Vein patch angioplasty with non-penetrating titanium clips. Comparison to standard suture technique.

Our purpose was to compare the Vascular Closure Staples (VCS) clips to a standard suture technique for vein patch angioplasty in a porcine model. Six female pigs underwent vein patch angioplasty of the common iliac arteries with either VCS clips or continuous suturing. The reconstructed vessels were evaluated macroscopically, angiographically and histologically after two months by re-operation. There was a non significant trend towards shorter reconstruction (6.5 +/- 1.8 min. for clips vs. 8.5 +/- 1.7 min. for sutures, p = 0.15) and clamp times when clips were used (8.4 +/- 1.5 min. vs. 10.1 +/- 1.3 min., p = 0.15). At re-operation all vessels were found patent without significant histological differences regarding the intimal reaction. VCS clips are a reliable alternative to sutures for vein patch angioplasty.

Late-presenting appendicitis: a laparoscopic approach to a complicated problem.

BACKGROUND: Acute appendicitis is the most common abdominal condition necessitating urgent surgical intervention in the United States. The objective of this study was to determine if interval laparoscopic appendectomy after initial nonoperative treatment for late appendicitis presenting as an appendiceal mass is a safe alternative to immediate appendectomy. METHODS: Thirty two consecutive patients (aged 16-74 years) during a 5-year period presented with appendiceal mass. Seventeen received initial nonsurgical treatment followed by interval laparoscopic appendectomy (aged 16-60 years; group 1). Fifteen underwent immediate appendectomy (aged 16-74 years; group 2). RESULTS: All patients in the interval laparoscopic appendectomy group improved with initial therapy and underwent surgery an average of 4.9 months later. Although the operative time and the complication rate were similar between groups 1 and 2, the time to return to baseline activities was significantly less in group 1 after adjusting for age (p = 0.02 or less). CONCLUSIONS: Interval laparoscopic appendectomy is safe in patients with chronic appendicitis and allows for judicious diagnostic evaluation of the appendiceal mass and planned surgery under controlled conditions.

Comparison of titanium vascular closure staples with suture repair of the thoracic aorta in swine.

OBJECTIVE: Devices that reduce technical difficulty and anastigmatic time when repairing large vessels such as the thoracic aorta would be beneficial. The aim of this study was to determine if titanium vascular closure staples (3 mm) could be safely and quickly applied in the repair of large vessels such as the thoracic aorta. DESIGN: Through a left thoracotomy in 10 female swine (110 to 130 lb), an interposition graft (14 to 16 mm textile) was placed into the aorta distal to the left subclavian artery. Animals were randomized at the time of repair to either running sutures (n = 5; 6-0 polypropylene) or vascular closure staples (n = 5; 3 mm). The anastomosis was evaluated after 2 months with aortograms, and the aorta was harvested to evaluate healing. RESULTS: The clamp times (mean +/- SD) were 30.8 +/- 8.2 min for suture repair and 24.8 +/- 5.1 min for vascular closure staple repair (p = 0.2). Anastomosis times were 20. 0 +/- 6.2 min for the suture group and 16.4 +/- 6.4 min for the vascular closure staple group (p = 0.4). Arch aortograms at 2 months revealed no significant difference in luminal narrowing between the two groups. Gross and microscopic examination revealed no thrombosis, well-healed wounds with a continuous intimal layer, and no differences in intimal thickness or inflammation between the two groups. CONCLUSION: Vascular closure staples were equivalent to sutures in terms of durability, graft patency, and wound healing at 2 months. Vascular closure staples may offer the trauma surgeon a quick and easy alternative when repairing large vessels such as the thoracic aorta.

Sutureless vascular reconstruction with titanium clips.

Attempts to find alternatives to sutured vascular reconstruction techniques has continued for decades and include various forms of rings, tubes, endoluminal stents as well as gluing or welding techniques of large vessel anastomoses. One recently introduced technique uses nonpenetrating titanium clips for everted vessel approximation and closure. Experimental work on their use in various types of large vessel repairs and reconstructions has shown that the clips are easily applied with a short learning curve, create good conditions for vessel wall healing without causing excessive inflammation or fibrosis, and are considerably faster to apply when compared to standard suture techniques. Although there are some clinical reports of defective clipped closures causing postoperative bleeding complications, they are rare and most probably related to technical errors in applying the clips. The main disadvantages of the clips include the limited experience of their applicability in atherosclerotic vessels, lack of long term follow-up and cost. Potentially, the clips could be useful in the repair of multiple vascular injuries, in vessel repair or ligation performed in confined spaces, and in vascular procedures requiring the shortest possible cross-clamping time. Future applications could include endoscopic procedures as well as the use of a one-shot device which simultaneously applies up to a dozen clips to symmetrically everted and approximated vessel edges.

Arterial repair with synthetic patch by using titanium clips.

BACKGROUND: Vascular closure staple (VCS) clips made of titanium were originally developed for microvascular anastomoses. There is limited experience with their applicability to vascular reconstruction in larger vessels. This study compares VCS clips to standard sutures in arterial repair using a synthetic patch. METHODS: In an experimental study with pigs, two sequential 10-mm abdominal aortotomies were allocated randomly to synthetic patch (polytetrafluoroethylene) repair with VCS clips or continuous 6-0 polypropylene sutures. Angiographic, macroscopic, and microscopic results were assessed after 2 months. RESULTS: There were no significant differences in the patency rate, vessel diameter at the repair site, or healing indices. The mean (SD) clamp time was 8.7 (3.0) minutes for clip repair and 14.3 (7.4) minutes for suture repair (p = 0.04), and the times required for the vessel reconstruction were 5.3 (1.3) and 9.3 (3.0) minutes, respectively (p = 0.009). CONCLUSION: Patched arterial repair with VCS clips is faster than sutured reconstruction with comparable results after 2 months of follow up.

Rapid arterial anastomosis with titanium clips.

BACKGROUND: The obvious advantages of rapid arterial anastomoses have prompted the continuing search for more rapid anastomotic techniques to complement the standard sutured anastomosis. Nonpenetrating, arcuate-legged titanium vascular closure staple (VCS) clips were initially developed for microvascular anastomoses. The purpose of this study was to compare VCS clips with sutured arterial end-to-end anastomosis in larger vessels. METHODS: In 6 pigs, transacted iliac arteries were reanastomosed with VCS clips on one side and continuous 6-0 polypropylene suture on the other. RESULTS: The reconstruction time was 8.4+/-5.2 minutes for clip closure and 12.0+/-6.6 minutes for suture closure (P = 0.033). All vessels were patent half an hour after completing the anastomoses with no signs of early thrombosis. CONCLUSIONS: Arterial end-to-end anastomosis can be performed more rapidly with VCS clips than continuous sutures, and are potentially useful in situations where the clamp time of the vessel is critical.

Ureteral repair with titanium staples: comparison with suture closure.

OBJECTIVES: Vascular closure staple (VCS) clips made of titanium were initially developed for microvascular anastomoses with little knowledge of their effectiveness in larger tubular tissue structures. This study compares VCS clips and sutures in the closure of longitudinal ureterotomy incisions. METHODS: In 9 pigs, 1-cm-long anterior, longitudinal ureterotomy incisions were randomly assigned to closure with either 4-0 interrupted polyglactin sutures or VCS clips. RESULTS: Clip closure was significantly faster (74+/-28 versus 534+/-182 seconds). All 18 ureters were patent and without signs of leakage, calculus formation, or stenoses after 3 months. Clip closure resulted in slightly but not statistically significantly less narrowing of the duct lumen, but there was no difference in wall thickness at the repair site. At histologic examination, all 18 incisions healed without signs of acute inflammation or marked fibrosis. CONCLUSIONS: Ureterotomy closure with VCS clips results in wound healing that is as effective as suture closure, with a comparable degree of narrowing. The time required for clip closure is only about 1/7 that required for suture closure.

Potential of a hand-held ultrasound in assessment of the injured patient.

Current studies indicate that portable ultrasound used by trained trauma surgeons in the emergency room can be performed using the focused abdominal sonogram for trauma technique in approximately 2 minutes to evaluate patients with blunt torso trauma. It has been shown to be as accurate as DPL and computed tomography (CT) in the detection of hemoperitoneum following abdominal trauma. It is also very accurate in detecting pericardial fluid and may have a role in the evaluation of penetrating injuries of the thorax, either from stab or gunshot wounds. The examination is best performed early on in the secondary survey of the injured patient. Miniaturization and hand-held ultrasound units are on the horizon. The faculty of the University of Washington in Seattle in conjunction with the Advanced Technology Laboratories in Seattle and the Advanced Research Project Agency of the Department of Defense are producing a battlefield hand-held ultrasound with the ultimate goal to have an ultrasound unit that will fit in the trauma surgeon's pocket. With the use of this new technology, the potential for early diagnosis of victims of trauma and prompt treatment is at hand. One of the greatest challenges remaining is that of training surgeons in the use of ultrasound. The author's experience in conducting ultrasound courses for surgeons at the Uniformed Services University of the Health Sciences is described.

Arterial reconstruction with vascular clips is safe and quicker than sutured repair.

BACKGROUND: Non-penetrating, arcuate-legged vascular-closure staple clips made of titanium were initially developed for microvascular anastomoses with little experience of their use in larger vessels. The purpose of this study was to compare vascular-closure staple clips to sutured anastomoses in common iliac arteries in a porcine model. METHODS: In an experimental study, transected iliac arteries on both sides of 11 pigs were randomly assigned to end-to-end anastomosis performed with vascular-closure staple clips or interrupted 6-0 polypropylene sutures. Angiographic, macroscopic and microscopic results were assessed after 2 months. RESULTS: There was no significant difference in the patency rate, tensile strength of the anastomoses, vessel diameter at the repair site, intimal thickness or wall thickness of the arteries after either method of closure. The mean (s.d.) clamp time was 19.8 (6.1) minutes for clip repair, and 36.0 (6.9) seconds for suture repair (P < 0.001). The times required for the reconstruction of the anastomoses were 17.4 (6.1) and 35.5 (7.1) minutes, respectively (P < 0.001). CONCLUSIONS: Arterial anastomoses performed with vascular-closure staple clips are faster than sutured anastomoses, and result in comparable wound healing when assessed for patency, tensile strength, degree of narrowing and intimal reaction.

Common bile duct repair with titanium staples. Comparison with suture closure.

BACKGROUND: Vascular Closure Staple (VCS) clips made of titanium were initially developed for microvascular anastomoses with little experience of their use in larger tubular structures. This study compares VCS clips and sutures in the closure of supraduodenal choledochotomy. METHODS: In nine pigs, two longitudinal incisions of the common bile duct (CBD) were randomly assigned to closure with 4-0 interrupted polyglactin sutures or VCS clips. RESULTS: Clip closure was significantly faster (116 +/- 28 vs 581 +/- 88 s). All nine CBDs were patent and without signs of calculus formation after 3 months. Clip closure resulted in slightly less narrowing of the duct lumen and thinner scar at the repair site. At histological examination, all 18 incisions had healed without signs of fistula formation or marked fibrosis. CONCLUSIONS: Choledochotomy closure with VCS clips results in as good or better wound healing than suture closure, with a comparable degree of narrowing. The time required for clip closure is only about one-fifth that of suture closure.

Arterial and venous repair with vascular clips: comparison with suture closure.

PURPOSE: Nonpenetrating, arcuate-legged titanium vascular closure staple (VCS) clips were initially developed for microvascular anastomoses with little experience of their use in larger vessels. The purpose of this study was to compare the VCS clips with standard suture closure of arteriotomies and venotomies in common iliac vessels of pigs. METHODS: In nine pigs, longitudinal 1 cm iliac arterial and venous incisions were repaired with VCS clips on one side and continuous 6-0 polypropylene suture on the other, and the macroscopic and microscopic results were assessed after 3 months. RESULTS: The time required for vessel repair was significantly shorter with clips than with sutures both in arteries (51 +/- 9 vs 414 +/- 36 seconds) and in veins (100 +/- 32 vs 439 +/- 45 seconds). There was no significant difference in the inner diameter, intimal thickness, or intima-to-media height ratios of the arteries or veins after either method of closure. CONCLUSIONS: Repair of 1 cm incisions in small-diameter arteries and veins with VCS clips results in wound healing as good as that achieved with standard suture closure, when assessed for patency, leakage, degree of narrowing, and intimal reaction. The time required for clip closure is considerably shorter than for suture closure.

An external audit of laparoscopic cholecystectomy in the steady state performed in medical treatment facilities of the Department of Defense.

OBJECTIVE: This study provides the first objective assessment of a complete patient population undergoing laparoscopic cholecystectomy in the steady state. The authors determined the frequency of complications, particularly bile duct, bowel, vascular injuries, and deaths. SUMMARY BACKGROUND DATA: This retrospective study, conducted for the Department of Defense healthcare system by the Civilian External Peer Review Program, is the second complete audit of laparoscopic cholecystectomy. Data were collected on 9130 patients undergoing laparoscopic cholecystectomy between January 1993 and May 1994. METHODS: The study sample consisted of clinical data abstracted from the complete records of 9054 (99.2%) of the 9130 laparoscopic cholecystectomies performed at 94 military medical treatment facilities. RESULTS: Of 10,458 cholecystectomies performed in the Military Health Services System, 9130 (87.3%) were laparoscopic and 1328 (12.7%) were traditional open procedures. Seventy-six medical records were incomplete: however, there was sufficient data to determine mortality and bile duct injury rates. Of the remaining 9054 cases, 6.09% experienced complications, including bile duct (0.41%), bowel (0.32%), and vascular injuries (0.10 percent). The mortality rate was 0.13%. Access via Veress technique was used in 57.6% and Hasson technique in 42.4% of patients. Intraoperative cholangiograms were performed in 42.7% of the cases with a success rate of 86.2%. Eight hundred ninety-two (9.8%) patients were converted to open cholecystectomies. CONCLUSIONS: In the steady state, despite an increase in the percentage of laparoscopic cholecystectomies performed for nonmalignant gallbladder disease, there continues to be minimal complications and low mortality.

A quick and simple method to close vascular, biliary, and urinary tract incisions using the new Vascular Closure Staples: a preliminary report.

Traditional suture reconstruction of tubular organs creates a perforating needle injury, leaves suture material on the endothelial or mucosal surfaces, and is cumbersome when done endoscopically. One alternative method of reconstruction of tubular organs could use the new nonpenetrating clip to create an everted closure. In five pigs, a longitudinal incision of the infrarenal aorta, inferior vena cava, left ureter, gallbladder, and the common bile duct (in two) was closed with Vascular Closure Staples (VCS-clips). Four weeks after surgery, all ten blood vessels remained patent with no thrombosis. There was a well-healed wound with continuous intimal layer. The ureteral, gallbladder, and common bile duct wounds healed without leakage or obstruction in all animals. There was complete mucosal bridging of the wound, although in some specimens one or two clips were exposed to the lumen. The VCS-clips are easily and quickly applied and are safe insofar as can be determined by short-term follow-up.

An external audit of laparoscopic cholecystectomy performed in medical treatment facilities of the department of Defense.

OBJECTIVE: This study provided an objective survey by an outside auditing group of a large, complete patient population undergoing laparoscopic cholecystectomies, determined the frequency of complications, especially bile duct injuries, and presented a system for classifying and comparing the severity of bile duct injuries. SUMMARY BACKGROUND DATA: This is the first study of laparoscopic cholecystectomy to encompass a large and complete patient population and to be based on objectively collected data rather than self-reported data. The Civilian External Peer Review Program (CEPRP) of the Department of Defense health care system conducted a retrospective study of 5642 patients who underwent laparoscopic cholecystectomies at 89 military medical treatment facilities from July 1990 through May 1992. METHODS: The study sample consisted of the complete records of 5607 (99.38%) of the 5642 laparoscopic cholecystectomy patients. RESULTS: Of the sample, 6.87% of patients experienced complications within 30 days of surgery, 0.57% sustained bile duct injuries, and 0.5% sustained bowel injuries. Among 5154 patients whose procedures were completed laparoscopically, 5.47% experienced complications. Laparoscopic procedures were converted to open cholecystectomies in 8.08% of cases. Intraoperative cholangiograms were attempted in 46.5% of cases and completed in 80.59% of those attempts. There were no intraoperative deaths; 0.04% of the patients died within 30 days of surgery. CONCLUSIONS: The frequency of complications found in this study is comparable to the frequency of complications reported in recent large civilian studies and earlier, smaller studies. The authors present a system for classifying bile duct injuries, which is designed to standardize references to such injuries and allow for accurate comparison of bile duct injuries in the future.

The yield of flexible fiberoptic sigmoidoscopy in the detection of asymptomatic colorectal neoplasia.

Recent evidence of a reduction in mortality rates from distal colorectal cancers in populations screened by rigid sigmoidoscopy suggests that further benefits may be achieved by the use of fiberoptic sigmoidoscopy as the screening modality. However, there is limited evidence as to the expected yield of neoplasia using the standard 60-cm instrument. The aim of this study was to determine the yield of neoplasia in an asymptomatic population in the at-risk age group undergoing fiberoptic sigmoidoscopy. Recruitment into the screening program was among State Department personnel. In total, 4,216 asymptomatic subjects (50-65 years) were offered flexible sigmoidoscopic screening performed following a simple enema bowel preparation. Those in whom a neoplastic condition was identified underwent further investigation (colonoscopy or barium enema). Of those offered screening 4,005 (95%) underwent the examination. Eleven carcinomas were detected at flexible sigmoidoscopy and two carcinomas were detected at further investigation in subjects with rectosigmoid polyps. The overall detection rate of carcinomas was 3.2 per 1,000 subjects screened. Histologically proven adenomas were detected in 217 subjects, 5.4% of the population screened. In this cohort of individuals flexible sigmoidoscopy appears to have been an acceptable form of screening. The detection rate of neoplasia, particularly colorectal adenomas, is higher than that reported from studies of fecal occult blood screening.

Prospective evaluation of thoracoscopy for diagnosing diaphragmatic injury in thoracoabdominal trauma: a preliminary report.

Diagnosis of diaphragmatic injury (DI) can be difficult in patients with penetrating trauma because physical examination, computed tomographic scan, chest x-ray films, and diagnostic peritoneal lavage may miss these injuries. Mandatory exploration has been recommended because of the increased mortality associated with missed DI. Thoracoscopy was prospectively evaluated as a less invasive method for diagnosing DI in patients with penetrating trauma. Over a 14-month period, 14 patients were evaluated by thoracoscopy; video thoracoscopy was used in the last 9. Findings of thoracoscopy were confirmed by laparotomy or laparoscopy. Thoracoscopy correctly identified the presence or absence of DI in nine and five patients, respectively (all patients). Video thoracoscopy was easier and faster to perform than non-video thoracoscopy. This is the first reported series in which video thoracoscopy has been used for trauma. We found this procedure to be safe, accurate, and less invasive than laparotomy for diagnosing DI.

Use of the ultrathin choledochoscope in cholecystectomy.

Use of the ultrathin choledochoscope (2mm) was evaluated in 80 patients undergoing routine cholecystectomy. It was used successfully in 67 (84 per cent) patients. There were eight (12 per cent) explorations of the common bile duct and no negative explorations. The instrument was helpful in determining the nature of an equivocal on-table cholangiogram. The ultrathin choledochoscope may be useful in reducing the rate of negative common bile duct exploration.

A randomized comparison of infrared photocoagulation with bipolar diathermy for the outpatient treatment of hemorrhoids.

One hundred two patients with symptomatic hemorrhoids were randomized to receive treatment with either infrared photocoagulation (IRPC) or a bipolar diathermy probe (BD). There was no significant difference in complications, number of treatments required (IRPC 1.7 [0.9], BD 1.6 [0.8]). Third-degree hemorrhoids required more treatments than smaller piles. BD has some practical advantages over IRPC but results are similar.