Gastrojejunostomy Closure Technique and Risk of Leak: an Evaluation in Ex Vivo Porcine Models.

INTRODUCTION: Roux-en-Y gastric bypass (RYGB) is one of the most commonly performed bariatric operations worldwide. Leaks following RYGB are rare, but the consequences can be devastating. Although most leaks occur at the gastrojejunostomy (GJ) anastomosis, there is a lack of data on modifiable technical factors that can reduce the risk of leaks. Therefore, we evaluated whether the leak pressure of a GJ linear stapled anastomosis is dependent on the closure technique. METHODS: Two expert surgeons constructed gastric pouches and GJ anastomoses on ex vivo porcine models in a laparoscopic simulator using 30-mm and 45-mm endoscopic staplers. The GJ anastomosis was closed using either a single layer suture, double layer suture or stapler. The endpoints were leak pressure to air insufflation, measured by two independent observers, site of leak and internal circumference of the GJ anastomosis. RESULTS: In total, 30 GJ anastomoses were constructed (30 mm, n = 15; 45 mm, n = 15). The GJ anastomosis was closed using single layer (n = 9), double layer (n = 9) and stapled techniques (n = 12). Inter-observer agreement was high. Stapled and double layer closures were more resilient than a single layer closure, with 75% (9/12) stapled closures remaining intact at < 70 mmHg. GJ stoma circumference was lower using a 30-mm stapler (64.8 mm vs 80.2 mm; p < 0.05) but independent of closure technique. The most common leak site was the corner of the closure (67%). CONCLUSION: In summary, the GJ anastomosis closure technique may be a modifiable factor to prevent anastomotic leak.

Animation supported communication on intensive care; a service improvement initiative.

Objective: COVID-19 has created unique challenges for families of patients admitted to intensive care units. Restricted visiting, language barriers and time constraints have limited communication, resulting in a lack of understanding and anxiety. We introduced digital animations to support communication and assessed the impact on families of patients admitted to intensive care. Methods: Multi-language animations explaining mechanical ventilation, (www.explainmyprocedure.com/icu) were introduced at two London intensive care units during the COVID-19 pandemic. Web-links were sent by email. Reported understanding of the treatment, its benefits, risks and alternatives was assessed among family contacts of 71 consecutive patients admitted to intensive care; 39 before the animations were introduced (no animation group) and 32 afterwards (animation group). Reported understanding in the two groups was assessed by telephone questionnaire and compared. Results: Following introduction, all relatives reported they had watched the animation. The proportions who reported complete understanding of mechanical ventilation, its benefits, risks and alternatives, in the no animation group (n = 39) were, respectively, 15%, 28%, 0% and 3% and in the animation group (n = 32), 94%, 97%, 84% and 66% (p < 0.0001 for all comparisons). Conclusion: Family use of online multi-language animations explaining mechanical ventilation is feasible, acceptable and associated with substantial improvement in understanding. The approach is not limited to mechanical ventilation, or to use in a pandemic, and has the potential to be applied to a wide range of treatment and recovery pathways on intensive care.