Sutureless small bowel anastomoses: experimental study in pigs.

OBJECTIVE: To evaluate a new technique for experimental anastomosis with fibrin glue, and to compare the results with those of stapled and one-layer sutured anastomosis. DESIGN: Open laboratory study. SETTING: Teaching hospital, Sweden. ANIMALS: Ten Swedish domestic pigs. INTERVENTIONS: Each pig had three anastomoses made in the small bowel, one by each technique. The pigs were killed on the 4th postoperative day. MAIN OUTCOME MEASURES: Blood flow, collagen concentration, anastomotic index, breaking strength, thickness of bowel wall, and histological appearance. RESULTS: Two pigs died postoperatively, leaving 8 for analysis. The blood flow at each anastomotic site studied by the microsphere technique was similar irrespective of the type of anastomosis (p = 0.3), as was anastomotic collagen concentration (p = 0.09). The anastomotic index, however, was significantly higher in the stapled than in the glued or sutured ones (p = 0.03). The glued anastomosis was the weakest, being only one fifth the strength of the stapled and one third the strength of the sutured anastomosis. There was no sign of rejection of the glue (of human origin) on histological examination. Glued and stapled anastomoses showed signs of mild inflammation, which did not reach the intensity of that around the sutured anastomoses. CONCLUSION: It is possible to make a sutureless anastomosis that does not leak with a modified stapler using fibrin glue instead of staples, but the anastomosis has considerably lower breaking strength than either stapled or sutured anastomoses.

Prediction of hospital stay after total gastrectomy.

The following factors were tested in the Cox proportional hazards model to determine their relationship to postoperative hospital stay in 174 patients who underwent total gastrectomy: age, sex, tumour stage, tumour free resection margins, anastomotic leakage, size of the EEA-stapler, preoperative hospital stay, location of the anastomosis and additional resection. Only anastomotic leakage and age independently affected postoperative hospital stay. Leakage, confirmed radiologically, developed in 20 patients (11.5%) of whom four died postoperatively. Another six patients who did not develop leakage also died, giving a postoperative mortality of 5.7%. The median age of the patients was 68 years (range 30-87), and the median postoperative hospital stay was 15 days (range 3-192). The operations were performed by 30 different surgeons of whom four performed more than ten, 9 performed 4-10 and 17 performed 1-3 total gastrectomies. There was a significant difference in postoperative mortality- and anastomotic leakage-rate between the surgeons who operated more than ten and less than four (p = 0.0122, p = 0.0453). However, when comparing the surgeons who operate more than 10 and 4-10 there was no difference in mortality or anastomotic leakage (p = 0.3493, p = 0.8867). When comparing the surgeons who operated on 4-10 with less than 4 there was no difference in postoperative mortality, but the anastomotic leakage rate was of borderline significance (p = 0.3916, p = 0.0582). Between the surgeons with the greatest experience there were significant differences as to leakage rate (p = 0.0003), time of operation (p < 0.001) but not in the number of thoracoabdominal incisions (p = 0.4939) or postoperative mortality (p = 0.8394). This study has shown conclusively that anastomotic leakage is the most important factor for prediction of postoperative hospital stay after total gastrectomy.

Anastomotic diameter of circular stapled oesophagojejunal anastomoses and its implication for weight development. A clinical and experimental study.

OBJECTIVE: To investigate the increase in diameter of the oesophagojejunal anastomosis after total gastrectomy with a circular stapler, and to assess experimentally the influence of oesophageal diameter on weight. DESIGN: Open prospective clinical and experimental studies. SETTING: University department of surgery, Sweden. SUBJECTS AND MATERIAL: 36 Consecutive patients who underwent total gastrectomy, and 13 domestic pigs. INTERVENTIONS: Clinical study: the end to side oesophagojejunal anastomoses were made with EEA staplers size 25 or 28, and the increase in diameter over a 12 month period was studied by by fibreoptic endoscopy. Experimental study: Each pig had 0.5 cm of the distal oesophagus resected; in 7 the oesophagus was anastomosed with one layer of continuous 3/0 polyglycolic acid, and in 6 an ILS21 stapler was used. Animals were weighed and killed at 4 1/2 months, and the width of the oesophagus at and below the anastomosis was measured. MAIN OUTCOME MEASURES: Clinical study: width of the oesophagus at 12 months. Experimental study: correlation between weight and oesophageal width at time of death. RESULTS: Clinical study: The median increase in size after 12 months with the size 25 cartridge was 8.45 mm (range 6.5-22), and for the size 28 cartridge 12 mm (2.3-30.2). The larger cartridge gave a significantly larger anastomosis (p = 0.007), but the comparative increases were similar. Experimental study: There was a significant correlation between increase in weight and anastomotic width in the 10 pigs that completed the study (r = 0.86, p < 0.001). CONCLUSION: A stapled oesophagojejunal anastomosis has the ability to dilate as necessary, and this ability is not prejudiced by the presence of the staples.

Are intersecting staple lines a hazard in intestinal anastomosis?

To determine the safety of intersecting staple lines, 22 pigs were operated upon with a functional end-to-end enteroanastomosis 40 cm distal to the ligament of Treitz using linear stapling devices. The procedure was repeated on the colon, where a colocolostomy was created. The blood flow at intersecting staple lines and single-row staple lines for each anastomosis was studied with the reference organ method 24 hours after the first operation. The purpose was to evaluate whether there is a reduction in blood flow at the site of intersecting staple lines, causing an increased risk for anastomotic leakage. The reduction in mean blood flow in crossing compared with noncrossing staple lines was 6 percent (-5-17 percent) for small bowel anastomoses and 7 percent (-6-19 percent) for colonic anastomoses. An equivalence test showed that, if a reduction in blood flow exists between crossing and noncrossing staple lines, it is most likely less than 30 percent (P less than 0.001) for both small bowel and colonic anastomoses. This experimental study demonstrates that intersecting staple lines in small bowel and colonic anastomoses do not reduce anastomotic blood flow to a dangerous level.

Left-sided hepatectomy with a linear stapling device: an experimental study on pigs.

Thirteen pigs underwent resection of the left liver lobe. By random selection, the animals were resected either with the aid of an RLG 90R linear stapling device or by the conventional finger-fracture technique. There was one postoperative death due to anaesthetic complications. The median operative time using the stapler was 27 min (range 19-40 min) which was significantly shorter (p = 0.0065) than that required for resection by the finger-fracture technique (42.5 min; range 37-55 min). The median blood loss, estimated by counting the number of gauze swabs used, was 425 ml and 275 ml for the finger-fracture resected and stapler resected groups, respectively (ranges 275-550 ml versus 175-300 ml; p = 0.015). The animals were sacrificed and examined one week after the operative procedure. Except for a small bile pseudo-cyst in one pig operated upon with conventional resection, no sign of bleeding or biliary leakage was revealed. This study demonstrates the feasibility of stapling the liver to facilitate resection.

Healing of colonic anastomoses: comparative experimental study of glued, manually sutured, and stapled anastomoses.

In 10 pigs a nonsutured, glued colonic anastomosis was constructed with a modified stapling device without staples and compared with an EEA-stapled anastomosis and a one-layer-sutured anastomosis concerning radiologic appearance, breaking strength, circulation, and collagen concentration. 141Ce-labeled microspheres were used for measurements of the anastomotic blood flow before the animals were sacrificed on the 4th postoperative day. The breaking strength was recorded and an anastomotic index calculated. No leakage was found. The anastomotic width did not differ between the groups, but the interindividual variation was more prominent in the sutured group. The handsewn and stapled anastomoses were stronger than the glued anastomosis (P = 0.0009 and 0.0054, respectively). There was an increase in the anastomotic circulation in all of the anastomoses, but no differences were seen between groups. The collagen concentration was independent of the technique used.

Intersecting staple lines and blood flow in oesophagojejunal anastomoses.

Total gastrectomy and oesophagojejunostomy with linear stapling devices were performed on 22 pigs to evaluate whether intersecting staple lines reduce the blood flow with an increased risk of anastomotic leakage. The blood flow at intersecting staple lines and single row staple lines of the anastomosis was studied with the reference organ method 24 h after the first operation. The mean blood flow in intersecting staple lines was 0.305 ml min-1 g-1 tissue and 0.307 ml min-1 g-1 tissue for single row staple lines. The confidence interval for the reduction in blood flow for intersecting staple lines compared with non-crossing staple lines was from -16 to +17 per cent. In one animal the reduction in blood flow was 37 per cent; in all other animals there was no reduction in blood flow or a reduction less than 25 per cent. An equivalence test shows that if a reduction in blood flow exists it is most likely to be less than 30 per cent (P less than 0.001). Our data confirm that intersecting staple lines in oesophagojejunal anastomoses do not reduce mean anastomotic blood flow to a dangerous level.

Segmental liver resection with linear stapling device. An experimental study on pigs.

Segmental liver resection was performed in 14 pigs. The pigs were randomized either to resection with conventional finger fracture technique or resection with linear stapling device (TA-90R, US Surgical Corporation). The median time for resection was shorter in the stapled group, although the difference was not statistically significant. The median weight of the specimen was the same in both groups. The median postoperative Haemoglobin value was somewhat lower in the finger fracture resected group as compared to the stapler resected group, 82.5 g/l versus 87.5 g/l, but there was no statistically significant difference between the groups. Blood loss, estimated by counting the number of compresses, amounted to 188 ml for the finger fracture resected group and 181 ml for the stapler resected group. At the post-mortem examination there were no signs of bile leakage or postoperative blood loss in any of the operated animals. This study demonstrates that hepatic resection in the pig can be performed quickly and safely by using linear stapling device. Stapler resection was easier and somewhat quicker to perform than conventional hepatic resection.

Delay in diagnosis of gastric cancer: a prospective study evaluating doctors'- and patients' delay and its influence on five year survival.

Despite new diagnostic techniques, gastric cancer in its less aggressive stages is not diagnosed more frequently and the prognosis still remains poor. Thus, a possibility exists that there is still a delay in diagnosis. This study was therefore designed to investigate whether a delay in diagnosis of gastric cancer exists, to identify factors leading to diagnostic delay, and to settle whether the prognosis is dependent on a delay. Fifty consecutive patients with gastric carcinoma were interviewed and the diagnostic attempts prior to diagnosis were checked. It was found that thirteen patients (26%) had patients' delay (more than three months of symptoms before consulting a doctor) whereas twelve (24%) had doctors' delay (more than three months of investigations before correct diagnosis was made). Doctors' delay was more common in female (7/13) than in male patients (5/37) (p less than 0.05) and in linitis plastica (5/8) than in other types of gastric cancers (7/42), (p less than 0.05). Seven of the twelve patients with doctors' delay had been on regular check ups before diagnosis. A negative barium meal was the most common reason for doctors' delay. Survival was influenced only by tumour stage (r = -0.71, p less than 0.05). Our conclusion is that both patients' and doctors' delay are considerable in the diagnosis of gastric cancer; it is therefore suggested that improvement in five-year survival requires improved presymptomatic diagnostic methods and screening programmes.

Total gastrectomy and oesophagojejunostomy with linear stapling devices.

When performing total gastrectomy and oesophagojejunostomy with a circular stapling device two disadvantages are obvious; firstly, a purse-string suture is needed, and secondly the instrument can be extremely difficult to introduce if the oesophagus is narrow, so that the risk of rupture is substantial. We therefore developed the following technique. When the specimen is attached only to the oesophagus, and the Roux-en-Y loop has already been divided with a linear stapling device, a small incision is made on the back wall of the oesophagus and antimesenterically 6 cm distal to the cut end of the Roux-en-Y loop. The two forks of the GIA or the PLC 50 instrument are introduced into the oesophagus and jejunum, and the two organs are brought together at the hiatus. The instrument is closed and fired. The residual opening is closed with a linear stapler which also includes the front wall of the oesophagus. With a knife, the oesophagus and excessive amounts of tissue are trimmed away, and the oesophagojejunostomy is completed. Fifteen patients (median age 67 years) had a postoperative hospital stay of 10 days (range 8-45 days) after this operation. Leakage occurred in one patient and one patient died. The anastomosis took 12 min to perform (range 8-20 min). Three reoperations were needed: intestinal obstruction, leakage and a negative exploration. The median width of the oesophagojejunal anastomosis 6 months after operation was 32 mm (range 27-40 mm). Oesophagojejunostomy performed with two linear staplers allows a quick and reliable anastomosis independent of oesophageal lumen size and a time-consuming purse-string suture.

Prediction of survival in gastric carcinoma and a new histopathologic approach.

During six years 188 consecutive patients with gastric carcinoma admitted to the Department of Surgery, University Hospital, Lund, were followed up to evaluate clinical as well as histopathologic factors which might be important to predict postoperative survival. We also introduced a new histopathologic scoring system based on nine different parameters. Radicality estimated by the surgeon, resection line margin, score at histologic grading and TNM were factors which in a multivariate analysis strongly correlated to survival.

Oesophagectomy without thoracotomy. Experiences from 30 cases.

In 26 patients with malignancies of the oesophagus or cardia and three with benign lesions the intrathoracic oesophagus was resected via abdominal and cervical incisions only and reconstructed with the stomach, a colon interposition or jejunal loop. The operation was chosen to omit the thoracotomy in patients with reduced tolerance to surgery or to secure a safe resectional margin in patients with easily resected tumours. With the exception of two patients, the method was not used for removal of mid-oesophageal tumours. Awareness of the possibility of intrathoracic complications such as bleeding into the pleural cavity is required during the procedure. A high mortality among the older patients contributed to a total mortality of 24%, indicating that the avoidance of a thoracotomy does not necessarily make the operation better tolerated, but it takes less time and postoperative morbidity is reduced.

Esophagojejunostomy with the EEA stapler.

Esophagojejunostomy after total gastrectomy was attempted in 27 operations with the EEA stapling device (U.S. Surgical Corp., Norwalk, Conn.). After removal of the specimen the anastomosis is performed with an end-to-side technique with insertion of the cartridge and its central rod through the open jejunal end. The 28 mm wide cartridge was used in 24 anastomoses and the 25 mm wide cartridge was used in two. In one case the 25 mm cartridge tore the distal esophagus, and the anastomosis had to be sutured manually. The median operation time was 305 minutes (range, 205 to 560 minutes), and the time to perform the anastomosis was 20 minutes (range, 15 to 60 minutes). Anastomotic leakage occurred in three patients, two of whom were stapled with the 25 mm cartridge. All healed with conservative treatment. One patient developed a stricture at the anastomotic site due to recurrence of the tumor. There was one hospital death. Median hospital stay was 16 days (range, 8 to 71 days) and median survival time was 11 months. It is concluded that the EEA stapler allows the construction of a fast and reliable esophagojejunostomy with good functional results after total gastrectomy for gastric cancer.