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Background: Hartmann's procedure is a treatment option for perforated acute diverticulitis, especially when organ dysfunction(s) are present. Its use has been criticized mostly out of fear of high permanent stoma rate. The aim of this study was to investigate the rate of stoma reversal, reasons behind non-reversal, and safety of reversal surgery. Methods: This was a single-center retrospective study of patients undergoing urgent Hartmann's pro-cedure due to acute diverticulitis between the years 2006 and 2017 with follow-up until March 2021. Results: A total of 3,319 episodes of diverticulitis in 2,932 patients were screened. The Hartmann's procedure was performed on 218 patients, of whom 157 (72%) had peritonitis (48 (22%) with organ dysfunction). At 2-years, 76 (34.9%) patients had died with stoma, 42 (19.3%) were alive with stoma, and 100 (45.9%) had undergone stoma reversal. The survival of patients with and without reversal were 100% and 42.7% at 1-year, 96.0% and 35.0% at 2-years and 88.9% and 20.7% at 5-years, respectively. The risk factors for nonreversal were old age, a need for outside assistance, low HElsinki Staging for Acute Diverticulitis stage, and higher C-reactive protein level upon hospital admission. The most common reasons for nonreversal in surviving patients were patient not willing to have the operation 18 (41%) and dementia 10 (23%). Twelve (12%) patients had a major complication after reversal (Clavien-Dindo IIIb-IV) and 90-day mortality after reversal was 0%. Conclusion: After the Hartmann's procedure for acute diverticulitis, one-third died, half underwent stoma reversal, and one-fifth did not undergo stoma reversal within 2 years. Patients who survive with stoma are either not willing to have reversal or have severe comorbidities excluding elective surgery. The Hartmann's procedure remains a viable option for high-risk patients with perforated acute diverticulitis. (c) 2022 The Author(s). Published by Elsevier Inc.

Objectives To identify the currently utilised techniques of anterior urethroplasty described in literature for treatment of urethral strictures, assess the effectiveness of the identified techniques based on re-stricture and complication rates, evaluate, and suggest treatment options based on current evidence for urethral strictures at different locations and of different lengths. Methods A systematic review of the MEDLINE, EMBASE, Scopus and Cochrane Library databases from conception up to September 2020 was performed. Primary outcomes included success rates measured via re-stricture rates and the post-operative maximum urinary flow rate (Qmax). Secondary outcomes included patient reported complication rates. Results A total of 52 papers, including 7 RCTs, met the inclusion criteria. Forty studies described the use of free graft urethroplasty with a median success rate of 86.5% (IQR=8.1). The best outcomes were found in dorsal onlay buccal mucosa (BM) grafting in the penile urethra (86.6%). Twelve described the use of pedicled flap urethroplasty with a median success rate of 76% (IQR=14.4). Excision and Primary Anastomosis results were reported in 5 studies and showed an overall highest success rate of 89.7% (IQR=7.0) but involved the shortest strictures of median lengths of 2.1cm (IQR=0.48). Conclusions Graft urethroplasty showed optimal outcomes when utilised in penile and bulbar strictures, with dorsal onlay buccal mucosa grafting presenting with the largest evidence base and best outcomes overall. Flap urethroplasty had the highest success rates in panurethral and bulbar strictures, while anastomotic urethroplasty had the greatest success in bulbar and penobulbar strictures.

Background Locoregional colon cancer recurrence occurs in around 10% of patients following initial curative intent primary resection. We hypothesized oncological results can vary based on the recurrence site. Our aim was to determine outcomes for patients undergoing resection with curative intent for locally recurrent colon cancer. Methods Patients with locoregional recurrence after curative intent resection for colon cancer were identified (1999–2017). Demographics, operative details and outcome data were recorded. Kaplan-Meier method was used to compare survival differences. Results Fifty-two patients (mean age, 62) were included. The most common recurrence site was primary anastomosis (48%). R0 resection was obtained in 68%. Major morbidity occurred in 37%. Patients with anastomotic recurrence had a statistically significant overall survival compared to other sites (71.6 vs. 40.8 months respectively with a P value of 0.05). Conclusions Excellent outcomes are possible for curative intent recurrent colon cancer surgery. The site of loco-regional recurrence plays a significant role in outcomes. Table of Contents Summary: Colon cancer recurrence can be treated surgically with optimal outcomes. Anastomotic recurrence is associated with improved survival.

Although rare, small bowel perforation post pregnancy related dilation and curettage presents a serious complication. Herein, we reported a case of 34-year-old female patient presenting for uterine-ileal perforation post pregnancy related dilatation and curettage managed successfully by laparoscopic small bowel resection and primary anastomosis.

Objectives To evaluate the magnetic resonance imaging (MRI) findings of traumatic bulbar stricture and to evaluate their ability to estimate repair complexity. Methods Eighty-nine men with traumatic bulbar stricture who underwent urethrography and MRI at least 3 months post-injury and subsequent excision and primary anastomosis were retrospectively analyzed. The associations of MRI findings, including continuity of the tunica albuginea of the corpus spongiosum, periurethral fistula, spongiofibrosis length (SFL), and distal and proximal bulbar urethral length (PBL) from the stricture, with urethrography and operative parameters were evaluated. Results Mean SFL was significantly longer than mean stricture length on urethrography (14.9 vs. 7.9 mm, p Conclusions In contrast to urethrography findings, MRI findings help predict traumatic bulbar stricture repair complexity.

Delayed primary repair is still the method of choice in the management of long-gap oesophageal atresia in many centres, but the timing of anastomoses varies. Some assume the infant's bodyweight to be an important factor, whereas others prefer age. We therefore aimed to clarify whether age or bodyweight determined oesophageal length in a rodent model.We explanted the oesophagi of 20 Sprague-Dawley rats, aged 15 to 444 days (n = two per time point), measured bodyweight, oesophageal length, weight, and linear breaking strength to measure tissue resilience. Univariate and multivariate regression analyses were conducted to determine the influence of age and bodyweight on oesophageal length and linear breaking strength.All parameters were highly correlated (R 0.8), except for age and linear breaking strength (R = 0.65). Both age and bodyweight were univariate significant predictors of oesophageal length, weight, and linear breaking strength (p 0.0001). Multivariate analyses showed bodyweight to be a significant predictor of oesophageal length (p 0.0001), whereas age was not (p = 0.18) [adjusted ROnly weight determines oesophageal length and tissue resilience in rodents, whereas age is irrelevant. If a similar relationship exists in humans, it may facilitate choosing the optimum time point for delayed primary anastomosis.IV - Experimental Paper.

Background: Necrotizing enterocolitis (NEC) and spontaneous intestinal perforation (SIP) are the most common abdominal surgical conditions in preemies. Associated mortality remains high and long periods of parenteral nutrition (PN) may be required. We assessed the developments in the outcomes of surgically treated NEC and SIP in the two largest Finnish neonatal intensive care units (NICU). Methods: Retrospective observational study based on hospital records during 1986-2014. Main outcome measures were three-month survival during 1986-2000 compared with 2001-2014 and predictors of mortality. Results: Included were 225 patients (NICU A 131 and NICU B 94) with NEC in 142 (63%) and SIP 83 (37%). The median birth weight (BW) (870 vs 900 g) and gestation age (GA) (27 vs 27 weeks, p = 0.96) were similar in NEC and SIP. Small intestine was affected in 85% of NEC and 76% of SIP patients (p = 0.12). In 5% of patients NEC was panintestinal. Median small intestinal loss was 25% in NEC and 4.0% in SIP (p

Objectives The treatment of long gap esophageal atresia (LGEA) is one of the most challenging congenital malformations in neonatal surgery. A preoperative bougienage stretching technique for elongation of the two segments of esophagus is applied to achieve utilizing the native esophagus to establish esophageal continuity by open or thoracoscopic approach. Methods From January 2015 to May 2017, 12 neonates who suffered from LGEA were admitted to our department. They were divided into 2 groups (A and B) according to their admission time. They all accepted bougienage stretching technique before esophageal anastomosis. Results Initially the lengths of esophageal gap in 12 infants ranged from 4 to 7.5 vertebral bodies ( M =5.8±1.1). The gap lengths became –1 to 2.5 vertebral bodies after bougienage stretching technique and tension-free anastomosis were performed successfully for all 12 cases: Group A (n=5) by thoracotomy and group B (n=7) by thoracoscopic approach. 12 cases have been followed up for 1–25 months ( M =12.4±8.5) after definitive surgery. Conclusions Bougienage stretching technique for LGEA is feasible with satisfactory clinical results. Thoracoscopic approach is a good choice for primary anastomosis in LGEA. Levels of evidence Treatment Study Level IV

Primary repair of long gap oesophagus atresia (LGEA) requires interdisciplinary expertise to achieve promising results. We report a 9 month old refugee with a spit fistula and a gastrostomy who achieved primary anastomosis in our hospital using the combined surgical methods of Kimura on the upper pouch and Foker in the lower pouch.

Atresia of the ileocecal valve is an extremely rarely described phenomenon, with only 11 cases previously reported in the literature. We present two cases resembling atresia, both of which were in premature infants who presented with obstruction after recovering from necrotizing enterocolitis. The apparent atresia was more likely a discrete stricture of the ileocecal valve. Both were successfully treated with ileocecectomy and primary anastomosis.

Introduction and Aims No consensus has been reached in the management of perforated diverticulitis. However, many surgeons opt for a Hartmann's procedure. A primary anastomosis has been shown to be a feasible alternative. We hypothesize that colorectal consultants and senior trainees are more likely to opt for a resection with primary anastomosis in selected cases than their non-colorectal counterparts. Methods A national survey was conducted electronically. A questionnaire was distributed via training program directors and social media to general surgeons across the country, to assess their views on primary anastomosis in perforated diverticulitis. Results Of the 90 responses to the survey, 72.2% said they would only consider an anastomosis in purulent peritonitis, 18.9% in both faecal and purulent and 8.9% would never consider it. There was a significant difference in choice of operation depending on patient and operative risk factors but no difference between grades of training or subspeciality. Conclusion The survey showed that high-risk patients are more likely to have an open Hartmann's procedure irrelevant of the grade or subspeciality of the surgeon. The choice of operation in the lower risk patients was varied.

The standard treatment of bulbar urethral strictures of appropriate length is excision and primary anastomosis (EPA), irrespective of the cause of the stricture. This involves transection of the corpus spongiosum (CS) and disruption of the blood flow within the CS as a consequence. The success rate of EPA in curing these strictures is very high, but there is a considerable body of evidence and of opinion to suggest that there is a significant risk of sexual dysfunction and, potentially, of other adverse consequences that occur because of transection of the CS.

Highlights • Sigmoid volvulus is rarely considered a diagnosis in children. • We are presenting a case of a child with sigmoid volvulus causing compression of the mesentery of the small intestine. • It is the first reported case worldwide of a sigmoid volvulus to cause short bowel syndrome. • We performed a sigmoidectomy with end colostomy (Hartman`s) and primary anastomosis of the healthy part of small intestine., Introduction We present a case of a male child 8 years old presenting with a sigmoid volvulus causing ischemia of most of bowel loops resulting in a short bowel syndrome. It is the first reported case worldwide. Presentation A male child presented with a picture of intestinal obstruction. After complete laboratory and radiological investigation, laparotomy was done revealing a sigmoid volvulus compessing most of the small bowel loops with gangrenous sigmoid colon for which sigmoidectomy with end colostomy, resection of gangrenous small bowel loops and primary anastomosis of the remaining healthy part. Discussion There are few reported cases describing sigmoid volvulus in this age group. However, none of them resulted in short bowel syndrome. The median age was 7 years with a higher ratio in males than females (3.5:1). Conclusion Sigmoid volvulus is not a common problem in children and adolescents, and is rarely considered as a cause of intestinal obstruction and it was never reported as a cause of short bowel syndrome. Early diagnosis and prompt treatment confer an excellent prognosis.

Mesenteric teratoma is a rare tumor in children. The present case is huge mesenteric teratoma (20 × 20 × 10 cm) and (1.96 kg) arising near the root of mesentery with ileal segment attached to it. Complete surgical excision of the mass with adherent intestinal segment with primary anastomosis. The histopathological examination showed bengin muture teratoma with no atypia or malignancy.

There are different strategies for the treatment of long gap esophageal atresia (LEA), but many aspects of its management is still controversial. The best treatment is conserving the native esophagus through the connection of two esophageal pouches. In this study, we shared our experiences in management of LEA treatment and introduced a new approch for the conservative management of this condition. In our experience, ten patients with long gap esophageal atresia were treated, followed up and managed by our own designed method. In our technique, we lengthened the both upper and lower pouches instead of one pouches. On the one hand, with the effect of saliva pressure, the upper pouch became longer without proximal esophagostomy. On the other hand, the lower pouch was mechanically lengthened by the feeding effect of gavage. These reduced the distance between the two ends of the esophagus and provided the conditions for the primary anastomosis and saving the native esophagus. There were no complication in these ten patients but this procedure needs more investigation.

Objective To describe the technique of robotic buccal mucosa graft ureteroplasty as a minimally invasive alternative method of ureteral reconstruction for proximal or multifocal ureteral strictures not amenable to primary anastomosis. Methods Between October 2013 and May 2014, we performed robotic-assisted ureteral reconstruction using buccal mucosa grafts in four patients (mean age 41.5, range 23-67). The indication for surgery was a proximal or multifocal stricture not amenable to ureteroureterostomy or ureteropyelostomy. Buccal mucosa grafts were harvested to be the length of the strictured segment and 1 cm in width and placed in the ureter as an anterior or posterior onlay. Follow up was performed with diuretic renogram at least 3 months postoperatively and renal ultrasound as well as clinical assessment of symptoms. Results All 4 patients underwent successful robotic-assisted reconstruction of the ureter using buccal mucosa graft. There were no intraoperative complications. At a median follow up of 15.5 months (range 10.7-18.6), there has been 100% success. Conclusion Robotic buccal mucosa graft ureteroplasty is a feasible option for reconstruction of proximal or multifocal ureteral strictures that are not amenable to primary anastomosis and it avoids the morbidity of alternative procedures.

Highlights • Ileosigmoid knotting is a very rare cause of intestinal obstruction in pregnancy. • A long small bowel mesentery and long sigmoid colon predisposes to Ileosigmoid knotting. • Normal pregnancy symptoms may obscure clinical presentation. • Treatment is emergency laparotomy, small bowel resection and Hartmann’s procedure., Ileosigmoid knotting refers to the wrapping of the ileum around the base of the sigmoid colon, or vice versa thus forming a knot. It is a rare cause of intestinal obstruction, more so in pregnancy. We herein report a case of a primigravid woman who presented with an acute abdomen at 13weeks of gestation. The patient underwent emergency surgery. Laparotomy showed ileosigmoid knotting with gangrenous loops of both small bowel and sigmoid colon. The gangrenous bowel was resected. Primary anastomosis of small bowel and a Hartman’s procedure was performed.

Pure esophageal atresia is typically characterized by a long gap between the upper and lower pouches, with a gasless abdomen and no fistula. The association of pure esophageal atresia with an atretic segment is extremely rare. We report a rare variant case of pure esophageal atresia in which the two blind esophageal pouches were joined by an atretic segment. Excision of the atretic segment and primary anastomosis were performed successfully.

INTRODUCTION Ileosigmoid knotting is a rare cause of acute abdomen with high morbidity and mortality. Its diagnosis is infrequently made before surgery because of its varying ways of presentation and rarity. PRESENTATION OF CASE The first was a 21-year-old male who presented with a history of sudden generalized abdominal pain and progressive abdominal distension. He was pale and severely dehydrated. His extremities were cold and clammy. His pulse rate was 110 per minute and blood pressure was 90/50 mmHg. The second case was 20-year-old male who presented with similar symptoms as above. He was not pale but mildly dehydrated. His pulse rate was 92 per minute and blood pressure 110/70 mmHg. Both patients were resuscitated and had exploratory laparotomy a few hours after presentation. The first patient was found to have ileosigmoid knotting with gangrenous sigmoid colon and terminal ileum. He had Hartmann's procedure and right hemicolectomy with ileo-transverse anastomosis. The second patient was found to have ileosigmoid knotting with viable loops of bowel. He had careful detorsion, sigmoidectomy with primary anastomosis. Both patients’ have good outcome. DISCUSSION This is to report two cases of ileosigmoid knotting in two male patients aged 21 and 20 years, respectively, with the hope of increasing awareness. CONCLUSION Ileosigmoid knotting though more common in fourth or fifth decade of life, can also occur in the 2nd decade. Early diagnosis, careful resuscitation and skilful surgical intervention will improve outcome.

KEYWORDS: Diverticulitis; Surgery; Colostomy; Anastomosis Abstract BACKGROUND: Primary anastomosis with or without proximal diversion is increasingly applied to patients requiring urgent colectomy for complicated disease of the left colon. As such, the Hartmann procedure is now often restricted to patients who are unstable or otherwise poor candidates for primary anastomosis. We sought to define the complication rate of Hartmann takedown in a contemporary set- ting. METHODS: Consecutive adult patients undergoing colostomy takedown with colorectal anastomosis at an academic teaching hospital from January 1, 2001, to December 31, 2010, were included in the study. Complications were captured prospectively by a single trained nurse practitioner. Demographics, body mass index, American Society of Anesthesiologists (ASA) classification, interval between Hart- mann procedure and subsequent takedown, surgical indication, duration of surgery, surgeonvolume and specialty, length of stay, and complications were recorded. RESULTS: One hundred three patients underwent Hartmann reversal by 16 different surgeons; 7 of these surgeons performed 4 or fewer procedures during the study period. During the same time period, 334 patients underwent a Hartmann procedure at our institution. Seventy-seven of 104 patients (74%) had their index resection for complicated diverticulitis; an anastomotic leak was the second most com- mon indication. The median age was 61 years (range 31 to 84 years), and the interval from Hartmann procedure to reversal ranged from 87 to 1,489 days. Only 8 patients (7.7%) had an ASA of 1. Thirty patients (29.1%) had postoperative complications, and 12 (11%) had 2 or more complications. There were 2 deaths and 4 anastomotic leaks, and 7 patients had inadvertent enterotomies. Only ASA status predicted postoperative complications (P 5 .01). CONCLUSIONS: Hartmann takedown is a morbid operation with a substantial risk of inadvertent en- terotomy and serious complications. Excluding cases referred from elsewhere, there were more than 5-fold the number of Hartmann procedures than takedowns performed during the study period. This suggests that Hartmann procedures are typically restricted to patients who are also poor candidates for takedown and that their colostomy is likely to be permanent.

Intestinal anastomosis is an essential part of surgical practice, and with it comes the inherent risk of complications including leaks, strictures, and bleeding, which result in significant morbidity and occasional mortality. Understanding the myriad of risk factors and the strength of the data helps guide a surgeon as to the safety of undertaking an operation in which a primary anastomosis is to be considered. This article reviews the risk factors, management, and outcomes associated with anastomotic complications.

Summary Introduction Idiopathic mesenteric venous thrombosis is a rare entity. An early diagnosis and thrombolytic and anticoagulant therapy are very important. Patient and methods We report a case of a patient, without any specific known risk factor, with small intestinal ischemia secondary to superior mesenteric vein thrombosis (SMVT). Results In our case, only a computed tomography (CT) abdominal scan permitted the diagnosis of SMVT. The patient was successfully treated by resection of the infarcted bowel with primary anastomosis and immediate postoperative anticoagulation. Conclusions Diagnosis of intestinal ischemia from mesenteric venous thrombosis (MVT) is often delayed because the symptoms are nonspecific. Moreover, when there is not any known predisposing factor, the diagnosis may become even more difficult with significant morbidity and mortality. CT abdominal scan done early in case of nonspecific abdominal pain, since the patients had a previous history of venous thrombosis, may not require a surgical treatment of MVT.

Herein, we report a case of an elderly woman with multiple co-morbidities who presented with clinical findings indicative of small bowel obstruction (SBO), which was confirmed on a CT scan. She underwent a laparotomy, which demonstrated herniation of small bowel into a retrocaecal position. Gangrenous small bowel was resected and primary anastomosis performed. After a brief period on the High Dependency Unit (HDU), she returned to the ward and was discharged back to the community.

Background/Purpose We aim to justify the need for surgical intervention in our patients with childhood small bowel intussusceptions (SBIs) and review the current concepts in childhood SBI. Materials and Methods We retrospectively reviewed the clinical charts of all patients with surgically confirmed SBI between July 1999 and October 2002. Demographic data, clinical presentation and investigations, operative and pathologic findings, and outcome were analyzed. Results Of 173 patients with intussusception, 6 (3.5%) were diagnosed with SBI. Median age was 11 months. Ultrasonography revealed intussusceptions in all patients, but only 1 was diagnosed with SBI. Air enema reductions were attempted in 4 of 6 patients with all ending up in failure and surgery. Surgery revealed ileoileal intussusceptions in 4 patients and jejunojejunal intussusceptions in 2 patients. Two patients had long intussusceptions measuring between 30 and 50 cm in length. Five patients had pathologic lead points, and bowel complications occurred in 2 patients. All underwent bowel resection and primary anastomosis. Conclusion Despite reports on spontaneous reduction of SBI, surgery was unavoidable in all our patients with SBI because of the presence of pathologic lead points and/or bowel complications. Air enema reduction was ineffective in SBI. Due caution should be exercised when selecting patients for expectant management.

Three surgeons were discussing a complication of a colleague: a leak following an emergency sigmoid resection and primary anastomosis for sigmoid diverticulitis with contained contamination. The patient was a 71-year-old man on antihypertensive therapy, known to have moderate chronic obstructive lung disease from a lifelong history of smoking, but otherwise active, and living independently with his spouse of close to 50 years. ‘‘Clearly,’’ said the first, ‘‘this was a serious lapse in judgment by Dr. X. I can’t imagine what she must have been thinking when she decided to put the colon back together again. She put her patient at risk unnecessarily. ‘‘I don’t agree,’’ said the second, ‘‘There is good evidence that anastomosis can be performed safely in unprepared bowel [1,2], even in the setting of diverticulitis and peritonitis [3]. This was a recognized complication, and simply reflects the fact that we will never eliminate complications entirely.’’ ‘‘Maybe,’’ said the third, ‘‘but data from experimental studies show that fecal loading impairs anastomotic healing [4], especially in the setting of local inflammation [5]. The approach may be safe in ideal circumstances, but not in a man who has known comorbidities, and I would not have attempted an anastomosis here.’’ ‘‘The point is,’’ snorted the first surgeon, ‘‘that in the real world, patients aren’t experimental rats or even the carefully chosen subjects who are enrolled in clinical trials, but living, breathing humans who have plenty of associated health problems, who are operated on not by ultraspecialists in quaternary care centers, but by surgeons like me and you. You don’t take chances; you do the safest thing possible, and for me, that would have been a Hartmann’s procedure.’’

Primary anastomotic urethroplasty with complete stricture excision provides for the most successful outcome in bulbar urethral reconstruction. However, there are times when, following stricture excision and urethral spatulation, too much tension would be present for a primary anastomosis. The augmented anastomotic urethroplasty is a combination repair that incorporates the principles of excision and substitution urethroplasty. It is intended for bulbar strictures deemed too long for straightforward primary anastomosis, particularly those with a dense area of scarring and adjacent wider caliber stricture. With this technique, up to 2 or 3 cm of strictured urethra may be excised, followed by reapproximation of either the dorsal or ventral walls. The opposite urethral wall is then closed with an onlay graft. In this chapter, we discuss our graded approach to the management of bulbar strictures and our rationale for utilizing the augmented anastomotic repair and outline our surgical technique.

Tracheal tumors are rare. The two most common histologic types (occurring in about equal numbers) are adenoid cystic carcinoma and squamous cell carcinoma. Current approaches for tracheal mobilization allow safe resection of up to 50% of the tracheal length and primary anastomosis in the vast majority of patients.

Purpose: To determine the frequency of use of resection and primary anastomosis in the management of acute sigmoid diverticulitis at Royal Columbian Hospital. Methods: A retrospective chart review of all patients undergoing emergency surgery for acute sigmoid diverticulitis between 1989 and 2000 at the Royal Columbian Hospital, New Westminster, BC, was carried out in order to determine the frequency of resection and primary anastomosis. Patients who underwent bowel preparation were excluded. Results: Ninety-seven cases met the criteria. There were 33 cases of resection and primary anastomosis (34%). Five of these cases were protected with a proximal diverting stoma giving an incidence of 85% unprotected primary anastomosis in a group of patients undergoing emergency surgery for acute sigmoid diverticulitis. There was 1 anastomotic leak, 7 wound infections, and 3 deaths with an average length of stay of 9 days. Conclusions: The practice of resection and primary anastomosis for acute sigmoid diverticulitis at the Royal Columbian Hospital has an acceptable morbidity and mortality.

Paraduodenal hernias are rare hernias that result from error of rotation of the mid-gut. It can be discovered incidentally at laparotomy, seen on radiological imagining or infrequently cause intestinal obstruction. We report a case of a left paraduodenal hernia diagnosed intraoperatively after being operated on in the emergency setting for generalized peritonitis. He required resection of multiple loops of small bowel with primary anastomosis. The mouth of the sac was obliterated by suture apposition to the posterior wall. The patient was discharged on day 4 after an uneventful recovery.

Severe laryngotracheal stenosis (LTS) in the pediatric age group has been traditionally treated by laryngotracheoplasty procedures. This approach may be complex and multistaged. High success rates have been reported in adults with severe LTS who underwent partial resection of the cricoid and primary thyrotracheal anastomosis. However, this procedure has not been widely reported in infants and children. Since November 1993, 38 patients with grade III or IV subglottic stenosis were treated with partial cricotracheal resection (CTR) and primary anastomosis. In some patients a posterior cricoid split or partial arytenoidectomy was performed as well. The preoperative evaluation, surgical techniques, and postoperative care are described. There were no significant operative complications or deaths. Thirty-three patients were decannulated after a single open surgical procedure. Our results as well as those of previous series suggest that CTR with primary anastomosis is a relatively safe and effective procedure in infants and children with severe LTS.

In colorectal resections, rectal stump lavage is commonly performed prior to primary anastomosis for reducing bacterial counts and minimizing the risk of anastomotic recurrence. Being a potent bactericidal and cytotoxic disinfectant, chlorhexidine is frequently chosen as the irrigation solution of choice for such purposes. Despite its widespread use, the potential for developing chlorhexidine allergy is still a major concern due to the ever-rising number of literature reports of hypersensitivity reactions to chlorhexidine in surgical patients. This report illustrates the first reported case of life-threatening chlorhexidine anaphylaxis after its use in rectal stump lavage for colorectal resection. This report serves as a reminder of the potential danger of this “hidden allergen” in clinical practice.

The records of 24 patients with enterovesical fistula treated at the urology sections of Telemark and Vestfold Central Hospitals are presented. Most fistulas were due to diverticulitis or a malignant tumor. The part of the intestine most frequently affected was the sigmoid colon in 14 patients, the rectum in 3, the cecum in 2 and the small intestine in 2. Of the 21 patients operated on, 12 underwent a one-stage procedure with resection of the fistula and primary anastomosis of the intestine. The postoperative course was uneventful for 16 patients. Recurrence of the fistula occurred in 1 patient. Three patients were conservatively treated. We recommend a one-stage operation for patients in a good general operating condition, with a well-organized fistula and no systemic infection.

This review encompasses 50 years (1942 through 1991) and 69 newborns (43 boys, 26 girls). Half the babies were premature (weighing less than 2.5 kg), and about one third had other anomalies. The procedures used in this series were late primary anastomosis (17), gastric tube reconstruction (16), staging esophagostomy and gastrostomy (13), gastric pull-up (13), early primary anastomosis (4), and colon replacement (3). Four neonates received no treatment. The most common repair in the 1940s and 1950s was the gastric pull-up; the gastric tube was the most popular in the 1960s and 1970s. Delayed primary anastomosis has been the operation of choice since the 1980s. Over the last decade, it has become apparent that primary repair is successful in three quarters of such infants if the wait is 3 months and/or the newborn weight has at least doubled. This repair appears to provide the best functional result, unless there is an anastomotic stricture. Before the 1970s, the survival rate was below 40%, but since the 1980s the rate has more than doubled, to 90% in our series, regardiess of the type of repair used.

Left-sided colonic obstruction in the neonate traditionally is managed with a multistaged defunctioning colostomy and resection. In adults, one-stage primary anastomosis has become increasingly popular with the use of on-table antegrade colonic lavage. In infants, and especially in premature neonates, enterostomies pose significant morbidity. O'Connor and Sawin reported a 68% complication rate in 50 infants with necrotizing enterocolitis who had survived until the time of enterostomal closure. This case discusses a modified application of on-table colonic lavage in the management of an obstructing sigmoid stricture in a premature infant.

A series of 181 stenoses of the upper airway were treated following the same therapeutic principles in the period between 1978 and 1989. One hundred one patients with tracheal stenoses were treated by resection with primary anastomosis, with 98 excellent results and 3 deaths. Length of the stenosis, old age, neuropsychological sequelae, and overall poor respiratory status of the patients make up the remaining difficulties in the treatment of these stenoses. The treatment of 80 patients with laryngotracheal stenoses was much more complex and difficult to manage: 47 underwent tracheal and subglottic resection-anastomosis (47 successes), 5 had resection-anastomosis with total cricoidectomy and stenting (5 successes), 3 had supraglottic resection-anastomosis (3 successes), 11 had underwent laryngeal enlargement over a T-tube (10 successes, 1 death), and 16 had complex combinations of resection and remodeling (15 successes, 1 death). Follow-up has shown long-term stability of most repairs. Despite these good results, the approach to laryngotracheal stenoses remains a matter for discussion.

Despite the numerous approaches described for the management of neonates with "long gap" esophageal atresia, controversy still exists as to the preferred method. Delayed primary anastomosis is probably the most frequently adopted practice, but often the native esophagus is abandoned, and the long gap is bridged by some form of esophageal replacement. A case is reported of a 1.38-kg newborn with pure esophageal atresia and a long gap undergoing early primary repair. The technique used in this patient and the various options available for management of long-gap esophageal atresia are discussed.

Compared with the prolonged cumulative hospitalization and morbidity that accompany staged resection for the treatment of obstructing or inflammatory disorders of the left colon, our results confirm that resection with intraoperative lavage and primary anastomosis is a safe alternative. In the absence of intraoperative lavage, all patients in our series would have required a multistage procedure. Intraoperative lavage with primary anastomosis does not challenge the accepted criteria for safe bowel anastomosis. Rather, it offers another means for meeting those criteria. This alternative should be considered in the management of any patient whose primary indication for colostomy is the lack of adequate mechanical preparation of the colon. Although our experience indicates that intraoperative lavage and primary anastomosis can be employed safely in the treatment of inflammatory disorders of the colon, it is not recommended in the presence of fecal peritonitis, a large contiguous pelvic abscess, or systemic sepsis. In these individuals, the additional operating time required for intraoperative lavage and the potential consequences of anastomotic dehiscence pose too great a risk.

Unilateral absence of a proximal pulmonary artery (UAPA) is rare and occurs in an isolated form or in the presence of other cardiovascular anomalies. There is a paucity of literature describing surgical correction of this anomaly. Most commonly, a primary anastomosis between the main and proximal right pulmonary arteries has been described. However, in cases of long-gap discontinuity, this can be difficult and may result in excess tension on the anastomosis, predisposing to decreased patency. We present a novel technique by which discontinuity in the right pulmonary artery (RPA) is surgically corrected in a semiautologous fashion using a main pulmonary artery (MPA) flap.

Multiple jejunoileal atresia is a challenge to the pediatric surgeon. The aim of the study is to preserve bowel length and prevent the long-term complications of short bowel syndrome. The authors present a rare case of combined multiple jejunoileal atresia and colonic atresia managed by 9 primary anastomoses over a gastroperineal transanastomotic tube. This technique avoided the use of stomas and their attendant complications.

A 17 year old male was admitted emergently with acute small bowel obstruction. An urgent laparotomy revealed a loop of gangreous ileum herniated through a right paraduodenal hernia. The compromised bowel was resected and a primary anastomosis was performed. This case report allows us to discuss the diagnostic and therapeutic features of this rare condition.

Extracranial carotid artery aneurysms (ECAAs) are rare and extremely challenging disease entities. Untreated ECAAs can lead to serious neurologic sequelae, primarily from thromboembolism. Because of the high incidence of major neurologic complications, surgical intervention is warranted in most cases. We report a 63-year-old woman with voice fatigue and difficulty swallowing. Upon work-up, we discovered bilateral giant ECAAs and treated them with a combination of aneurysmectomy, primary anastomosis, and an interposition polytetrafluoroethylene graft. Unique features of the aneurysms include their unprecedented size and bilaterality, which is exceedingly rare.

We report a case of a primary tracheal schwannoma causing symptoms of airway obstruction in a 33-year-old man. Bronchoscopy and computerized tomography demonstrated a polypoid intratracheal mass obstructing 90% of the lumen. Tracheal resection with primary anastomosis was performed. Histologic analysis revealed a benign neurogenic tumor of Schwann cell origin.