[Endoscopic hand-suturing combined with titanium clips for rectal defects closure after endoscopic submucosal dissection: a pilot study].

Objective: To explore the feasibility of endoscopic hand-suturing (EHS) for rectal defects closure after endoscopic submucosal dissection (ESD), and the clinical practicability of EHS combined with titanium clips. Methods: This is a prospective study performed by two experienced endoscopists from the Cancer Hospital, Chinese Academy of Medical Sciences who had received EHS training in sixporcine gastric ESD defects in vivo before the study. From December 2022 to February 2022, 20 patients with rectal mucosal lesions or submucosal diseases underwent ESD. Then EHS combined with titanium clips was adopted to close the rectal ESD defects. Specifically, we first sutured the defects as much as possible through EHS, then use titanium clips to fix the tail of the suture, and finally use additional titanium clips to close the residual parts of the defects that cannot be sutured. The main observational indicators were complete closure of the wound and delayed bleeding within one month after surgery. Results: In the 20 rectal cases, the size of defects ranged from 2.2 to 3.6 cm, with a median of 2.7 cm. All cases achieved complete closure without delayed bleeding, of which 12 (60.0%) were completely sutured with EHS and 8 (40.0%) required additional titanium clips to achieve complete closure after suturing. Conclusion: EHS technique is feasible and safe for rectum. EHS combined with titanium clips can also effectively close the rectal ESD defects, prevent postoperative delayed bleeding, and may be easier to be implemented in clinical practice.

Risk factors for complications of therapeutic endoscopy for upper gastrointestinal subepithelial lesions. / ä¸Šæ¶ˆåŒ–é“ä¸Šçš®ä¸‹ç— å˜è¡Œå† é•œæ²»ç–—åŽå¹¶å‘ç—‡çš„å±é™©å› ç´ .

OBJECTIVES: To study the risk factors for complications after endoscopic therapy for upper gastrointestinal subepithelial lesions (SELs). METHODS: Retrospective analysis was performed on 184 patients in the Department of Gastroenterology in the Third Xiangya Hospital, Central South University after therapeutic endoscopy [endoscopic submucosal dissection (ESD), endoscopic full-thickness resection (EFR), endoscopic submucosal excavation (ESE), and submucosal tunneling endoscopic resection (STER)] for the upper gastrointestinal SELs from 2014-09-01 to 2019-09-30. The clinic data were collected and risk factors for postoperative complications were analyzed. RESULTS: Among the 184 patients, 22 patients were in the complication group (including 3 cases of delayed bleeding, 2 cases of delayed perforation, and 17 cases of electrocoagulation syndrome) and 162 patients were in the non-complication group. There was no significant difference between the complication group and the non-complication group in gender, age over 70 year, basic diseases, lesion location, lesion invasion layers, pathological results, endoscopic therapy, and preventive closure of wounds (all P>0.05). The differences between the two groups in lesion diameter over 40 mm, operative time over 120 minutes, and rate of intraoperative perforation were significant (all P<0.05). Logistic regression analysis showed that lesion diameter over 40 mm and operative time over 120 minutes were independent risk factors for postoperative complications. CONCLUSIONS: For the patients with upper gastrointestinal SELs after endoscopic minimally invasive therapy with the lesion diameter over 40 mm and the operative time over 120 minutes, it needs to highly alert to the occurrence of postoperative complications.

Morphological Changes in Blood Cells After Implantation of Titanium and Plastic Clips in the Neurocranium - Experimental Study on Dogs.

INTRODUCTION: Various studies confirm the biocompatibility and efficacy of clips for certain target tissues, but without any comparative analysis of hematological parameters. Therefore, we conducted a study to assess the possible association of the implantation of titanium and plastic clips in the neurocranium with possible morphological changes in the blood cells of experimental animals. MATERIALS AND METHODS: As a control, the peripheral blood smears were taken before surgery from 12 adult dogs that were divided into two experimental groups. After placing titanium and plastic clips in the neurocranium, the peripheral blood of the first group was analyzed on the seventh postoperative day, while the peripheral blood of the second group was analyzed on the sixtieth day. By microscopy of the blood smears, the following parameters were analyzed: the presence of poikilocytosis of the red blood cells, degenerative changes in the leukocytes and leukogram. RESULTS: There were no statistically significant differences between the mean values of the groups. Monocytosis was detected (first group 22.83 % and second 16.30 %), as well as neutropenia (46.80 %, in the second group). Degenerative changes to neutrophils and the occurrence of atypical lymphocytes were observed in the second experimental group (60th postoperative day). CONCLUSION: A mild adverse effect from the biomaterials present in the neurocranium of dogs was detected, affecting the majority of leukocytic cells. A chronic recurrent inflammatory process was caused by the presence of the plastic and titanium clips in the brain tissue. No adverse effect of biomaterials on erythrocytes in the neurocranium was detected in the dogs studied. Further studies are necessary to explain the occurrence of degenerative changes in the neutrophils and lymphocytes.

Primary Repair of Posteriorly Located Anterior Skull Base Dural Defects Using Nonpenetrating Titanium Clips in Cranial Trauma.

Objective Primary repair of posteriorly located anterior skull base (ASB) dural defects following cranial trauma is made difficult by narrow operative corridors and adherent dura mater. Inadequate closure may result in continued cerebrospinal fluid (CSF) leak and infectious sequelae. Here, we report surgical outcomes following the use of nonpenetrating titanium microclips as an adjunctive repair technique in traumatic anterior skull base dural defects extending from the olfactory groove to the tuberculum sellae. Methods All trauma patients who underwent a bifrontal craniotomy from January 2013 to October 2019 were retrospectively reviewed. Patients with ASB defects located at posterior to the olfactory groove were analyzed. Patients with isolated frontal sinus fractures were excluded. All patients presented with CSF leak or radiographic signs of dural compromise. Patients were divided according to posterior extent of injury. Patient characteristics, imaging, surgical technique, and outcomes are reported. Results A total of 19 patients who underwent a bifrontal craniotomy for repair of posteriorly located ASB dural defects using nonpenetrating titanium microclips were included. Defects were divided by location: olfactory groove (10/19), planum sphenoidale (6/19), and tuberculum sellae (3/19). No patients demonstrated a postoperative CSF leak. No complications related to the microclip technique was observed. Clip artifact did not compromise postoperative imaging interpretation. Conclusion Primary repair of posteriorly located ASB dural defects is challenging due to narrow working angles and thin dura mater. Use of nonpenetrating titanium microclips for primary repair of posteriorly located dural defects is a reasonable adjunctive repair technique and was associated with no postoperative CSF leaks in this cohort.

Incidental Durotomy During Endoscopic Stenosis Lumbar Decompression: Incidence, Classification, and Proposed Management Strategies.

OBJECTIVE: We sought to review the types of incidental durotomies (IDs) that occurred during the endoscopic stenosis lumbar decompression through interlaminar approach (ESLD) and discuss the management strategies according to our classification. METHODS: A retrospective evaluation was performed for patients with spinal stenosis who underwent ESLD. Out of 330 patients, 27 patients of ID were clinically evaluated preoperatively and postoperatively on the basis of a visual analog scale score, Oswestry Disability Index, and MacNab's criteria. ID patterns are classified according to the size, location, and involvement of neural elements. Intraoperative and postoperative surgical management was evaluated. RESULTS: Intraoperative incidence of ID was 8.2%. According to lumbar levels, 11 (40.7%) occurred at L3-4, 12 (44.4%) at L4-5, and 4 (14.8%) at L5-S1 ID cases. IDs were divided into 4 types: 29.6% are type 1, 70% are type 2, 7.4% are type 3, and 3.7% are type 4. Overall for mean and standard deviation preoperative, 1 week postoperative, 3 months, and final follow-up for visual analog scale are 7.6 ± 1.4, 3.3 ± 1.1, 2.6 ± 1.1, and 1.9 ± 1.3, and for Oswestry Disability Index are 74.5 ± 9.0, 32.3 ± 9.4, 27.3 ± 7.2, and 24.4 ± 6.5 after patch blocking dura repair of ID. CONCLUSIONS: ID is a more common surgical complication in ESLD compared with the transforaminal approach. The endoscopic patch blocking dura repair technique should be considered in type 1 to type 3A of dura tear with good prognosis and clinical outcome. Consideration is made for conversion to open repair in types 3B, 3C and 4 dura tears with fair to poor outcome.

Failure Pressures of Dural Repairs in a Porcine Ex Vivo Model: Novel Use of Titanium Clips Versus Tissue Glue.

OBJECTIVE: Endoscopic skull base surgery is advancing, and it is important to have reliable methods to repair the resulting defect. The objective of this study was to determine the failure pressures of 2 commonly used methods to repair large dural defects: collagen matrix underlay with fibrin glue and collagen matrix underlay with polyethylene glue, as well as a novel repair method: fascia lata with nonpenetrating titanium vascular clips. METHODS: The failure pressure of the 3 dural repairs was determined in a closed testing apparatus. Defects in porcine dura were created and collagen matrix grafts were used as an underlay followed by either fibrin glue (FG/CMG) or polyethylene glycol glue (PEG/CMG). A third condition using a segment of fascia lata was positioned flush with the edges of the dural defect and secured with titanium clips (TC/FL). Saline was infused to simulate increasing intracranial pressure (ICP) applied to the undersurface of the grafts until the repairs failed. RESULTS: The mean failure pressure of the PEG/CMG repair was 34.506 ± 14.822 cm H2O, FG/CMG was 12.413 ± 5.114 cm H2O, and TC/FL was 8.330 ± 3.483 cm H2O. There were statistically significant differences in mean failure pressures among the 3 repair methods. CONCLUSION: In this ex vivo model comparing skull base repairs' ability to withstand cerebrospinal fluid leak, the repairs that utilized PEG/CMG tolerated the greatest amount of pressure and was the only repair that exceeded normal physiologic ICP's. Repair methods utilizing glues generally tolerated higher pressures compared to the novel repair using clips alone.

Spinal dural closure without suture: Minimizing the risk of CSF leakage with a flat non-penetrating titanium U-clip.

BACKGROUND: The classic surgical spinal dural closure technique in surgery on intradural lesions is performed with continuous suture or loose stitches using 4-0 to 6-0 polypropylene monofilament or nylon suture. Dural closure with suture causes irritant damage to the dural/arachnoid interface. The penetrating suture causes new dural holes. Even the needle of the suture can cause harm to the patient and the surgeon. For these reasons, other non-penetrating techniques for dural closure have been sought. OBJECTIVE: The purpose of this review was to show the efficacy of using the titanium clip (U-clip) (Ligaclip-MCA of Ethicon Endo-Surgery, LLC, Medical GmbH, Norderstedt, Germany) with a flat internal surface in spinal neurosurgical procedures, and to evaluate the effects of its use on post-operative magnetic resonance imaging (MRI). METHODS: We performed a retrospective analysis of a cohort of 50 consecutive patients who underwent intradural spinal surgeries for intradural spinal lesions in the neurosurgery department of our institution between 2013 and 2018. RESULTS: The mean follow-up period was 27 months. No patient developed a post-operative cerebrospinal fluid (CSF) dural-cutaneous fistula. CSF leakage was not observed in the control MRIs at 6 weeks. CONCLUSIONS: We describe, for the first time, the use of this type of U-clip with a flat inner side. The non-penetrating titanium U-clip facilitates effective and rapid dural closure at all spinal levels due to its flat internal face when closed. The U-clips did not cause significant artefacts or distortions on the magnetic resonance imaging.

Comparison of the results of laparoscopic appendectomies with application of different techniques for closure of the appendicular stump.

BACKGROUND: Nowadays laparoscopy is used frequently not only in elective surgery but also in abdominal emergencies, including acute appendicitis. There are several techniques used to close the appendicular stump during laparoscopic appendectomy. The aim of the study was to present and compare the results of minimally invasive appendectomies performed with the use of endoscopic staplers (group A), titanium endoclips (group B) and invaginating sutures (group C). METHODS: Three hundred seven patients (mean age = 35.6; SD = 15.9; 178 males,129 females) operated on laparoscopically for acute appendicitis from January 2010 to December 2014 at our department were included in the study. We reviewed retrospectively patients' data including: age, sex, duration of the surgical procedure and hospital stay, mortality, intraoperative and postoperative complication rates in all analyzed groups. RESULTS: There were 102 patients in group A (mean age = 35.8;SD = 15.4; 57 males, 45 females). The average hospital stay in this group was 4.3 days (SD = 1.7), average operation time was 62.0 min (SD = 15), postoperative complication rate was 5.9 %. There were 160 patients in group B (mean age = 35.0; SD = 16.3; 96 males, 64 females). The average hospital stay in this group was 3.6 days (SD = 1.4), average operation time was 62.9 min (SD = 13.5), postoperative complication rate was 5.6 %. There were 45 patients in group C (mean age =37.3; SD = 15.8; 25 males, 20 females). The average hospital stay in this group was 4.6 days (SD = 2.0), average operation time was 73.9 min (SD = 20.8), postoperative complication rate was 6.7 %. There were no intraoperative complications and no mortality in all compared groups of patients operated on laparoscopically for acute appendicitis. CONCLUSIONS: Laparoscopic appendectomies with application of different techniques for closure of the appendicular stump are useful and safe. In our study the shortest hospital stay and lowest complication rate were observed in patients operated with the use of titanium endoclips. The longest hospital stay and operation time and the highest complication rate was associated with the use of invaginating sutures.

Durotomy repair in minimally invasive transforaminal lumbar interbody fusion by nonpenetrating clips.

BACKGROUND: Closure of the dura defect may be easy to perform in open lumbar surgery but could be difficult in minimally invasive transforaminal lumbar interbody fusions (MIS-TLIF) since MIS-TLIF was done through a small tube, which limited the use of standard dural repair instruments. We used nonpenetrating titanium clips that were originally designed for the vascular anastomoses to repair the dura defect, which is never described in the literature. METHODS: We presented a case of spinal stenosis with incidental durotomy while performing MIS-TLIF. We closed the dura laceration with three medium-sized nonpenetrating titanium clips (AnastoClip Vessel Closure System, LeMaitre Vascular, Inc., Burlington, MA). RESULTS: Nonpenetrating titanium clips have the benefits of being technically easy to use, reduced durotomy repair time, decreased bed rest due to related medical complications, superior postoperation with immediate hydrostatic strength, and better reapproximation if it fails to clip successfully. As for the postoperation follow up, clips are tiny and reveal no obvious artifact, especially in cases where the pedicle screws are already causing much artifact. CONCLUSION: Primary dural closure during MIS-TLIF with clips is an effective way in cases that involve limited tubular space.

Clipes de titânio no tratamento de aneurismas saculares intracranianos / Titanium clips in the treatment of intracranial saccular aneurysms

Este trabalho descreve a utilização de 25 clipes de titânio no tratamento de 20 pacientes com hemor ragia subaracnóide aneur ismática. Todos os pacientes apresentavam hemorragias de graus I e II na escala de Hunt e Hess, provocadas por aneurismas da circulação anterior. O resultado do tratamento cirúrgico foi bom, não ocorrendo qualquer complicação, precoce ou tardia, que pudesse ser atribuída aos clipes de titânio. As dimensões médias dos artefatos provocados pelos clipes na tomografia computadorizada (TC) (comprimento) e ressonância magnética (RM)(volume) foram de 17,65 mm e 1,64 cm3 , respectivamente. Os clipes de titânio demonstraram ser cirurgicamente seguros e efetivos e, quando comparados com os clipes de liga de cobalto disponíveis no comércio, produziram artefatos bem menores nas imagens obtidas pela TC e RM, devido a sua menor susceptibilidade magnética. Com base nessas importantes vantagens, acreditamos que os clipes de titânio devam ser considerados como a opção ideal para uso rotineiro em cirurgiasde aneurismas.

This report describes the clinical use of 25 titanium clips in the treatment of 20 patients with aneurysmal subarachnoid hemorrhage. All patients had Hunt and Hess Grade I-II hemorrhages from aneurysms of the anterior circulation. The surgical outcome was good in the entire series, with no immediate or delayed complication related to the t i tanium cl ips. The average cl ip ar t i facts on the postoperat ive computerized tomography (CT) (lenght) and magnetic resonance imaging (MRI) (volume) was 17.65 milimeters and 1.64 cubic centimeters, respectively. The titaniumaneurysm clips seem to be surgically safe and effective and to reduce the clip artifacts on CT and MRI studies, when compared with commercially available cobalt alloy clips. Based on these important advantages over conventional clips, titanium clips should be considered as the ideal option for routine use in aneurysm surgery.