device; 75 patients on-table colonoscopy. The study spanned a 3 years from September 1999 to August 2002. The observed variables were the volume of irrigated saline, time for irrigation and colonoscopic examination, synchronous pathology, operative mortality and morbidity, time to passage of flatus, restarting day of oral intake, and length of hospital stay.Results The mean volume of irrigated saline was a mean of 12.5 l (range 1–32) over a mean of 14.2 min (range 1–45). Subsequent colonoscopic examination added a mean of 10.7 min (range 3–15). The incidence of synchronous polyps was 47% (35 of 75 cases) in performing the on-table colonoscopic investigations. On-table colonoscopy induced surgeons to extend resection because of synchronous malignancy attested by frozen biopsy specimen in ten patients and because of mucosal necrosis of the proximal colon in three. There were two anastomotic leakages, six wound infections, and one operative mortality. The time to passage of flatus was an average of 3.6 days (range 1.0–7). The time to oral intake was an average of 4.3 days (range 3–8). The length of hospital stay was 11.7 days (range 6–43).Conclusion These findings suggest that our device is an effective tool to facilitate acceptance of the one-stage procedure in patients with obstructing left-sided colonic cancer. Specifically, our device enables quick and easy on-table colonoscopy.     

Gastric venous congestion and bleeding in association with total pancreatectomy

Background

Gastric venous congestion and bleeding in association with total pancreatectomy (TP) were evaluated.

Methods

Thirty‐eight patients of TP were retrospectively analyzed. TP was classified as TP with distal gastrectomy (TPDG), pylorus‐preserving TP (PPTP), subtotal stomach‐preserving TP (SSPTP), and TP with segmental duodenectomy (TPSD).

Results

Portal vein or superior mesenteric vein resection and reconstruction was performed in 24 patients (62.2%). Gastric bleeding occurred immediately after tumor resection in one of eight patients who underwent SSPTP, and urgent anastomosis between the right gastroepiploic and left ovarian vein stopped the bleeding. Another case of gastric bleeding was observed a few hours after TP in one of nine patients who underwent PPTP, and hemostasis was achieved after conservative therapy. Gastric bleeding was not observed in 16 patients who underwent TPDG and five who underwent TPSD. Some patients underwent preservation of gastric drainage veins (left gastric vein, right gastric vein, or right gastroepiploic vein). Neither patient with bleeding underwent preservation of a gastric drainage vein.

Conclusions

To preserve the subtotal or whole stomach when performing TP, one of the gastric drainage veins should undergo preservation or reconstruction, and anastomosis between the right gastroepiploic vein and left ovarian vein may be beneficial.     

Significance of coupling device for vessel anastomosis in esophageal reconstruction

BACKGROUND/AIMS: To prevent an anastomotic failure due to impaired blood supply, several trials have been performed such as preoperative ischemic conditioning by transarterial embolization of the left gastric, right gastric and splenic arteries or microvascular anastomosis. We assess the significance of an automatic anastomotic coupling device for vessel anastomosis, which we have continuously utilized, to simplify the task and shorten the anastomotic time since March 1999. METHODOLOGY: 8 patients who underwent venous anastomosis by an automatic anastomotic coupling device were evaluated for the time of anastomosis, total ischemic time and outcomes. RESULTS: Venous anastomosis was completed within 5 minutes on average. Microscopic arterial anastomosis by hand took 35 minutes on average. For gastric tube reconstruction, venous anastomosis by an automatic coupling device took only 5 minutes. The top of the gastric tube showed congestion before venous anastomosis, but rapidly recovered from it after anastomosis. Postoperative endoscopic observation of the mucosal color of the replaced intestine or gastric tube was started 3 days after surgery and revealed no ischemia or congestion. The postoperative course was uneventful except one case suffering from pneumonia but leakage was not observed in any case. CONCUSION: An automatic anastomotic coupling device can perform an easy and reliable vascular anastomosis for patients who undergo esophageal reconstruction. The device may shorten the operating time and consequently the ischemic time of the gastric tube or jejunal or colonic graft, which in turn may lead to a decrease of complications.     

Refinement of recto-sigmoid colon vaginoplasty using a three-dimensional laparoscopic technique

To investigate the feasibility, safety, and outcomes of three-dimensional (3D) laparoscopic vaginoplasty with a rectosigmoid colon flap for vaginal reconstruction.Following appropriate preoperative patient counseling, 17 consecutive patients underwent vaginoplasty using a 3D laparoscopic system. Perioperative and postoperative outcomes were retrospectively evaluated.Between September 2016 and February 2020, 17 patients underwent 3D laparoscopic vaginoplasty with a rectosigmoid colon flap. Of them, 15 (88%) were transgender female patients, and 2 (12%) were cisgender female patients with congenital deformities. Among the 15 transgender patients, 12 (80%) underwent de novo surgeries and 3 (20%) underwent re-do surgeries. The mean age at the time of operation was 33.0 years, and the mean total operation time was 529 ± 128 minutes. The initial intraoperative mean vaginal depth was 15.2 ± 1.3 cm, and the 30-day readmission rate was 5.9% (1/17 cases). The mean follow-up duration was 24.8 months.Perioperative and postoperative outcomes suggest that 3D laparoscopic rectosigmoid colon vaginoplasty is a potentially acceptable, effective, and safe method for vaginal reconstruction.