Compression pre-stapler firing and post-ignition wait during sleeve gastrectomy: a prospective randomized trial

ABSTRACT BACKGROUND: Insufficient research exists on the stapling technique in and duration of laparoscopic sleeve gastrectomy (LSG). OBJECTIVES: This study aimed to assess the clinical outcomes using a 30-second precompression and post-firing waiting time without extra support for the stapling line. DESIGN AND SETTINGS: Randomized controlled prospective study at a university hospital. METHODS: This study included 120 patients treated between January 2022 and February 2023. The patients were divided into the non-waiting group (T0) and waiting group (T1), each with 60 patients. Perioperative complications were analyzed using statistical tests. RESULTS: The waiting group (T1) showed a significant reduction in the number of intraoperative bleeding points requiring intervention compared with the non-waiting group (T0) (81 versus 134, P < 0.05). In T0, postoperative C-reactive protein (CRP) levels increased (P < 0.05) and hemoglobin levels decreased significantly (P <0.05). The study recorded 22 postoperative complications, accounting for 18.3% of all cases during the 30-day postoperative period. CONCLUSIONS: The study concluded that the 30 sec + 30 sec stapling technique reduces perioperative bleeding, length of stay, and serious complication rates and is practical and effective for LSG. CLINICAL TRIAL REGISTRATION: ClinicalTrials.gov with registration code NCT05703035; link: https://clinicaltrials.gov/ct2/show/NCT05703035.

Mechanobiological considerations in colorectal stapling: Implications for technology development.

Technological advancements in minimally invasive surgery have led to significant improvements in patient outcomes. One such technology is surgical stapling, which has evolved into a key component of many operating rooms by facilitating ease and efficacy in resection and repair of diseased or otherwise compromised tissue. Despite such advancements, adverse post-operative outcomes such as anastomotic leak remain a persistent problem in surgical stapling and its correlates (i.e., hand-sewing), most notably in low colorectal or coloanal procedures. Many factors may drive anastomotic leaks, including tissue perfusion, microbiome composition, and patient factors such as pre-existing disease. Surgical intervention induces complex acute and chronic changes to the mechanical environment of the tissue; however, roles of mechanical forces in post-operative healing remain poorly characterized. It is well known that cells sense and respond to their local mechanical environment and that dysfunction of this "mechanosensing" phenomenon contributes to a myriad of diseases. Mechanosensing has been investigated in wound healing contexts such as dermal incisional and excisional wounds and development of pressure ulcers; however, reports investigating roles of mechanical forces in adverse post-operative gastrointestinal wound healing are lacking. To understand this relationship well, it is critical to understand: 1) the intraoperative material responses of tissue to surgical intervention, and 2) the post-operative mechanobiological response of the tissue to surgically imposed forces. In this review, we summarize the state of the field in each of these contexts while highlighting areas of opportunity for discovery and innovation which can positively impact patient outcomes in minimally invasive surgery.

Correct Stapling Technique in Laparoscopic Sleeve Gastrectomy: Are We Increasing the Bleeding? A Prospective Cohort Study.

Introduction: Laparoscopic sleeve gastrectomy (LSG) has become the most common bariatric surgery procedure. Bleeding is the most common complication of this surgery and mostly occurs from the staple line. The aim of this study was to evaluate whether waiting between compression and firing during the stapling phase reduces the postoperative bleeding. Methods: A total of 325 patients who underwent LSG between April and July 2022 were analyzed prospectively. In terms of postoperative bleeding, the two groups, which we waited 30 seconds between staple firings and the no wait group, were compared. Results: The mean age of patients was 37.36 (±11.12) years and mean body mass index was 45.18 (±3.1) kg/m2. Eleven patients needed transfusion. The rate of haemorrhagic complications was 3.38% (Group 1% 6.21 and Group 2% 1.11) (P = .012). The duration of surgery was ∼10 minutes longer in the study group, which we waited (P = .0001). Conclusions: During the stapling stage in LSG, waiting between compression and firing can help reduce postoperative bleeding.

A comparison of extracorporeal side to side or end to side anastomosis following a laparoscopic right hemicolectomy for colon cancer.

BACKGROUND: This study aimed to investigate whether an extracorporeal side-to-side (SS) or end-to-side (ES) stapled anastomosis impacts short-term and long-term outcomes after an oncological laparoscopic right hemicolectomy. METHODS: A retrospective cohort study of prospectively collected data from two Victorian tertiary referral hospitals was performed. Patients who underwent oncological resection for colorectal cancer between February 2010 and September 2020 were selected from the colorectal neoplasia database. Patients were divided into two groups depending on the type of stapled anastomosis: Group 1 (functional end-to-end/side-to-side (SS)); and Group 2 (end-to-side (ES)). Primary outcomes were anastomotic leak, postoperative ileus, mortality and morbidity, length of stay post-surgery, readmission to hospital, and 30-day mortality. RESULTS: This large case series of 1040 patients (SS = 625, ES = 415) demonstrated that the type of stapling technique impacted operative duration and postoperative ileus rates. Patients in the SS group had a faster operation of 108 min rather than 130 min in the ES group (p < 0.001). The SS group were more likely to experience a post-operative ileus (p < 0.001) with no impact on length of stay (SS, 7 days versus ES, 7 days; p = 0.14). There were no differences between the two groups with respect to lymph node yield, lymph node ratio, anastomotic leaks, return to theatre, 30-day mortality and 5-year overall survival. DISCUSSION: The type of extracorporeal stapled anastomosis following an oncological laparoscopic right hemicolectomy has minimal impact on morbidity and survival outcomes; however, a side-to-side stapled anastomosis is more likely to be a faster operation with a higher postoperative ileus rate.

Current Concepts in Small Animal Gastrointestinal Surgery.

Both handsewn and stapled anastomosis techniques are performed commonly in veterinary medicine. This article discusses variations and comparisons of these techniques with different suture patterns, suture materials, types of stapling equipment, and staple sizes along with benefits of surgical reinforcement techniques and leak testing. In addition, a minimally invasive surgical approach for gastrointestinal surgery is discussed briefly. This article also briefly highlights current research under way in determining more accurate means of assessing intestinal tissue viability, because determining when and where to resect compromised, and potentially devitalized, intestine is of utmost importance for patient outcomes.

Rectal perforation and perirectal abscess following stapled hemorrhoidectomy for prolapsed hemorrhoids successfully managed with Endo-SPONGE endoluminal vacuum-assisted wound closure system.

Active drains, which work by negative pressure, are commonly used to drain closed airtight wounds. Higher negative pressure is used in vacuum-assisted wound closure dressings. Gastrointestinal leaks may be difficult to treat by surgical approach because of their association with high morbidity and mortality. Recently, endoscopic approaches have been applied with several degrees of success. Most recently, endoluminal vacuum-assisted wound closure (EVAC) has been employed with high success rates in decreasing both morbidity and mortality. In the present paper, the authors describe the successful use of Endo-SPONGE (B. Braun Medical B.V.) EVAC system therapy to drain an open rectal wound, following a perforation occurred during stapled hemorrhoidectomy.

Impact of the calibration bougie diametre during laparoscopic sleeve gastrectomy on the rate of postoperative staple-line leak (BOUST): study protocol for a multicentre randomized prospective trial.

BACKGROUND: Laparoscopic sleeve gastrectomy (LSG) has become an increasing bariatric procedure. The basic principle is to create a narrow stomach along the lesser curvature, using a calibration bougie as a template to perform a vertical partial gastrectomy, resecting the greater curvature and fundus of the stomach. The most common postoperative complication is gastric leak from the staple line, observed in approximately 3% of cases, which can result in long and incapacitating treatment. The diametre of the bougie used to calibrate the remnant stomach could impact the rate of postoperative gastric leak, a higher diametre being correlated with a lower risk of leak, without lowering long-term weight loss. This is the first randomized trial to compare the outcomes of LSG regarding the use of two different bougie diametres on postoperative gastric leak and mid-term weight loss. METHODS: Bougie Sleeve Trial (BOUST) is a superiority single-blinded randomized national trial, involving 17 centres. Participants will be randomized into two groups. LSG will be performed using a 48-Fr diametre calibration bougie in the experimental group and a standard care (34 to 38-Fr diametre) calibration bougie in the control group. Both groups will take part in a 2-year postoperative follow-up to assess postoperative gastric leak rate and weight loss and quality of life evolution. DISCUSSION: This study protocol will allow the investigators to determine if the use of a larger calibration bougie during LSG is associated with lower postoperative gastric leak occurrence without impairing mid-term weight loss and quality of life. The results of this trial will provide important data on patient safety and promote best practice for LSG procedures. TRIAL REGISTRATION: ClinicalTrials.gov NCT02937649 . Registered on 18 October 2016.

Endoscopic Management of Staple Line Leak after Bariatric Surgery: Surgeon's Perspective.

Laparoscopic sleeve gastrectomy (LSG) has become a standalone primary procedure as a bariatric metabolic surgery since the early 2000s. The overall complication rate of LSG is reported to range from 2% to 15%. Staple line leakage (SLL) remains a major adverse event and occurs in approximately 1-6% of patients. Choosing the optimal treatment modality is a complex process. Clinicians must understand that nutritional support and drainage of fluid collection are essential for initial management. Conservative endoscopic management and sufficient drainage can resolve approximately 70% of SLLs. Endoscopic management of bariatric complications has been rapidly evolving in recent years and can be considered in all patients who are hemodynamically stable. We will review the available endoscopic management techniques, including stent placement (self-expanding stents and bariatric-specific stents), clipping, tissue sealant application, and internal drainage (double-pigtail stents [DPS] placement, endoscopic vacuum therapy, and septotomy). Stent placement remains the mainstream treatment for SLLs. However, healing with stents requires multiple sessions/stents and a long course of recovery. Endoscopic internal drainage is gaining popularity and has the potential to be a superior method. The importance of early intervention and combined endoscopic methods should be recognized.

Perineal stapled prolapse resection for external rectal prolapse: a systematic review and meta-analysis.

AIM: Rectal prolapse is an uncommon but debilitating pelvic floor disorder that significantly decreases the quality of life of affected patients. Perineal stapled prolapse resection is a relatively new perineal approach that offers an promising alternative technique in the surgical management of rectal prolapse. It appears to be a simple, reproducible and efficient method. However, long-term outcomes are limited. The aims of this review are to assess the safety and effectiveness of perineal stapled prolapse resection in the management of rectal prolapse. METHOD: A systematic review of all articles describing this approach was searched using MEDLINE, Embase, PubMed, Cochrane, Scopus, Web of Science and China National Knowledge Infrastructure. Included in this review were all randomized and nonrandomized prospective and retrospective studies reporting patients (aged 16 years and older) with complete rectal prolapse who underwent perineal stapled prolapse resection for the surgical treatment of the rectal prolapse. RESULTS: A total of 408 patients across 20 articles were included. There were 58 cases of recurrence out of 368 patients over a median length of follow-up of 18 months (interquartile range 12-34 months). The total weighted overall recurrence was 12%. There were 51 cases of postoperative complications in 350 cases, bleeding being the most common complication. CONCLUSION: The recurrence rate is comparable to those of the well-established Altemeier and Delorme procedures. However, given the heterogeneity of studies and variations in lengths of follow-up, further randomized prospective studies are needed to adequately compare this technique against other procedures for complete rectal prolapse.

Surgical skin adhesive bond is safe and feasible wound closure method to reduce surgical site infection following minimally invasive colorectal cancer surgery.

PURPOSE: Minimally invasive colorectal surgery had reduced the rate of surgical site infection. The use of surgical skin adhesive bond (2-octyl cyanoacrylate) for wound closure reduces postoperative pain and provides better cosmetic effect compared to conventional sutures or staples. But role of surgical skin adhesive bond for reducing surgical site infection is unclear. Our objective in this study was to evaluate the role of surgical skin adhesive bond in reducing surgical site infection following minimally invasive colorectal surgery. METHODS: We performed a retrospective analysis of 492 patients treated using minimally invasive surgery for colorectal cancer at Seoul St. Mary's Hospital, the Catholic University of Korea. Of these, surgical skin adhesive bond was used for wound closure in 284 cases and skin stapling in 208. The rate of surgical site infection including deep or organ/space level infections was compared between the 2 groups. RESULTS: The rate of superficial surgical site infection was significantly lower in the group using skin adhesive (P = 0.024), and total costs for wound care were significantly lower in the skin adhesive group (P < 0.001). CONCLUSION: This study showed that surgical skin adhesive bond reduced surgical site infection and total cost for wound care following minimally invasive colorectal cancer surgery compared to conventional skin stapler technique. Surgical skin adhesive bond is a safe and feasible alternative surgical wound closure technique following minimally invasive colorectal cancer surgery.

Pharyngeal closure after a total laryngectomy: mechanical versus manual technique.

OBJECTIVE: To verify the main advantages and drawbacks of mechanical suturing for pharyngeal closure after total laryngectomy versus a manual suturing technique. METHODS: A retrospective review was carried out of 126 total laryngectomies performed between 2008 and 2018. Manual closure was performed in 80 cases (63.5 per cent) and mechanical suturing was performed in 46 cases (36.5 per cent). RESULTS: Mechanical suturing was used significantly more frequently in patients with: glottic tumours (p = 0.008), less local tumour extension (p = 0.017) and less pre-operative morbidity (p = 0.014). There were no significant differences in the incidence of pharyngocutaneous fistula between the manual suture group (16.3 per cent) and the mechanical suture group (13.0 per cent) (p = 0.628). None of the patients treated with mechanical suturing had positive surgical margins. Cancer-specific survival for the mechanical suture group was higher than that for the manual suture group (p = 0.009). CONCLUSION: Mechanical suturing of the pharynx after total laryngectomy is an oncologically safe technique if used in suitable cases.

Mark M. Ravitch MD: Surgeon, author, teacher, soldier.

Mark M. Ravitch (1910-1989) was the most prolific surgeon-author of the 20th Century as well as an outstanding clinical surgeon, scholar, historian, and researcher. While today he would not be considered a "pure pediatric surgeon," he was a charter member of the American Pediatric Surgical Association and received the William E. Ladd medal from the Surgical Section of the American Academy of Pediatrics and the Denis Brown Medal from the British Association of Pediatric Surgeons. He contributed to the treatment of benign colon and rectal disease, intussusception, and chest wall deformities. His most enduring contribution was surgical stapling, a technology that he brought from Russia during the Cold War that opened the door to minimally invasive surgery.

Initial clinical experience with a powered circular stapler for colorectal anastomosis.

BACKGROUND: The Echelon circular™ powered stapler (ECP stapler) obviates the need for manual firing of conventional circular staplers during the construction of a colorectal anastomosis, but has not been evaluated clinically. The aim of this study was to perform a clinical evaluation of this stapler. METHODS: A retrospective review of the initial clinical experience of a single surgeon using the ECP stapler for left-sided colorectal anastomosis construction during elective colorectal resections for benign and malignant disease was conducted by analyzing results from a prospectively maintained study database. Additionally, four attending colorectal and/or general surgeons who had performed ≥ 5 colorectal operations with the ECP stapler were invited to complete an anonymous online survey to subjectively assess the user experience with the device. Statistical analysis was conducted using Microsoft Excel Version 15.33. RESULTS: Seventeen patients underwent left-sided anastomotic reconstruction using the ECP stapler. All donuts (proximal and distal) were intact. Anastomotic integrity was evaluated using the air-leak test utilizing flexible video sigmoidoscopy. No leaks were observed, although one patient (5.9%) developed a postoperative pelvic abscess. The anonymous survey was completed by all four surgeons. Subjective evaluation of the ECP stapler suggests that the overall stapling quality, overall device ease-of-use, and the overall perception of anastomotic quality as above average when compared to manual 'end-to-end anastomosis' (EEA) stapling devices. CONCLUSIONS: In an initial clinical evaluation of the ECP stapler, the safety and ease-of-use of the device appears to be satisfactory. Powered stapling and the design of '3D stapling' may provide advantages over manual systems, and may improve the construction quality of left-sided colorectal anastomosis.

EndoAnchors Minimize Endoleaks in Chimney-Graft Endovascular Repair of Juxtarenal Abdominal Aortic Aneurysms.

Juxtarenal abdominal aortic aneurysms (AAAs) are difficult to treat because they often have little or no proximal aortic neck. Patients with this complex anatomy are not usually candidates for an endovascular aneurysm repair (EVAR). Chimney-graft EVAR has been introduced, but type Ia endoleak is a typical risk. We have begun using EndoAnchors to determine whether this risk can be reduced. From July 2013 through July 2014, we used the chimney-graft EVAR technique in 5 patients whose juxtarenal AAAs had a short or no proximal aortic neck. During the procedure, we implanted EndoAnchors as needed. Postprocedurally, at 30 days, and through end of follow-up (duration, 11-18 mo), all patients had patent endografts without type Ia endoleak (our primary endpoint), visceral stent-graft thrombosis, or renal complications. One patient who received 4 chimney grafts had a postprocedural type II endoleak, which was treated with embolization. We found it feasible to use EndoAnchors with the chimney-graft technique to prevent type Ia endoleaks in the treatment of juxtarenal AAAs. Further studies are needed to validate this adjunctive technique and to determine its durability.

Systematic review of operative outcomes of robotic surgical procedures performed with endoscopic linear staplers or robotic staplers.

A comprehensive review of operative outcomes of robotic surgical procedures performed with the da Vinci robotic system using either endoscopic linear staplers (ELS) or robotic staplers is not available in the published literature. We conducted a literature search to identify publications of robotic surgical procedures in all specialties performed with either ELS or robotic staplers. Twenty-nine manuscripts and six abstracts with relevant information on operative outcomes published from January 2011 to September 2017 were identified. Given the relatively recent market release of robotic staplers in 2014, comparative perioperative clinical outcomes data on the performance of ELS vs. robotic staplers in robotic surgery is very sparse in the published literature. Only three comparative studies of surgeries with the da Vinci robotic system plus ELS vs. da Vinci plus robotic staplers were identified; two in robotic colorectal surgery and the other in robotic gastric bypass surgery. These comparative studies illustrate some nuances in device design and usability, which may impact outcomes and cost, and therefore may be important to consider when selecting the appropriate stapling technologies/technique for different robotic surgeries. Comparative perioperative data on the use of ELS vs. robotic staplers in robotic surgery is scarce (three studies), and current literature identifies both types of devices as safe and effective. Given the longer clinical history of ELS and its relatively more robust evidence base, there may be trade-offs to consider before switching to robotic staplers in certain robotic procedures. However, this literature review may serve as an initial reference for future research.

Pelvic floor function following ventral rectopexy versus STARR in the treatment of obstructed defecation.

BACKGROUND: Obstructed defecation syndrome (ODS), most commonly found in females, can be treated by a transanal or abdominal approach with good success rate. Nevertheless, patients may experience de novo or persisting pelvic floor dysfunctions after surgery. The aim of this study was to compare the functional outcome of stapled transanal rectal resection (STARR) and ventral rectopexy (VRP) in a series of ODS patients. METHODS: Forty-nine female patients who had surgery for ODS between 2006 and 2016 were retrospectively evaluated: 28 (median age 60 years, IQR 54-69 years) had VRP and 21 (median age 58 years, IQR 51-66 years) had STARR. ODS was scored with the ODS score while the overall pelvic floor function was assessed with the three axial perineal evaluation (TAPE) score. Quality-of-life was evaluated by the patient assessment of constipation quality-of-life (PAC-Qol) questionnaire administered preoperatively and after 1 year of follow-up. RESULTS: The preoperative median ODS score and TAPE score were comparable in both groups. After a median follow-up of 12 months (range 12-18 months), the median ODS score was 12 (range 10-20) in the STARR group and 9 (range 3-15) in the VRP one (p = 0.02), while the median TAPE score was 70.5 (IQR 60.6-77.3) in the former and 76.8 (IQR 70.2-89.7) in the latter (p = 0.01). Postoperatively the physical domain of the PAC-QoL score had a median value of 2.74 (IQR 1.7-3.75) in the STARR group compared to 1.5 (IQR 1-2.5) in the VRP group (p = 0.03). No major complications were recorded in either group. CONCLUSIONS: VRP and STARR can improve defecation in patients with ODS with minimal complications, but the overall pelvic wellness evaluated by the TAPE score improves significantly only after VRP, suggesting a better performance of VRP than STARR when overall pelvic floor function is concerned.

Treatment of obstructed defecation syndrome due to rectocele and rectal intussusception with a high volume stapler (TST STARR-plus).

BACKGROUND: In recent years, stapled transanal resection (STARR) has been adopted worldwide with convincing short-term results. However, due to the high recurrence rate and some major complications after STARR, there is still controversy about when the procedure is indicated. The aim of this study was to assess the safety, efficacy and feasibility of STARR performed with a new dedicated device for tailored transanal stapled surgery. METHODS: All the consecutive patients affected by obstructed defecation syndrome (ODS) due to rectocele or/and rectal intussusception, who underwent STARR with the TST STARR-Plus stapler, were included in a prospective study. Pain, Cleveland Clinic Score for Constipation (CCCS) and incontinence, patient satisfaction, number of hemostatic stitches, operative time, hospital stay and perioperative complications were recorded. Postoperative complications and recurrence were also reported. RESULTS: Forty-five consecutive patients (median age 50; range 24-79) were included in the study. Median resected volume was 15 cm3 (range 12-19 cm3) with a median height of surgical specimen of 5.6 cm (range 4.5-10 cm). The mean CCCS decreased from 17.26 (± 3.77) to 5.42 (± 2.78) postoperatively (p < 0.001). Patient satisfaction grade was excellent in 14 patients (31.1%), good in 25 (55.5%), sufficient in three (6.7%) and poor in three patients (6.7%). No major complications occurred. Five patients (11%) reported urgency after 30 days and two patients (4%) after 12 months. The Cleveland Clinic Incontinence score did not significantly change. At a median follow-up of 23 months (range 12-30 months), only three patients (6.7%) reported recurrent symptoms of obstructed defecation comparable to those reported at baseline. CONCLUSIONS: TST STARR-Plus seems to be safe and effective for the treatment of ODS due to rectocele and rectal intussusception, and technical improvement could reduce the risk of some complications. However, careful patient selection is still the best means of preventing complications.

Cost and efficacy examination of alvimopan for the prevention of postoperative ileus.

Opioid analgesics exacerbate ileus through peripheral µ-opioid receptor action. Alvimopan, a µ-opioid receptor antagonist, has been proposed to alleviate postoperative ileus, leading to decreased time to return of gastrointestinal function and hospital discharge. As opioid-induced motility issues are only one factor affecting postoperative ileus, continued examination of the cost of the use and efficacy of the drug is needed. Data for this study were collected retrospectively from the charts of 55 patients who received an anastomosis and were given alvimopan at Morristown Medical Center between 2010 and 2013 as well as from 58 appropriately matched controls. The billing record and chart for each patient was examined, and information on total hospital charges, age, sex, body mas index, primary diagnosis, procedure type, length of stay (days), time to return of bowel function (hours), and outcomes were recorded for analysis. No difference between patients given alvimopan and controls was observed for the length of hospital stay (4.6 vs 4.8 days) or for time to return of bowel function (68.5 vs 67.3 hours). Total hospital charges were higher for treated patients (p=0.0080), averaging $48 705.15 and $41 068.80, respectively. Alvimopan was not associated with improved clinical outcome but was associated with an increase in hospital charges within this population.

Hemorroidopexia por grampeamento parcial: aspectos clínicos e impacto sob a fisiologia anorretal / Partial stapled hemorrhoidopexy: clinical aspects and impact on anorectal physiology

RESUMO Objetivo: avaliar o impacto na fisiologia anorretal da hemorroidopexia por grampeamento parcial, das complicações relacionadas à técnica cirúrgica, dor e sangramento pós-operatório e recidiva de doença hemorroidária após um ano de cirurgia. Métodos: estudo prospectivo, descritivo, em pacientes consecutivos, portadores de doença hemorroidária do tipo mista ou interna, com componente interno classificado como grau III ou IV, submetidos à hemorroidopexia por grampeamento parcial. Resultados: foram estudados 17 pacientes, dos quais 82% apresentavam hemorroidas internas grau III, e 18% grau IV. A média de tempo operatório foi de 09:09 minutos (07:03 a 12:13 minutos). A mediana de dor no pós-operatório imediato avaliada pela escala numérica de dor foi de 1 (0 a 7). A mediana de retorno ao trabalho foi de nove dias (4 a 19). Nenhum paciente apresentou estenose de canal anal e 76% ficaram satisfeitos com a cirurgia com 90 dias de pós-operatório. Comparando-se os dados manométricos pré-operatórios e após 90 dias, nenhuma das variáveis avaliadas apresentou diferença com significância estatística. Não houve recidiva da doença hemorroidária com um ano de acompanhamento pós-operatório. Conclusão: a hemorroidopexia por grampeamento parcial não demonstrou impacto na fisiologia anorretal, apresentando baixos níveis de complicações e de dor pós-operatória, e sem recidivas após um ano de acompanhamento.

ABSTRACT Objective: to evaluate the impact of partial stapled hemorrhoidopexy on anorectal physiology, the complications related to this surgical technique, pain, postoperative bleeding and recurrence of hemorrhoidal disease one year after surgery. Methods: this is a prospective, descriptive study in consecutive patients with mixed or internal hemorrhoidal disease, the internal component being classified as grade III or IV, undergoing partial stapled hemorrhoidopexy. Results: we studied 17 patients, 82% of them with internal hemorrhoids grade III and 18% grade IV. The mean operative time was 09:09 minutes (07:03 to 12:13). The median pain in the immediate postoperative period evaluated by the numerical pain scale was one (0 to 7). The median time to return to work was nine days (4 to 19). No patient had anal stenosis and 76% were satisfied with the surgery 90 days postoperatively. When comparing the preoperative manometry data with that measured 90 days after surgery, none of the variables studied showed statistically significant difference. There was no recurrence of hemorrhoidal disease with one year of postoperative follow-up. Conclusion: partial stapled hemorrhoidopexy showed no impact on anorectal physiology, presenting low levels of complications and postoperative pain, without recurrence of hemorrhoidal disease in one year of follow-up.

Comparison of Harmonic scalpel and Ligasure devices in laparoscopic Roux-en-Y gastric bypass.

INTRODUCTION: Laparoscopic Roux-en-Y gastric bypass (LRYGB) is one of the most preferred bariatric procedures in the world for surgical treatment of morbid obesity. The Harmonic scalpel (HS) and LigaSure (LS) are the most commonly used devices in laparoscopic surgery. As far as we know, there is no comparative study of the two energy devices in LRYGB for morbid obesity. AIM: To compare the intraoperative performances of the two energy devices in LRYGB for morbid obesity. MATERIAL AND METHODS: The HS and LS were used in 43 and 42 cases, respectively. The patient demographics of both groups were comparable. The duration of the procedures (gastric pouch creation time and total operation time), quantity of bleeding (during gastric pouch creation and total quantities of bleeding) and the number of pneumoperitoneum desufflations due to smoking that impaired sight fields were recorded prospectively. RESULTS: Gastric pouch creation time (HS: 22.5 ±9.5 vs. LS: 19.5 ±9.7 min, p = 0.15), bleeding during gastric pouch preparation (HS: 15.3 ±30.5 vs. LS: 17.5 ±31.3 ml, p = 0.74), total operation time (HS: 183.2 ±47 vs. LS: 165.3 ±37.1 min, p = 0.06) and total bleeding (HS: 110 ±195.5 vs. LS: 102.5 ±70 ml, p = 0.81) were similar in the two groups. Only the mean number of pneumoperitoneum desufflations due to smoking was lower in the HS group (HS: 0.28 ±0.49 vs. LS: 0.57 ±0.78, p = 0.04). CONCLUSIONS: The HS and LS performed similarly in LRYGB, with fewer desufflations from smoking in the HS group.