Staples, tension-band plates, and percutaneous epiphysiodesis screws used for leg-length discrepancy treatment: a systematic review and proportional meta-analysis.

BACKGROUND AND PURPOSE: The primary aim of this systematic review and meta-analysis was to evaluate the success rate of 3 different epiphysiodesis techniques with implant usage for the treatment of leg-length discrepancy (LLD) in the pediatric population. The secondary aim was to address effectiveness (final LLD) and the reported complications of staples, tension-band plates (TBP), and percutaneous epiphysiodesis screws (PETS). METHODS: In this systematic review we searched MEDLINE (PubMed), Embase, Cochrane Library, Web of Science and Scopus for studies on skeletally immature patients with LLD treated with epiphysiodesis with an implant. The extracted outcome categories were effectiveness of epiphysiodesis (LLD measurements pre-/postoperatively, successful/unsuccessful) and complications that were graded on severity. RESULTS: 44 studies (2,184 patients) were included. 455 underwent epiphysiodesis with PETS, 578 patients with TBP, and 1,048 with staples. Successful epiphysiodesis was reported in 76% (95% confidence interval [CI] 61-89) with PETS (9 studies), 67% (CI 54-79) with TBP (10 studies), and 51% (CI 28-65) with Blount staples (8 studies). From pooled analysis, the severe complications rate was 7% for PETS, 17% for TBP, and 16% for Blount staples. Angular deformity was reported in 4% after PETS, 10% after TBP, and 17% after Blount staples. CONCLUSION: Our results showed that epiphysiodesis with PETS implants was the most successful technique. PETS had a higher success rate, fewer severe complications, and a lower proportion with angular deformity.

Incidence of anastomotic leakage using powered circular staplers versus manual circular staplers for left colorectal anastomosis: a cost-effectiveness analysis.

BACKGROUND: Colorectal anastomotic leakage causes severe consequences for patients and healthcare system as it will lead to increased consumption of hospital resources and costs. Technological improvements in anastomotic devices could reduce the incidence of leakage and its economic impact. The aim of the present study was to assess if the use of a new powered circular stapler is cost-effective. METHOD: This observational study included patients undergoing left-sided circular stapled colorectal anastomosis between January 2018 and December 2021. Propensity score matching was carried out to create two comparable groups depending on whether the anastomosis was performed using a manual or powered circular device. The rate of anastomotic leakage, its severity, the consumption of hospital resources, and its cost were the main outcome measures. A cost-effectiveness analysis comparing the powered circular stapler versus manual circular staplers was performed. RESULTS: A total of 330 patients were included in the study, 165 in each group. Anastomotic leakage rates were significantly different (p = 0.012): 22 patients (13.3%) in the manual group versus 8 patients (4.8%) in the powered group. The effectiveness of the powered stapler and manual stapler was 98.27% and 93.69%, respectively. The average cost per patient in the powered group was €6238.38, compared with €9700.12 in the manual group. The incremental cost-effectiveness ratio was - €74,915.28 per patient without anastomotic complications. CONCLUSION: The incremental cost of powered circular stapler compared with manual devices was offset by the savings from lowered incidence and cost of management of anastomotic leaks.

Clip or staple in laparoscopic live donor nephrectomy? A systematic literature review.

INTRODUCTION: Ligation of the renal pedicle is a crucial step in laparoscopic renal harvesting. Currently, two devices are widely used: Hem-o-Lok® clips and staplers. Each has its advantages and disadvantages. METHODS: A systematic literature review was conducted following the PRISMA methodology on PubMed, EMBASE, and Cochrane databases with no time restrictions. Registered in the PROSPERO database (CRD42023460585), the study's primary outcome measures include the failure rate of the ligation tool, conversion to open surgery, rate of severe bleeding, and device-related death. Other secondary variables are also explored. An assessment of the quality of included comparative studies was performed using the Risk Of Bias In Non-randomised Studies of Interventions (ROBINS-I) tool. RESULTS: Out of 393 articles identified using our keywords, 32 were included. Overall, clips have a lower failure rate during application, elongate graft vessel length, and are more cost-effective. Staples are associated with a shorter warm ischemia time and lower blood loss. There is no significant difference between the two devices in terms of conversion, severe bleeding, death, and blood transfusion. CONCLUSION: There is no perfect modality for renal pedicle control during laparoscopic harvesting, as each instrument has its pros and cons. Hem-o-Lok® clips are a safe and cost-effective option, particularly suitable for right-sided harvesting or in cases of vascular variations. However, they are still associated with a risk of secondary displacement with potentially serious consequences. Certain technical tricks can mitigate this risk.

Biomechanical comparison of bone staple fixation methods with suture material for median sternotomy closure using 3D-printed bone models.

AIM: To compare the biomechanical properties of three different sternal closure techniques in a 3D-printed bone model of a sternum from a 30-kg dog. METHODS: Median sternotomy was performed on a total of 90 three-dimensional (3D) copies of a polycarbonate (PC) model of a sternum, generated from the CT images of the sternum of a 30-kg German Shepherd dog. Three different methods were used to repair the sternotomies: polydioxanone suture (group PDS, n = 30), stainless steel bone staples (group SS, n = 30), and nitinol bone staples (group NS, n = 30). Each repair method was tested by applying tensile force in one of three ways (longitudinally, laterally, or torsionally) resulting in a sample size of n = 10 for each repair method-loading combination. In all experiments, the loads at 1-mm and 2-mm gap formation, failure, and the displacement at the failure point were measured. RESULTS: In lateral distraction and longitudinal shear tests, NS and SS staple repairs required application of significantly greater force than PDS across all displacement criteria (1 and 2 mm). NS exhibited significantly greater failure load than PDS. In torsion tests, NS required significantly greater application of force compared to SS or PDS at all displacement criteria (1 and 2 mm) and exhibited a greater failure load than PDS. In terms of displacement at failure point, PDS suture showed more displacement than SS or NS across all experiments (laterally, longitudinally, torsionally). CONCLUSIONS: In this study, bone staples were mechanically superior to PDS suture in median sternotomy closure using 3D-printed bone model in terms of 1-mm, 2-mm displacement loads, and displacement at failure. NS had a higher failure load than PDS under lateral, longitudinal, and torsional distraction. CLINICAL RELEVANCE: These study results imply that bone staples can be considered as an alternative surgical method for median sternotomy closure in dogs.

A sutureless overlapped anastomosis technique using linear staplers with reinforced bioabsorbable material in robotic right colectomy with intracorporeal anastomosis.

AIM: Creation of an overlapped anastomosis using handsewn sutures for common enterotomy is very popular in robotic right colectomy (RRC) with intracorpareal anastomosis (IA). The aim of this study is to present a simple method for constructing a sutureless overlapped anastomosis using a 60 mm linear stapler with a reinforced bioabsorbable material in RRC with IA. METHOD: The distal ileum and proximal colon were put in overlapping positions. Enterotomies were created 2 cm proximal to the ileal stump and 8 cm distal to the colonic stump on the antimesenteric side. Subsequently, a 60 mm linear stapler with a reinforced bioabsorbable material was inserted into each lumen and fired. Finally, the bowel was elevated while holding the bioabsorbable material, and the common enterotomy was grasped with the robotic instrument in the middle and closed using a linear stapler with a reinforced bioabsorbable material. RESULTS: This technique was applied to 10 patients with tumours of the caecum, ascending colon, or transverse colon. The median operating time, anastomosis construction time, blood loss, and postoperative stay were 281 min (range 228-459 min), 12 min (range 11-17 min), 10 mL (range 0-110 mL), and 10 days (range 8-15 days), respectively. No adverse intraoperative events were observed. Postoperatively, one patient developed chylous ascites, but there were no other complications. CONCLUSION: The simple technique for constructing a sutureless overlapped anastomosis using a 60 mm linear stapler with a reinforced bioabsorbable material in robotic right colectomy with intracorporeal anastomosis appears to be safe and feasible.

Intracorporeal antimesenteric ancillary trocar: an anastomotic technique facilitating natural orifice specimen extraction in left-sided colorectal surgery.

AIM: Natural orifice specimen extraction (NOSE) in left-sided colorectal surgery requires application of the circular stapler anvil to the proximal bowel without exteriorization through an additional abdominal incision. We describe an intracorporeal method to secure the stapler anvil, termed the intracorporeal antimesenteric ancillary trocar (IAAT) technique. METHOD: The ancillary trocar is attached to the stapler anvil before introduction into the abdominal cavity through the anal or vaginal orifice. The colon is incised before the trocar spike is brought out through the antimesenteric surface 3-4 cm within the cut edge. A linear stapler is used to seal the bowel end. The ancillary trocar is detached and retrieved via the NOSE conduit. Following the NOSE procedure, a side-to-end colorectal anastomosis is performed with the transanal circular stapler. RESULTS: Ten consecutive patients underwent elective left-sided colorectal resection with IAAT for NOSE (seven transanal, three transvaginal) from January to June 2023. Median age and body mass index were 66 (range 47-74) years and 24.3 (range 17.9-30.8) kg/m2 respectively. Two (20%) patients underwent sigmoid colectomy for sigmoid volvulus while eight (80%) underwent anterior resection for colorectal cancer. Median operating time, operative blood loss and postoperative length of hospital stay were 170 (range 140-240) min, 20 (range 10-40) mL and 1 (range 1-3) day respectively. There were no postoperative complications, readmissions or reoperations. Median follow-up duration was 3 (range 1-6) months. CONCLUSION: The IAAT double-stapling side-to-end anastomotic technique is safe and feasible for patients undergoing left-sided colorectal resection with NOSE, resulting in good outcomes.

Efficacy of the slow firing method using a reinforced triple-row stapler for preventing postoperative pancreatic fistula during laparoscopic distal pancreatectomy.

PURPOSE: Postoperative pancreatic fistula (POPF) remains the most clinically relevant complication of laparoscopic distal pancreatectomy (LDP). The present study evaluated the efficacy of the "slow firing method" using a reinforced triple-row stapler (Covidien, Tokyo, Japan) during LDP. METHODS: This retrospective single-center study included 73 consecutive patients who underwent LDP using the slow firing method. A black cartridge was used in all patients. The primary endpoint was the rate of clinically relevant POPF (CR-POPF) after LDP. Secondary endpoints included perioperative outcomes and factors associated with CR-POPF as well as the correlation between the transection time and thickness of the pancreas. RESULTS: Four patients (5.5%) developed CR-POPF (grade B). Overall morbidity rates, defined as grade ≥ II and ≥ III according to the Clavien-Dindo classification, were 21 and 11%, respectively. The median postoperative hospital stay was 10 days. Preoperative diabetes (13.6 vs. 0.2%, P = 0.044) and thickness of the pancreas ≥ 15 mm (13.8% vs. 0%, P = 0.006) were identified as independent risk factors for CR-POPF. The median transection time was 16 (8-29) min. CONCLUSION: The slow firing method using a reinforced triple-row stapler for pancreatic transection is simple, safe, and effective for preventing CR-POPF after LDP.

Anastomosis-Related Complications After Stapled Anastomosis With Reinforced Sutures in Transanal Total Mesorectal Excision for Low Rectal Cancer: A Retrospective Single-Center Study.

BACKGROUND: The International Transanal Total Mesorectal Excision Registry group showed that transanal total mesorectal excision included clinical issues regarding anastomosis-related complications. OBJECTIVE: This study evaluated anastomotic complications in patients whose anastomoses were created with the stapler plus reinforced sutures procedure after transanal total mesorectal excision for low rectal cancer. DESIGN: This was a retrospective single-center study. SETTING: The study was conducted at the National Cancer Center Hospital East, Japan. PATIENTS: Between June 2016 and December 2019, 150 patients underwent transanal total mesorectal excision for low rectal cancer. Stapled anastomosis was performed for 55 patients, and coloanal handsewn anastomosis was performed for 95 patients. Blood perfusion of the colon was routinely evaluated with intraoperative indocyanine green fluorescence angiography. All patients who underwent stapled anastomosis received additional handsewn sutures on all rounds of the stapled line. Patients who underwent intersphincteric resection were excluded. MAIN OUTCOME MEASURES: The anastomosis-related complications were compared between the groups. RESULTS: Early anastomotic leakage was found in one (1.8%) and eight (8.4%) patients in the stapled group and handsewn group. Overall anastomosis-related complications, pelvic abscess, and anastomotic stenosis were significantly less frequent in the stapled group (p < 0.001, p < 0.048, and p < 0.032). Incomplete donuts after the stapled anastomosis were observed in 9 patients (16.4%); however, we reinforced all around the stapled line in these patients, and this reduced the subsequent occurrence of anastomotic leakage. LIMITATIONS: First, this was a retrospective single-center study that was not randomized or controlled. Second, there were chronological differences regarding the anastomotic method between the two groups. Third, our study included a relatively small number of patients who received preoperative chemoradiotherapy. CONCLUSIONS: Stapled anastomosis with reinforced handsewn sutures resulted in fewer anastomosis-related complications than did coloanal handsewn anastomosis after transanal total mesorectal excision for low rectal cancer; thus, the former may be superior and should be the preferred method, when technically possible. See Video Abstract at http://links.lww.com/DCR/B749.COMPLICACIONES RELACIONADAS CON LAS ANASTOMOSIS ENGRAMPADAS Y REFORZADAS CON SUTURAS EN LA EXCISIÓN TOTAL DEL MESORRECTO POR VÍA TRANSANAL EN CASOS DE CÁNCER DE RECTO BAJO: ESTUDIO RETROSPECTIVO UNICÉNTRICO. ANTECEDENTES: El grupo del Registro Internacional de Excisión Total del Mesorrecto por vía Transanal mostró que la excisión total mesorrectal transanal incluía problemas clínicos relacionados a las complicaciones involucradas con la anastomosis. OBJETIVO: Se evaluaron las complicaciones anastomóticas en pacientes cuyas anastomosis se realizaron con engrampadora reforzada de suturas después de la excisión total de l mesorrecto por vía transanal en casos de cáncer de recto bajo. DISEO: Estudio retrospectivo unicéntrico. AJUSTE: El Hospital del Centro Nacional del Cáncer del Este, Japón. PACIENTES: Entre junio de 2016 y diciembre de 2019, 150 pacientes se sometieron a excisión total del mesorrecto por vía transanal en casos de cáncer de recto bajo. Se realizó anastomosis con engrampadora en 55 y anastomosis coloanal suturada a mano en 95 pacientes. La perfusión tisular sanguínea del colon operado se evaluó de forma rutinaria con angiografía de fluorescencia con verde de indocianina intraoperatoria. Todos los pacientes que se sometieron a anastomosis con grapas recibieron suturas realizadas a mano adicionales sobre la totalidad de la línea de grapas. Se excluyeron los pacientes sometidos a resección interesfintérica. PRINCIPALES MEDIDAS DE RESULTADO: Las complicaciones relacionadas con la anastomosis se compararon entre los grupos. RESULTADOS: Se encontró fuga anastomótica temprana en 1 (1.8%) y 8 (8.4%) pacientes en el grupo de engrampado y en el grupo suturado a mano, respectivamente. En general, las complicaciones relacionadas con la anastomosis, el absceso pélvico y la estenosis anastomótica fueron significativamente menos frecuentes en el grupo con grapas (p < 0.001, p < 0.048, p < 0.032, respectivamente). Se observaron donas incompletas después de la anastomosis grapada en 9 pacientes (16,4%); sin embargo, reforzamos todo alrededor de la línea de grapas en estos pacientes, y esto redujo la aparición posterior de fugas anastomóticas. LIMITACIONES: Inicialmente, este fue un estudio retrospectivo de un solo centro que no fue aleatorizado ni controlado. En segundo lugar, hubo diferencias cronológicas con respecto al método anastomótico entre los dos grupos. En tercer lugar, nuestro estudio incluyó un número relativamente pequeño de pacientes que recibieron quimiorradioterapia preoperatoria. CONCLUSIONES: La anastomosis engrapada reforzada con suturas realizadas a mano dio como resultado menos complicaciones relacionadas con la anastomosis que la anastomosis coloanal suturada a mano después de la excisión total del mesorrecto por vía transanal en casos de cáncer de recto bajo; por tanto, el primero puede ser superior y debería ser el método preferido, cuando sea técnicamente posible. Consulte Video Resumen en http://links.lww.com/DCR/B749. (Traducción-Dr. Xavier Delgadillo).

A Novel Predictive Model for Anastomotic Leakage in Colorectal Cancer Using Auto-artificial Intelligence.

AIM: Anastomotic leakage (AL) in left-sided colorectal cancer is a serious complication, with an incidence rate of 6-18%. We developed a novel predictive model for AL in colorectal surgery with double-stapling technique (DST) anastomosis using auto-artificial intelligence (AI). PATIENTS AND METHODS: A total of 256 patients who underwent curative surgery for left-sided colorectal cancer between 2017 and 2021 were included. In addition to conventional clinicopathological factors, we included the type of circular stapler using DST, conventional double-row circular stapler (DCS) or EEA™ circular stapler with Tri-Staple™ technology, 28 mm Medium/Thick (Covidien, New Haven, CT, USA) which had triple-row circular stapler (TCS) as a covariate. Auto-AI software Prediction One (Sony Network Communications Inc.) was used to predict AL with 5-fold cross validation. Predictive accuracy was assessed using the area under the receiver operating characteristic curve. Prediction One also evaluated the 'importance of variables' (IOV) using a method based on permutation feature importance. RESULTS: The area under the curve of the AI model was 0.766. The type of circular stapler used was the most influential factor contributing to AL (IOV=0.551). CONCLUSION: This auto-AI predictive model demonstrated an improvement in accuracy compared to the conventional model. It was suggested that use of a TCS may contribute to a reduction in the AL rate.

Robotic stapler use: Is it safe?-FDA database analysis across multiple surgical specialties.

INTRODUCTION: Robotic-assisted techniques are common across many surgical subspecialties. While robotic stapling offers increased surgeon control, there is limited information on surgical complications related to robotic stapler use. METHODS: We reviewed the FDA's MAUDE database for adverse events related to robotic stapler use. RESULTS: Upon review of the FDA database, the most frequently reported robotic stapler complications were malfunction, failure to form staple line, device fragmentation, and misfire. 31 Clavien-Dindo grade II or higher complications were attributed to stapler use since 2014. CONCLUSIONS: Further research on prevalence of robotic stapler use is needed to quantity the associated complication rate.

Reinforced versus standard stapler transection on postoperative pancreatic fistula in distal pancreatectomy: multicentre randomized clinical trial.

BACKGROUND: Postoperative pancreatic fistula is the leading cause of morbidity after distal pancreatectomy. Strategies investigated to reduce the incidence have been disappointing. Recent data showed a reduction in postoperative pancreatic fistula with the use of synthetic mesh reinforcement of the staple line. METHODS: An RCT was conducted between May 2014 and February 2016 at four tertiary referral centres in Sweden. Patients scheduled for distal pancreatectomy were eligible. Enrolled patients were randomized during surgery to stapler transection with biological reinforcement or standard stapler transection. Patients were blinded to the allocation. The primary endpoint was the development of any postoperative pancreatic fistula. Secondary endpoints included morbidity, mortality, and duration of hospital stay. RESULTS: Some 107 patients were randomized and 106 included in an intention-to-treat analysis (56 in reinforced stapling group, 50 in standard stapling group). No difference was demonstrated in terms of clinically relevant fistulas (grade B and C): 6 of 56 (11 per cent) with reinforced stapling versus 8 of 50 (16 per cent) with standard stapling (P = 0.332). There was no difference between groups in overall postoperative complications: 45 (80 per cent) and 39 (78 per cent) in reinforced and standard stapling groups respectively (P = 0.765). Duration of hospital stay was comparable: median 8 (range 2-35) and 9 (2-114) days respectively (P = 0.541). CONCLUSION: Biodegradable stapler reinforcement at the transection line of the pancreas did not reduce postoperative pancreatic fistula compared with regular stapler transection in distal pancreatectomy. Registration number: NCT02149446 (http://www.clinicaltrials.gov).

[Clinical efficacy of stent-assisted coil embolization for recurrent intracranial bifurcation aneurysms].

Objective: To evaluate the safety and efficacy of stent-assisted coil embolization in patients with recurrent intracranial bifurcation aneurysms,after initial simple coiling or microsurgical clipping. Methods: Clinical data of 20 patients with recurrent intracranial bifurcation aneurysms who initially underwent simple coiling or surgical clipping and subsequently re-treated by stent-assisted coiling embolization at the Radiology Intervention Department of Huashan Hospital between March 2009 and November 2019 were collected and analyzed retrospectively.There were 9 males and 11 females,with a median age of 55.5 years (range:33 to 71 years),including 17 aneurysms initially treated with simple coiling and 3 treated with surgical clipping.All cases were re-treated with stent-assisted coiling,15 using a single stent and 5 employing two stents in a Y-configuration.Peri-and post-operative complications and outcomes were evaluated.Mann-Whitney U tests were performed to compare the follow-up duration between initial treatment and re-treatment.Student's t tests were used to compare the parent artery angles before re-treatment, after re-treatment and at the last follow-up. The parent artery angle was defined using the proximal main trunk and the stented branch. Results: Immediate complete occlusion (Raymond Ⅰ) was achieved in 18 aneurysms (90.0%) while 2 aneurysms (10.0%) had a residual neck (Raymond Ⅱ).The median follow-up time(M(QR)) was 8.5(16.3)months,which had no significantly different from the initial treatment follow-up duration (15.5(27.0)months)(U=157.7,P=0.25). During the follow-up period,2 aneurysms (10.0%) with immediate post-operative residual necks recanalized again,including 1 aneurysm re-treated with the Y-configuration stent.Symptomatic thromboembolic complications occurred in 6 patients,including 4 re-treated with the Y-configuration stent.No peri-operative hemorrhagic complications occurred,along with no operation-related permanent disability or death. The parent artery angle increased significantly from pre-operative(90.1±21.1)°to post-operative and the last follow-up ((115.4±28.9)° and (132.6±26.8)°);t=5.14,P<0.01;t=7.78,P<0.01). Conclusion: For recurrent intracranial bifurcation aneurysms after initial surgical clipping or simple coiling,stent assisted coil embolization is proved to be safe and can decrease recurrence rate.

Stapled Hemorrhoidopexy: Technique and Long Term Results.

Background: Stapled hemorrhoidopexy (Longo operation) is a infrequent technique in our area. A different concept from hemorrhoidectomy, a proportionally important raise in cost and a special training may have contributed to it. We report our long-term results with the standard technique. Methods: The data of 35 patients with symptomatic second- and third-degree hemorrhoids who had stapled hemorrhoidopexy using a PPH03 stapler, from 01 January 2012 to 04 December 2020, were retrospectively collected. The sex ratio male: female was 3:4 and the mean age 45 (range 28-60) years. The follow-up consisted in a rectal exam and evaluated anatomical recurrence or prolapse. Results: The mean operative time was 42 (30-70) min. The mean parenteral analgesic doses during the first 24 h were 1,52. The mean postoperative hospital stay was 1.55 (1-2) days. A single patient needed reoperation for a staple line bleeding, two patients had a thrombosis of internal hemorrhoids and in one patient a small prolapse was diagnosed at 3 months follow-up. No hematoma, anastomotic stenosis, persistent anal pain, tenesmus, or impaired anal continence was recorded. One patient mentioned discomfort related to the presence of staples. Patients were followed-up for 6 (1-9) years. Global satisfaction rate was 94%. Conclusion: Stapled hemorrhoidopexy procedure is a safe and feasible procedure, which necessitates few analgesics and allows an early discharge. A rigorous selection of cases and a correct surgical technique allow to obtain good long-term results and offer a high level of patients satisfaction.

Is early anvil placement an alternative technique to reduce anastomotic leak after rectosigmoid cancer resection?

INTRODUCTION: Anastomotic leakage (AL) is one of the most disastrous complications after rectosigmoid cancer operations. The aim of this study is to investigate the effect of the insertion time of circular stapler anvil on assessing the blood supply of the proximal colon segment, and thus to evaluate the prevention of early anastomotic leaks. MATERIAL METHODS: A total of 57 patients were included in the study, 25 patients in group A and 32 patients in group B, respectively. From the beginning of the operation to the time of anvil placement in group A, it was 32.08 (± 7.34) minutes, and in group B it was 92.19 (± 16.63) minutes. None of the patients in group A had AL, and 4 patients in group B had AL. DISCUSSION: Our study shows that the anvil must be placed at the beginning of the dissection to evaluate the anomalies that cause anastomotic leaks. We think that this method increases the reliability of the anastomosis line. Thus, the hospitalization period of the patients was shortened and they returned to their active lives faster. In addition, patients used less antibiotics and they needed less medical treatment. KEY WORDS: Anastomotic leaks, Anvil, Rectosigmoid cancer placement, Stapler colorectal.

Preventive procedure for stenosis after esophagojejunostomy using a circular stapler and transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy and total gastrectomy involving reduction of anastomotic tension.

BACKGROUND: Recently, due to increasing reports of stenosis after esophagojejunostomy created using circular staplers and a transorally inserted anvil (OrVil™) following laparoscopic proximal gastrectomy (LPG) and total gastrectomy (LTG), linear staplers are being used instead. We investigated our preventive procedure for esophagojejunostomy stenosis following use of circular staplers. METHODS: Since the anastomotic stenosis is considered to be mainly caused by tension in the esophageal and jejunal stumps at the anastomotic site, we have been performing procedures to relieve this tension, by cutting off the rubber band and pushing the shaft of the circular stapler toward the esophageal side, since July 2015. We retrospectively compared the incidence of anastomotic stenosis in cases of LPG and LTG performed before July 2015 (early phase, 30 cases) versus those performed after this period (later phase, 22 cases). RESULTS: Comparison of the incidence of anastomotic stenosis according to the type of surgery, LPG or LTG, and between the two time periods versus all cases, indicated a significantly lower incidence in the later phase than in the early phase (4.5 vs. 26.7%, p < 0.05), especially for LPG (0 vs. 38.5%, p < 0.05). CONCLUSIONS: It is possible to use a circular stapler during laparoscopic esophagojejunostomy, as with open surgery, if steps to reduce tension on the anastomotic site are undertaken. These procedures will contribute to the spread of safe and simple laparoscopic anastomotic techniques.

Evaluation of staple line reinforcement after partial gastrectomy closure in an ex vivo canine model.

OBJECTIVE: To determine the influence of stapling on leakage pressures after canine partial gastrectomy. STUDY DESIGN: Ex vivo study. SAMPLE POPULATION: Gastric specimens from 24 adult canine cadavers. METHODS: Partial gastrectomy constructs were assigned to one of three closure techniques (n = 8 per group): group 1, stapled closure with a 90-mm thoracoabdominal stapling device and a 4.8-mm staple cartridge; group 2, hand-sewn double-layer inverting suture closure with 3-0 glycomer 631; and group 3, staple line reinforcement with an inverting Cushing suture pattern. Leakage and pressure testing were performed. Initial leakage pressure (ILP), maximal leakage pressure (MLP), and leakage location were recorded. Significance was set at P < .05. RESULTS: Placement of a Cushing suture (group 3) increased ILP and MLP by 3.2-fold and 2.8-fold, respectively, compared with stapled closures alone (P < .001). Constructs closed with double-layer suture closure reached ILP and MLP 4.5-fold and threefold greater, respectively, compared with those with stapled closures alone (P < .001). Maximal leakage pressure did not differ between groups 2 and 3 (P = .14). Leakage occurred from the inverting suture line in all constructs of groups 2 and 3 and from staple holes in six of eight group 1 constructs. CONCLUSION: Double-layer suture closure of canine partial gastrectomies achieved superior biomechanical properties compared with stapled closure techniques. Reinforcing staple closures with an inverting suture line improved resistance to leakage. CLINICAL SIGNIFICANCE: Reinforcing single-layer closure of partial gastrectomies with an inverting Cushing pattern is recommended to improve resistance to leakage. In vivo investigation is warranted to evaluate influence of closure technique on gastric healing, postoperative stasis, ischemic injury, and postoperative dehiscence.

Single-Port vs Conventional Three-Port Video-Assisted Thoracoscopic Pulmonary Wedge Resection: Comparison of Postoperative Pain and Surgical Costs.

PURPOSE: Single-port video-assisted thoracoscopic (VATS) pulmonary wedge resection was reported in 2004. We started using single-port VATS (SPVATS) pulmonary wedge resection in 2017 and compared results between conventional three-port VATS (VATS group) and SPVATS (SPVATS group). METHODS: We identified 145 consecutive patients with VATS group and SPVATS group. Perioperative characteristics including pain and the number of stapler cartridges used were examined as the surgical outcomes, retrospectively. RESULTS: In all, 66 cases of SPVATS group and 79 cases of VATS group pulmonary wedge resection were compared. The rate of epidural anesthesia (p <0.0001) was significantly higher and operative time (p <0.0001) was significantly longer with VATS group than with SPVATS group. The number of stapler cartridges used, duration of drain insertion, and rate of postoperative complications did not differ significantly between groups. Average numerical rating scale (NRS) score on postoperative day 1 and postoperative day 7 (p <0.0001 each), maximum NRS score on postoperative day 7 (p = 0.0082) and amount of 25 mg tramadol (p = 0.0062) were significantly lower in SPVAS group than in VATS group. CONCLUSION: Our results suggest that SPVATS pulmonary wedge resection offers better pain control and cost-effectiveness than three-port VATS pulmonary wedge resection. These findings should contribute to the body of evidence for SPVATS.

Comparison of greater curvature and lesser curvature circular-stapled esophagogastrostomy after esophagectomy in patients with esophageal cancer: a prospective randomized controlled trial.

PURPOSE: Using a circular stapler to create an anastomosis for esophagogastrostomy after esophagectomy is well accepted; however, it remains uncertain if the greater curvature (GC) or lesser curvature (LC) of the gastric conduit is better for the anastomosis. We conducted this prospective study to compare the integrity of esophagogastrostomy between the esophagus and the GC or LC side of the gastric conduit. METHODS: The subjects of this study were 70 patients who underwent esophagectomy and were randomized to a "GC" group and an "LC" group (n = 35 each). The primary and secondary end points were anastomotic leakage (AL) and anastomotic stricture (AS), respectively. RESULTS: The overall AL rate was 22.1%, without a significant difference between the groups. Stump leakage developed in eight of nine patients in the GC group, whereas leakage developed at the esophagogastric anastomosis in five of six patients in the LC group. The rate of stump leakage was significantly higher than that of esophagogastric AL in the GC group. The overall AS rate was 4.4%, with a significant difference between the groups (0% in the GC group vs. 9.1% in the LC group). CONCLUSIONS: AL rates were comparable in the two groups, but the sites of leakage were significantly different.