Anastomotic Closure Research Articles

Design of Three-Dimensional-Printed Compression Ring for Enhanced Wound Healing of Colorectal Anastomosis to Minimize Dehiscence and Leakage Post Colectomy

Abstract Bowel resection surgery, also known as colectomy, is a primary therapeutic intervention where a neoplastic or cancerous segment of the bowel is removed and an anastomosis constructed to reestablish intestinal continuity. Several techniques can be used to create the anastomosis, including mechanical staplers or manual sutures. A potentially life-threatening complication in colon anastomosis is dehiscence and leakage. Various contributing factors can hinder the formation of anastomosis, including technical failure (human error, staple malfunction), inflammation caused by foreign body response (sutures and staples), collagenolytic bacteria, and patient comorbidities (chemotherapy, old age, and obesity). Here, we report a three-dimensional (3D)-printed compression ring with electrical stimulation (ES) functionality to improve wound healing and anastomotic closure. The device consists of a one-way locking mechanism for initial deployment, an elastic band tightening mechanism to secure seal as tissue heals, and electrodes for electrical stimulation to enhance wound healing. The compression ring was assembled with 83.4±3.9 N of force and delivers 147.5±8.8 kPa of pressure to tissue, effectively restricting blood flow to the clamped tissue. This helps to create the anastomosis between remaining tissue on either side. Our design facilitates manual assembly without necessitating an additional delivery device. Electrical impedance analysis confirmed adequate tissue–electrode contact. We tested this device with ex vivo ovine intestinal tissue and confirmed that the compression ring was able to withstand up to 2.0±0.4 kPa intraluminal pressure immediately following installation. By combining mechanical strength and electrical stimulation, this device could potentially improve wound healing, anastomotic closure, and minimize the risk of leaks.

Cholangioscopy and double-balloon enteroscopy mediated "sandwich puncture" of a completely closed choledochojejunostomy.

Video 1Percutaneous cholangioscopy was performed to confirm complete closure of the choledochojejunostomy. Percutaneous cholangioscopy revealed complete closure of the anastomosis. Our attempt to pass a guidewire through the anastomosis failed accordingly.

Application of endoscopic technique in completely occluded anastomosis with anastomotic separation after radical resection of colon cancer: a case report and literature review

BackgroundAnastomosis-related complications are common after the radical resection of colon cancer. Among such complications, severe stenosis or completely occluded anastomosis (COA) are uncommon in clinical practice, and the separation of the anastomosis is even rarer. For such difficult problems as COA or anastomotic separation, clinicians tend to adopt surgical interventions, and few clinicians try to solve them through endoscopic operations.Case presentationIn this article, we present a case of endoscopic treatment of anastomotic closure and separation after radical resection for sigmoid carcinoma. After imaging examination and endoscopic evaluation, we found that the patient had a COA accompanied by a 3–4 cm anastomotic separation. With the aid of fluoroscopy, we attempted to use the titanium clip marker as a guide to perform an endoscopic incision and successfully achieved recanalization. We used a self-expanding covered metal stent to bridge the intestinal canal to resolve the anastomotic separation. Finally, the patient underwent ileostomy takedown, and the postoperative recovery was smooth. The follow-up evaluation results showed that the anastomotic stoma was unobstructed.ConclusionsWe reported the successful application of endoscopic technique in a rare case of COA and separation after colon cancer surgery, which is worth exploring and verifying through more clinical studies in the future.

Network meta-analysis comparing techniques and outcomes of stump closure after distal pancreatectomy.

The incidence of postoperative pancreatic fistula (POPF) after distal pancreatectomy remains high, and different pancreatic stump closure techniques have been used to reduce the incidence. A network meta-analysis was undertaken to compare the most frequently performed pancreatic stump closure techniques after distal pancreatectomy and determine the technique associated with the lowest POPF rate. A systematic search of the Scopus, PubMed, MEDLINE and Embase databases was conducted to identify eligible RCTs. The primary outcome was the occurrence of clinically relevant POPF. Secondary outcomes were duration of operation, blood loss, intrabdominal collections, postoperative complications and 30-day mortality. Sixteen RCTs including 1984 patients and eight different pancreatic stump closure techniques were included in the network meta-analysis. Patch coverage of the pancreatic stump (round ligament or seromuscular patch) after stapler or suture closure ranked best, with the lowest rates of clinically relevant POPF, lowest volume of intraoperative blood loss, fewer intra-abdominal abscesses, and lower rates of overall complications and 30-day mortality. Round ligament patch closure outperformed seromuscular patch closure in preventing clinically relevant POPF with a significantly larger cohort for comparative analysis. Pancreaticoenteric anastomotic closure consistently ranked poorly for most reported postoperative outcomes. Patch coverage after stapler or suture closure has the lowest POPF rate and best outcomes among stump closure techniques after distal pancreatectomy.

Total Colo-Rectal Anastomotic Closure Corrected by Placement of an Axios Stent via an Endoscopic Double Illumination Technique

Total Colo-Rectal Anastomotic Closure Corrected by Placement of an Axios Stent via an Endoscopic Double Illumination Technique

Assessment of the effect on blood loss and transfusion requirements when adding a polyethylene glycol sealant to the anastomotic closure of aortic procedures: a case–control analysis of 102 patients undergoing Bentall procedures

BackgroundThe use of CoSeal®, a polyethylene glycol sealant, in cardiac and vascular surgery for prevention of anastomotic bleeding has been subject to prior investigations. We analysed our perioperative data to determine the clinical benefit of using polyethylene glycol sealant to inhibit suture line bleeding in aortic surgery.MethodsFrom January 2004 to June 2006, 124 patients underwent aortic surgical procedures such as full root replacements, reconstruction and/or replacement of ascending aorta and aortic arch procedures. A Bentall procedure was employed in 102 of these patients. In 48 of these, a polyethylene glycol sealant was added to the anastomotic closure of the aortic procedure (sealant group) and the other 54 patients did not have this additive treatment to the suture line (control group).ResultsThere were no significant between-group differences in the demographic characteristics of the patients undergoing Bentall procedures. Mean EuroSCORES (European System for Cardiac Operative Risk Evaluation) were 13.7 ± 7.7 (sealant group) and 14.4 ± 6.2 (control group), p = NS. The polyethylene glycol sealant group had reduced intraoperative and postoperative transfusion requirements (red blood cells: 761 ± 863 versus 1248 ± 1206 ml, p = 0.02; fresh frozen plasma: 413 ± 532 versus 779 ± 834 ml, p = 0.009); and less postoperative drainage loss (985 ± 972 versus 1709 ± 1302 ml, p = 0.002). A trend towards a lower rate of rethoracotomy was observed in the sealant group (1/48 versus 6/54, p = 0.07) and there was significantly less time spent in the intensive care unit or hospital (both p = 0.03). Based on hypothesis-generating calculations, the resulting economic benefit conferred by shorter intensive care unit and hospital stays, reduced transfusion requirements and a potentially lower rethoracotomy rate is estimated at €1,943 per patient in this data analysis.ConclusionsThe use of this polymeric surgical sealant demonstrated improved intraoperative and postoperative management of anastomotic bleeding in Bentall procedures, leading to reduced postoperative drainage loss, less transfusion requirements, and a trend towards a lower rate of rethoracotomy. Hypothesis-generating calculations indicate that the use of this sealant translates to cost savings. Further studies are warranted to investigate the clinical and economic benefits of CoSeal in a prospective manner.

Early, minimally invasive closure of anastomotic leaks: a new concept

Chronic pelvic sepsis after ileoanal or coloanal anastomosis precludes ileostomy closure and, even if closure is ultimately possible, function of the neorectum is badly affected. Early closure of the anastomotic leak might prevent chronic pelvic sepsis and its adverse sequelae. In our experience of early closure in a consecutive group of six patients with a leaking low anastomosis (five with ileoanal pouch anastomosis and one after a low anterior resection), we were able to achieve anastomotic closure in five by means of initial endosponge therapy followed either by early suture (four patients) or endoscopic clip repair (one patient). Early minimally invasive closure of low anastomotic leaks is therefore possible provided that the para-anastomotic cavity is drained well prior to closure and the anastomosis is defunctioned.

Minimally invasive treatment of benign complete stenosis of colorectal anastomosis

rectal surgery are leaks and stenosis, which occur with a frequency of 0.3%± 30% [1,2]. Strictures are commonly treated with conservative treatments such as balloon dilatation, endoscopic incision, and placement of self-expanding metal stent (SEMS) [3±5]. Two patients with complete colorectal anastomotic closure were successfully treated with an endoscopic±radiologic rendezvous procedure. A 27-year-old woman who had undergone low anterior resection due to cancer of the rectum, and a 69-year-old man who had undergone left colonic resection because of acute diverticulitis were referred to our department. Both patients had a loop ileostomy. Endoscopic and radiologic follow-up before recanalization showed complete anastomotic stricture (l Fig. 1) at 8 cm and 16 cm from the anal verge, respectively. In both patients malignancy was excluded by means of multiple biopsies. Both patients were treated as follows. An incision of the fibrotic stenosis of the anastomosis was made through the rectum using a needle normally used for transjugular intrahepatic portosystemic shunt (TIPS). Direct vision of the puncture place was assured by an anterograde colonoscopy from the ileostomy (l Fig. 2). A guide wire was passed through and a drainage catheter was placed. The drainage catheter was kept in place for 3 days (l Fig. 3). Following two balloon dilatations, a fully covered and removable stent was placed (l Fig. 4). After 60 days, the stent was removed (l Fig. 5). In one patient the stent gave mild tenesmus, which was alleviated by analgesic drugs. In both patients the neo-anastomosis (l Fig. 6) was still wide open and functioning well after 24 months. Even in such difficult cases, in which the use of surgery seemed inevitable and furthermore not free of risks, the cooperation between endoscopist and radiologist made conservative treatment possible. The placement of removable SEMS in order to maintain an adequate lumen and to eliminate any possible leak was demonstrated to be a safe and efficient technique.

Robotic Radical Prostatectomy: Assurance of Water-Tight Vesicourethral Anastomotic Closure with the Lapra-Ty Clip

Most surgeons use a continuous running suture technique during robot-assisted radical prostatectomy followed by knot tying. Because of lack of haptic feedback and the potential for suboptimal suture tension after knot tying, the anastomotic closure may not be water-tight. Use of the Lapra-Ty clip (LTc) during anastomotic reconstruction offers the surgeon the ability to readjust suture tension as well as salvage torn sutures. Here we discuss our current anastomotic technique and highlight specific situations in which LTc use may prove beneficial.

Bladder Neck Contracture after Robot-Assisted Laparoscopic Radical Prostatectomy: Evaluation of Incidence, Risk Factors, and Impact on Urinary Function

Bladder neck contracture (BNC) after radical prostatectomy has been reported to occur in 5% to 32% of men after open radical retropubic prostatectomy (RRP) and 0% to 3% after laparoscopic RRP. Optimal anastomotic closure involves creating a watertight, tension-free anastomosis with well-vascularized, mucosal apposition and correct realignment of the urethra. The cause of BNC is poorly understood; however, it is likely related to multiple factors, including excessive luminal narrowing at the site of reconstruction, local tissue ischemia, failed mucosal apposition, and urinary leakage. In this large series of patients who underwent robot-assisted laparoscopic radical prostatectomy (RLRP), we report the incidence of BNC, evaluate the influence of age, body mass index (BMI), estimated blood loss (EBL), surgical time, and prostate weight on its development and assess follow-up urinary function.Between February 2003 and July 2006, 650 consecutive men underwent RLRP at our institution. Patients with aborted or open conversion procedures were excluded from analysis. The mean overall follow-up for the remaining 634 patients was 19.5 months. Patients presenting with symptoms of outlet obstruction were evaluated with cystoscopy to confirm a BNC. Comparisons of age, BMI, EBL, operative time, and prostate weight were performed using the Student t-test and chi-square analysis.BNC was the diagnosis in seven patients (1.1%), with a mean time of presentation of 4.8 (3-12) months postoperatively. The BNC patients had comparable mean age, BMI, prostate weight, and EBL to the non-BNC cohort. Their operative time, however, was significantly longer (283 v 225 min, P = 0.04).The incidence of BNC after radical prostatectomy is 1.1% in a large series of men undergoing RLRP. The diagnosis was made within 1 year. No significant impact on urinary continence or quality-of-life urinary function was observed after BNC management. A running anastomosis, better visualization, improved instrument maneuverability, and decreased blood loss may account for such a low rate.

A CASE OF REFRACTORY DUODENO-CUTANEOUS FISTURA

A 62-year-old man developed a refractory duodeno-cutaneous fistula after undergoing an operation for postoperative adhesion. Five previous simple anastomotic closure failed at another hospital. He underwent long-term intraveous parental hyperalimentation and showed hypoablbuminemia. We started elementary diet and performed an adhesiotomy electively. After successful dissection of postoperative adhesion, the duodenal defect was covered with elevated jejunum, and side-to-side duodeno-jejunostomy was performed. To facilitate decompression of he duodenum, a cholecystostomy and insertion of a cannula into the pancreatic duct was carried out. His postoperative course was uneventful. The large duodenal defect was a good candidate for a side to side anastomosis using elevated jejunal segment in such as this case.

Laser tissue soldering in urinary tract reconstruction: First human experience

Objectives Laser tissue soldering (LTS) in the urinary tract provides an immediate leak-free seal and may avoid complications seen with conventional repair (such as fistula and stricture). We have begun a Phase I clinical trial investigating the use of LTS in performing urologic reconstructive surgery. Methods Ten patients (aged 3 months to 38 years) underwent urologic reconstruction using LTS with a protein solder composed of human albumin (42%) and indocyanine green dye. In each case standard microsuture repair preceded laser-soldered suture line reinforcement. Anastomotic closure time and immediate leak pressure were measured. Postoperatively, all patients were evaluated for evidence of complications, including stricture, fistula formation, or impaired healing. Results Using LTS as an adjunct to suturing added an average of 7.9 ± 3.0 minutes (28%) to the overall mean anastomotic time of 28.3 ± 9.4 minutes. Intraoperative leak pressure measurements for laser-soldered anastomoses (≥94.2 ± 24.2 mm Hg) were significantly higher ( P < 0.001) than primarily sutured anastomoses (20 ± 2.9 mm Hg). Two instances of suture disruption (20%) occurred during laser activation, neither of which were repaired with sutures. Average follow-up for all patients was 7.1 ± 2.2 months. There were no intraoperative or postoperative complications, including the 2 patients with suture disruption. Conclusions These initial clinical results indicate that LTS is safe, easy to perform, and, contrary to conventional suturing, provides an immediate leak-free closure. Follow-up in these and other patients, as well as those undergoing sutureless and stent-free procedures, will determine whether our method of LTS benefits patients undergoing urologic reconstruction.

Temporary colostomy--an outmoded procedure? A report on the intracolonic bypass.

The intracolonic bypass is a procedure preventing the gastrointestinal secretions and fecal contents from coming into contact with an anastomotic closure site without interrupting the intraluminal continuity of fecal flow from proximal to distal colon. Experimental and clinical data have indicated that the intracolonic bypass can protect such an anastomosis, in the presence of maximal colonic loadings, dehiscences, and fecal peritonitis. This single stage procedure obviates the necessity for construction and subsequent closure of a temporary colostomy in situations where it is currently indicated; the morbidity, mortality, psychologic problems, and economic costs associated with these multiple procedures are avoided. Sufficient experience now has been gained to recommend the intracolonic bypass as a viable alternate to temporary colostomy.