Influence of barbed suture oversew of the transverse staple line during functional end-to-end stapled anastomosis in a canine jejunal enterectomy model.

OBJECTIVE: To evaluate the influence of barbed suture oversew of the transverse staple line during functional end-to-end stapled anastomosis (FEESA) in dogs. STUDY DESIGN: Randomized, experimental, ex vivo. ANIMALS OR SAMPLE POPULATION: Grossly normal jejunal segments from 14 adult canine cadavers. METHODS: Ninety-eight jejunal segments (n = 14/FEESA group, n = 14 controls) were harvested and randomly assigned to a control group, FEESA + monofilament suture oversew, FEESA + unidirectional barbed suture oversew or FEESA + bidirectional barbed suture oversew. Oversew techniques were performed using a Cushing suture pattern. Initial (ILP) and maximum leakage pressure (MLP), repair time (s), and location of observed leakage were recorded. RESULTS: No differences were detected in ILP (p = .439) or MLP (p = .644) respectively between experimental groups. Repairs times using barbed suture were ~ 18% faster (~25 s faster; p < .001) compared to monofilament suture. There was no difference between barbed suture types (p = .697). Mean ILP (p < .001) and MLP (p < .0001) were 6.6x and 5.1x greater respectively in the control group. Leakage location occurred predominately at the crotch of the FEESA in all groups. CONCLUSION: FEESAs closed with a transverse staple line oversew using barbed suture, regardless of barb orientation, were completed faster and resulted in similar resistance to anastomotic leakage compared to monofilament suture. CLINICAL SIGNIFICANCE: Oversewing the transverse staple line following FEESA using barbed suture offers similar resistance to anastomotic leakage, and may be associated with decreased surgical times in dogs compared to monofilament suture. Further studies are necessary to determine the benefits of barbed suture use in both open and laparoscopic gastrointestinal surgical applications following FEESA in dogs.

Influence of oversewing the transverse staple line during functional end-to-end stapled intestinal anastomoses in dogs.

OBJECTIVE: To determine the effect of oversewing the transverse staple line after functional end-to-end stapled intestinal anastomoses (FEESA) on canine jejunal leakage pressures. STUDY DESIGN: Experimental, ex vivo, randomized study. SAMPLE POPULATION: Jejunal segments from three adult canine cadavers. METHODS: Jejunal segments were harvested within 2 hours of euthanasia and anastomosed (24 jejunal segments per group, consisting of two segments per construct with n = 12/ group). Constructs were then randomly assigned to receive FEESA alone, FEESA + Cushing oversew, or FEESA + simple-continuous oversew of the transverse staple line with 3-0 polydioxanone. Results for initial leakage pressure (ILP) and maximal leakage pressure (MLP) and initial leakage location (LL) were compared between groups. RESULTS: Mean ILP was 1.8-fold higher for FEESA + Cushing oversew (62.4 ± 7.8 mm Hg) compared with FEESA alone and FEESA + simple-continuous oversew (P < .001). Mean MLP were higher for both oversewn techniques compared with FEESA alone (P < .001). Oversewing the transverse staple line with either pattern increased mean MLP by 1.4-fold compared with FEESA alone. Leakage occurred at the level of the transverse staple line in nonoversewn constructs (P < .001). CONCLUSION: Oversewing the transverse staple line after FEESA increased MLP and decreased the occurrence of leakage at this location. Oversewing with a Cushing pattern increased ILP compared with oversew with a simple-continuous pattern. CLINICAL SIGNIFICANCE: Our results provide evidence to support oversewing the transverse staple line after FEESA. Doing so may reduce the occurrence of postoperative dehiscence. These findings warrant additional focused investigation in vivo through a prospective randomized clinical trial.

Influence of closure technique on leakage pressures in an ex vivo canine typhlectomy model.

OBJECTIVE: To determine the influence of three closure techniques on leakage pressures of canine typhlectomies. STUDY DESIGN: Experimental, ex vivo. SAMPLE POPULATION: Grossly normal cecal segments from 24 adult canine cadavers. METHODS: Typhlectomies were assigned to one of three closure techniques: simple continuous closure with a Parker-Kerr pattern with 4-0 polydioxanone (group 1), closure with a 60-mm gastrointestinal stapler loaded with a 3.8-mm staple cartridge (group 2), and placement of a Cushing suture to augment the stapled closure (group 3). The median (range) of initial leakage pressure (ILP) and maximum leakage pressure (MLP) was compared between groups along with leakage location. RESULTS: Typhlectomies in group 3 leaked at higher ILP (310 mm Hg; 188-310) than those in groups 1 (43 mm Hg; 31-80) and 2 (109.5 mm Hg; 68-173; P < .0001). Maximum leakage pressure were greater in group 3 than in other groups (P < .0001). Leakage was detected in 20 of 24 (83%) typhlectomies, located at the incisional line in 13 of 24 (54%) specimens and from suture holes in seven of 24 (29%) specimens. CONCLUSION: Placement of a Cushing suture pattern to augment stapled incisions improved the ability of typhlectomies to sustain pressure compared with sutured or stapled cadaveric specimens alone. CLINICAL SIGNIFICANCE: These results provide evidence to support placement of a Cushing suture pattern to augment the staple line for typhlectomies in dogs, although in vivo studies are required to determine the clinical significance of these findings.

Effects of a surgical sealant on leakage pressure and circumference of fresh canine cadaver small intestinal anastomoses.

OBJECTIVE To evaluate the effect of a bovine albumin-derivatized glutaraldehyde (BA-DG) biopolymer sealant on leakage pressures of intestinal anastomoses in jejunal tissue collected from fresh canine cadavers and to evaluate changes in circumference and cross-sectional area of the anastomotic site resulting from sealant application. SAMPLE 24 jejunal anastomoses from 4 fresh canine cadavers. PROCEDURES Jejunal tissue specimens were collected, and adjacent segment anastomoses were created within 12 hours after euthanasia of each dog. The tissue constructs were randomly assigned to 1 of 2 groups in which sealant was or was not applied. The outer circumference of all anastomoses in the sealant group was measured before and after application of the sealant; the cross-sectional area at the anastomotic site was then calculated at each time point. Tissue constructs were pressure tested, and leakage pressure and site were recorded. All testing was completed within 24 hours after tissue collection. RESULTS Compared with preapplication findings, there were no significant changes in outer circumference or cross-sectional area at the anastomotic site after sealant application. Leakage pressures in the sealant group were significantly higher than those in the no-sealant group. CONCLUSIONS AND CLINICAL RELEVANCE The use of surgical sealant on fresh canine cadaver jejunal anastomoses resulted in significantly higher leakage pressure at the anastomotic site; no immediate tissue deformation of the outer circumference or cross-sectional area occurred after sealant application. Future in vivo investigations are warranted to evaluate the effects of this sealant and potential benefits for clinical patients undergoing enterectomy.

One stage functional end-to-end stapled intestinal anastomosis and resection performed by nonexpert surgeons for the treatment of small intestinal obstruction in 30 dogs.

OBJECTIVES: To describe stapled 1-stage functional end-to-end intestinal anastomosis for treatment of small intestinal obstruction in dogs and evaluate outcome when the technique is performed by nonexpert surgeons after limited training in the technique. STUDY DESIGN: Case series. ANIMALS: Dogs (n=30) with intestinal lesions requiring an enterectomy. METHODS: Stapled 1-stage functional end-to-end anastomosis and resection using a GIA-60 and a TA-55 stapling devices were performed under supervision of senior residents and faculty surgeons by junior surgeons previously trained in the technique on pigs. Procedure duration and technical problems were recorded. Short-term results were collected during hospitalization and at suture removal. Long-term outcome was established by clinical and ultrasonographic examinations at least 2 months after surgery and from written questionnaires, completed by owners. RESULTS: Mean±SD procedure duration was 15±12 minutes. Postoperative recovery was uneventful in 25 dogs. One dog had anastomotic leakage, 1 had a localized abscess at the transverse staple line, and 3 dogs developed an incisional abdominal wall abscess. No long-term complications occurred (follow-up, 2-32 months). CONCLUSION: Stapled 1-stage functional end-to-end anastomosis and resection is a fast and safe procedure in the hand of nonexpert but trained surgeons.

Saline volume necessary to achieve predetermined intraluminal pressures during leak testing of small intestinal biopsy sites in the dog.

OBJECTIVE: To determine the volume of saline needed to achieve targeted intraluminal pressures during leak testing of closed jejunal biopsy sites in the dog. STUDY DESIGN: Experimental. ANIMALS: Dogs (n=38). METHODS: Jejunal biopsies in dogs were performed and closed using 3-4 full thickness simple interrupted sutures. Saline volumes needed to achieve 2 predetermined intraluminal pressures (20 and 34 cm water [15 and 25 mmHg]) in a 10 cm canine jejunal segment containing a closed biopsy site using 2 methods of luminal occlusion were recorded. RESULTS: The 95% confidence intervals for the volume of saline needed to achieve 20 and 34 cm water intraluminal pressure were 10.9-13.6 and 16.3-19.0 mL, respectively with digital occlusion and 8.5-11.1 and 12.1-14.8 mL, respectively with Doyen occlusion. Correlation between volume of saline instilled and the pressure achieved was 0.76 for digital occlusion and 0.86 for Doyen occlusion. CONCLUSION: Correlation between volume of saline instilled and pressure achieved was greater with Doyen than digital occlusion. CLINICAL RELEVANCE: For canine jejunum, saline volumes of 16.3-19 mL (digital occlusion) and 12.1-14.8 mL (Doyen occlusion) can be used to achieve intraluminal pressures of 34 cm water during leak testing of a 10 cm segment containing a closed biopsy site.