Anastomotic Ring Research Articles

Decision on Preserving Ankle Joint Function in Neglected Neck Talus Fracture Hawkins Type IV

Introduction: Talus fractures are rare injuries to the hindfoot that still challenging in treatment. Accounting for <1% of foot and ankle fractures, and approximately 50% of them occur at the level of the neck. The anastomotic ring of blood supply is likely to be damaged in neck talus fractures, which disrupt the blood flow and cause significant problems affecting fracture healing and its complication. Case Illustration: We follow the progress of the illness from a 47 years old female complain pain on her left ankle after falling down 6 months before outpatient. Patient diagnosed as neglected close fracture left neck talus Hawkins type IV. Then patient undergo an ankle arthroscopy to evaluate the ankle joint in decision to preserve the tibiotalar joint, while arthrodesis performed in subtalar and talonavicular joints in this patient. This procedure achieved a good result in preserve ankle alignment, stability and soft tissue damage reduction. Improvement of VAS and AOFAS Score from 5 and 39 preoperative to 0 and 81 in follow-up of 3 months after surgery with good compliance of the patient. Discussion: Arthroscopy is safe procedure obtaining anatomical joint surface and reduce tissue damage. Therefore, a clear articular surface must be found during arthroscopy in deciding to preserve the joint function. While subtalar arthrodesis also another option that can enhance blood supply to encourage union, although loss of some ankle motion has significant effect on ambulation.

PREVALENCE OF ANATOMICAL VARIATIONS OF CIRCLE OF WILLIS IN SOUTH INDIAN POPULATION SUCCUMBING TO ISOLATED TRAUMATIC BRAIN INJURY - A CADAVERIC STUDY

Introduction: The Circle of Willis (COW) is a large arterial anastomotic ring present at the basal cistern of the brain, uniting the internal carotid and the vertebro-basilar system. Sir Thomas Willis was the first to describe the importance of the circle in maintaining collateral flow. It was observed that there is very little mixing of blood between the collateral branches of the circle. These collaterals may however open up during occlusive episodes of the proximal feeding vessels or in case of severe stress such as stroke and traumatic brain injury (TBI) in order to maintain metabolic activity in the brain. This phenomenon is affected to various degrees in the presence of anomalies. The prevalence of anomalies of COW in the general population is up to 75.72% was demonstrated in other studies. Materials and Methodology: This is a cross sectional observational study. 20 consecutive patients above 18 years of age succumbed to isolated TBI who were subjected to medico-legal autopsy in our hospital were included. The anomalies were classified as per the criteria laid down by Stojanovi´c et al. Results: 9 Normal variants (Type A) of COW (45%) was found. The most common type of anomaly was Type C which was noted in 4 cases (20%). Conclusion: Anatomical variations of COW has proven association in the areas of stroke, aneurysm, migraine, carotid endarterectomy and ageing brains. Further studies are needed to determine whether the anomalies of COW really contribute to the mortality in TBI.

Transanal formation of anastomosis using C-REX device is feasible and effective in high anterior resection

PurposeC-REX is a novel instrument for creating stapleless colorectal anastomosis by compression. The aim of this study was to evaluate the feasibility and effectiveness of C-REX in open and laparoscopic high anterior resections.MethodsA prospective clinical safety study on 21 patients reconstructed with C-REX colorectal anastomosis following high anterior resection of the sigmoid colon using two different devices for intraabdominal (n = 6) or transanal (n = 15) placement of the anastomotic rings. Any signs of complications were prospectively monitored by a predefined protocol. Anastomotic contact pressure (ACP) was measured via a catheter-based system, and time for evacuation of the anastomotic rings by the natural route was noted. Blood samples were collected daily, and flexible endoscopy was performed postoperatively to examine macroscopic appearance of the anastomoses.ResultsOne of six patients operated with the intraabdominal anastomosis technique with an ACP of 50 mBar had to be reoperated because of anastomotic leakage. None of the 15 patients operated with the transanal technique (5 open and 10 laparoscopic procedures) had anastomotic complications, and their ACP ranged between 145 and 300 mBar. C-REX rings were uneventfully expelled by the natural route in all patients after a median of 10 days. Flexible endoscopy showed well-healed anastomoses without stenosis in 17 patients and a moderate subclinical stricture in one patient.ConclusionThese results indicate that the novel transanal C-REX device is a feasible and effective method for colorectal anastomosis following high anterior resections, irrespective of open or laparoscopic approach. Moreover, C-REX allows measurement of intraoperative ACP and thereby a quantitative evaluation of the anastomotic integrity.

MP78-09 SALVAGE DIRECT VISION INTERNAL URETHROTOMY FOR AFTER FAILED SUBSTITUTION URETHROPLASTY: EXTENDED LONG-TERM FOLLOW-UP FROM A RECONSTRUCTIVE REFERRAL CENTER

You have accessJournal of UrologyCME1 Apr 2023MP78-09 SALVAGE DIRECT VISION INTERNAL URETHROTOMY FOR AFTER FAILED SUBSTITUTION URETHROPLASTY: EXTENDED LONG-TERM FOLLOW-UP FROM A RECONSTRUCTIVE REFERRAL CENTER Dejan K. Filipas, Roland Dahlem, Phillip Marks, Tim A. Ludwig, Silke Riechardt, Margit Fisch, and Malte W. Vetterlein Dejan K. FilipasDejan K. Filipas More articles by this author , Roland DahlemRoland Dahlem More articles by this author , Phillip MarksPhillip Marks More articles by this author , Tim A. LudwigTim A. Ludwig More articles by this author , Silke RiechardtSilke Riechardt More articles by this author , Margit FischMargit Fisch More articles by this author , and Malte W. VetterleinMalte W. Vetterlein More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003355.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: There is controversy regarding the optimal salvage treatment option for stricture recurrence after anterior buccal mucosal graft urethroplasty (BMGU). Data on retreatment modalities and their outcomes are scarce. Thus, we aimed to report on our extended follow-up of patients undergoing direct vision internal urethrotomy (DVIU) for short, veil-like recurrences after anterior BMGU. METHODS: We included all men undergoing salvage DVIU for recurrence with short segment, anastomotic fibrous rings after prior BMGU at our center between 2009-2021. We recorded clinical characteristics such as stricture location relative to the buccal graft (proximal, middle, distal), time from BMGU to DVIU in months, and etiology. Primary endpoint was retreatment-free survival after salvage DVIU. Kaplan-Meier analysis was performed for censoring and subsequent treatment modalities in the case of recurrence after salvage DVIU were extracted. RESULTS: Overall, 105 patients underwent DVIU after BMGU for bulbar (66%), penobulbar (16%), penile (15%), or membranous stricture (2.9%). 45% of strictures were proximal of the graft, 43% distal, and 12% were located in a middle position or both proximal and distal of the graft. The majority of strictures were iatrogenic (67%), followed by idiopathic (13%), inflammatory (9.6%), and posttraumatic etiology (7.7%). Median time from BMGU to salvage DVIU was 10 mo (IQR 4.2-28). 13 men (12%) were lost to follow-up and at a median follow-up of 74 mo (IQR 32-127), 53 men (58%) suffered from stricture recurrence (median time to recurrence: 15 mo [IQR 5.0-41]). 12-mo retreatment-free survival was 86%, 82%, and 70% for proximal, distal, and middle/both proximal+distal stricture position, respectively (p=0.1; Figure 1). In patients recurring after salvage DVIU, most subsequent interventions consisted of redo BMGU (46%) and redo salvage DVIU (31%). CONCLUSIONS: Salvage DVIU for veil-like, short segment recurrences remains a limited but viable endoscopic treatment option after anterior BMGU. Pending larger multi-institutional validation, the benefit of DVIU appears more pronounced for anastomotic rings developing at the distal edge of the buccal graft. Source of Funding: n/a © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e1135 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Dejan K. Filipas More articles by this author Roland Dahlem More articles by this author Phillip Marks More articles by this author Tim A. Ludwig More articles by this author Silke Riechardt More articles by this author Margit Fisch More articles by this author Malte W. Vetterlein More articles by this author Expand All Advertisement PDF downloadLoading ...

Decision to Preserving Ankle Joint Function in Neglected Neck Talus Fracture with Type 2 Diabetic Mellitus Patient : A Case Report

Talus fractures are rare injuries to the hindfoot that still challenging in treatment. The anastomotic ring is likely to be damaged in neck talus fractures, which disrupt the blood flow and cause significant problems affecting fracture healing. Poor fracture healing and an increased risk of surgical complications were also associated with complex diabetes mellitus. We follow the progress of the illness from a 47 year old female complaint pain on her left ankle after falling down 6 months before outpatient. Physical examination shows swelling and varus deformed on affected ankle. Ankle x-ray and CT scan were done. Patient diagnosed as neglected close fracture left neck talus Hawkins type IV with type 2 diabetes mellitus. Then patient undergo an ankle arthroscopy to evaluate ankle joint and preserving ankle joint procedure by subtalar arthrodesis and iliac bone graft. This procedure achieved an excellent result in preserve ankle aligment, stability and soft tissue management. After 2 weeks wound heals without signs of infection and 3 weeks of followup VAS score mention from 0 to 1, with good compliance of the patient. Arthroscopy is safe procedure obtaining anatomical joint surface and reduce tissue damage. While arthrodesis enhance blood supply to encourage bone union, though loss of its ankle motion also has significant effect on ambulation.

Anastomotic Rings and Inflammation Values as Biomarkers for Leakage of Stapled Circular Colorectal Anastomoses.

Reliable markers to predict or diagnose anastomotic leakage (AL) of stapled circular anastomoses following colorectal resections are an important clinical need. Here, we aim to quantitatively investigate the morphology of anastomotic rings as an early available prognostic marker for AL and compare them to established inflammatory markers. We perform a prospective single-center cohort study, including patients undergoing stapled circular anastomosis between August 2020 and August 2021. The predictive value of the anastomotic ring configuration and the neutrophil-to-lymphocyte ratio (NLR) regarding anastomotic leakage is examined by ROC analyses and compared to the C-reactive protein (CRP) as an established marker. We included 204 patients, of which 19 suffered from anastomotic leakage (LEAK group), while in 185 patients the anastomoses healed well (HEAL group). The minimal height of the anastomotic rings as a binary classifier had a good ROC-AUC of 0.81 but was inferior to the NLR at postoperative day (POD) 5, with an excellent ROC-AUC of 0.93. Still, it was superior to the NLR at POD 3 (0.74) and the CRP at POD 3 (ROC-AUC 0.54) and 5 (ROC-AUC 0.70). The minimal height of the anastomotic rings as indicator for technically insufficient anastomoses is a good predictor of AL, while postoperatively the NLR was superior to the CRP in prediction of AL.

Consequences of anastomotic leaks after minimally invasive esophagectomy: A single-center experience

BackgroundAnastomotic leak (AL) after minimally invasive esophagectomy (MIE) is a well-described source of morbidity for patients undergoing surgical treatment of esophageal neoplasm. With improved early recognition and endoscopic management techniques, the long-term impact remains unclear. MethodsA retrospective review was conducted of patients who underwent MIE for esophageal neoplasm between January 2015 and June 2021 at a single institution. Cohorts were stratified by development of AL and subsequent management. Baseline demographics, perioperative data, and post-operative outcomes were examined. ResultsDuring this period, 172 MIEs were performed, with 35 of 172 (20.3%) complicated by an AL. Perioperative factors independently associated with AL were post-operative blood transfusion (leak rate 52.9% versus 16.8%; p = 0.0017), incompleteness of anastomotic rings (75.0% vs 19.1%; p = 0.027), and receiving neoadjuvant therapy (18.5% vs 30.8%; p < 0.0001). Inferior short-term outcomes associated with AL included number of esophageal dilations in the first post-operative year (1.40 vs 0.46, p = 0.0397), discharge disposition to a location other than home (22.9% vs 8.8%, p = 0.012), length of hospital stay (17.7 days vs 9.6 days; p = 0.002), and time until jejunostomy tube removal (134 days vs 79 days; p = 0.0023). There was no significant difference in overall survival between patients with or without an AL at 1 year (79% vs 83%) or 5 years (50% vs 47%) (overall log rank p = 0.758). ConclusionsIn this large single-center series of MIEs, AL was associated with inferior short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, without an accompanying impact on 1-year or 5-year survival. Key messageIn this large, single-center series of minimally invasive esophagectomies, anastomotic leak was associated with worse short-term outcomes including hospital length of stay, discharge disposition other than to home, and need for additional endoscopic procedures, but was not associated with worse long-term survival. The significant association between neoadjuvant therapy and decreased leak rates is difficult to interpret, given the potential for confounding factors, thus careful attention to modifiable pre- and peri-operative patient factors associated with anastomotic leak is warranted.

Routine pathologic evaluation of circular stapler anastomotic rings is not useful after resection for colorectal cancer: retrospective study and systematic review with meta-analysis.

BackgroundCircular staplers are commonly used for reconstruction after radical resection for colorectal cancer. Pathological analysis of the anastomotic rings is common practice, although the benefits are unclear. The purpose of this study was to evaluate the usefulness of routine histopathological analysis of anastomotic rings in an original series and in a systematic review of the literature.MethodThe retrospective study was performed at two university-associated academic hospitals in Winnipeg, Canada, including patients investigated for colorectal cancers (within 30 cm of the anal verge) who underwent resection between 2007 and 2020. The systematic review involved Ovid MEDLINE, Embase, Scopus, and Web of Science databases, selecting for adult human studies involving analysis of anastomotic rings in elective colorectal cancer resections. The main outcome measure was the proportion of patients with cancer in the anastomotic ring specimens. The frequency of benign pathology findings and changes to patient management were also examined.ResultsOut of 673 eligible patients, 487 were included in the retrospective analysis. No patients had cancer within the anastomotic ring specimens. Twenty-five patients (5.1 per cent) had benign pathological findings within the anastomotic ring specimens, and patient management was never affected. In the systematic review, 27 articles were included in the final analysis out of 5848 records reviewed. The rate of cancer within anastomotic ring specimens was 0.34 per cent, and the rate of change in patient management was 0.19 per cent.ConclusionThe likelihood of finding cancer within anastomotic rings is rare and their histopathological examination seldom changes patient management.

End to side circular stapled anastomosis during robotic-assisted Ivor Lewis minimally invasive esophagectomy (RAMIE).

Robotic-assisted minimally invasive esophagectomy (RAMIE) represents an established approach for the treatment of esophageal cancer. Aim of this study is to evaluate the feasibility and safety of our technique for performing the intrathoracic anastomosis during RAMIE.All the procedures were performed by the same surgeon using the same technique for performing the intrathoracic anastomosis. Intraoperative and postoperative outcomes were recorded. Postoperative complications were classified according to the Esophagectomy Complications Consensus Group (ECCG); the primary outcome was the evaluation of the feasibility and safety of our technique. From 2016 to 2021, 204 patients underwent Ivor Lewis RAMIE at our Center. Two patients (0.9%) were converted during the thoracic phase. The anastomosis was completed in all the other patients forming complete anastomotic rings. The median duration for the robotic-assisted thoracoscopic phase was 224minutes. Twenty-two of the RAMIE-Ivor Lewis patients had an anastomotic leakage (10.3%). The overall 90-day postoperative mortality was 1.9%. The procedure resulted to be feasible and safe in our cohort of patients.

OCT-angiography for the diagnosis of radiation maculopathy in patients treated with proton beam therapy: A 2-year prospective study.

Radiation maculopathy (RM) is the leading cause of visual acuity (VA) loss after proton beam therapy (PBT) of choroidal melanoma. The aim of this study was to assess the value of optical coherence tomography-angiography (OCT-A) for the diagnosis of RM in patients with choroidal melanoma treated with PBT. This 2-year prospective, descriptive, single-center study included patients treated with PBT for choroidal melanoma. VA measurement, retinography, OCT and OCT-A were performed. Vascular density (VD) in the superficial capillary plexus (SCP), peri-foveal anastomotic ring changes and foveal avascular zone (FAZ) enlargement were studied. Nineteen patients were included in the study. The median baseline melanoma thickness was 5.7 [3.6-8.1] mm. The median melanoma-to-macula distance was 3.5 [2.6-4.6] mm. The earliest signs of RM identified on retinography were hard exudates developing at 12 [12-24] months, followed by retinal hemorrhages at 18 [12-30] months, found in 88.9% and 77.8% of patients respectively. On OCT, the earliest sign was the onset/progression of cystoid macular edema (CME) at 12 [6-12] months, found in 10 patients (52.6%). On OCT-A, 100% of patients presented with a discontinuity of the perifoveal anastomotic ring and a FAZ enlargement after 12 [6-24] months. After 12 months, a VD loss in the SCP by 11.7% and 10.8% compared to baseline, was found in the macular and foveal areas respectively. A significant negative correlation was found between the VA and the VD in the macular SCP (R = -0.43; p = 0.029). OCT-A is a reliable and effective diagnostic tool for RM in patients with choroidal melanoma treated with PBT.

The Clinical Significance of Anastomotic Ulcers After Ileocolic Resection to Predict Postoperative Recurrence of Crohn’s Disease

The Rutgeerts score is used to predict postoperative recurrence in CD patients after ileocolic resection and is primarily based on endoscopic findings at the neoterminal ileum. However, the optimal assessment of anastomotic ulcers (AUs) remains subject to debate. We aimed to investigate the association between anastomotic ulcers (AUs) and endoscopic recurrence in postoperative Crohn's disease (CD) patients. This single-center retrospective study, conducted between 2000 and 2016, evaluated postoperative CD patients with endoscopic remission at the first ileocolonoscopy within 1year after ileocolic resection and those who underwent subsequent ileocolonoscopic follow-up. The study outcome was the clinical significance of AUs in predicting endoscopic recurrence. Among 116 patients who were in endoscopic remission defined as the RS of i0 to i1 at the index postoperative ileocolonoscopy, 84.5% (98/116) underwent subsequent ileocolonoscopies. During the median 30.0months (interquartile range, 21.3-53.3) of follow-up after the first ileocolonoscopy, 56.1% (55/98) of patients showed endoscopic recurrence. Furthermore, 65.8% (48/73) with AUs and 75.5% (40/53) with major AUs, defined as either an ulcer occupying ≥ 1/4 of the circumference, ≥ 3 ulcers confined to anastomotic ring, or any ulcers extending to the ileocolonic mucosa, showed endoscopic recurrence. On multivariable analysis, AUs (adjusted hazard ratio [aHR], 4.33; 95% confidence interval [CI], 1.87-10.0; P < 0.001) and major AUs (aHR, 3.64; 95% CI, 1.95-79; P < 0.001) were associated with endoscopic recurrence. AUs are associated with a significantly high risk of endoscopic recurrence in postoperative CD patients who are in endoscopic remission.

Management of 6 Months old Neglected Talus Neck Fracture: A Case Report with Review of Literature

Talus fractures are very rarely seen and account for approximately 1 percent of fractures around the foot and ankle Talar neck fractures are likely to damage the anastomotic ring, resulting in disruption of blood supply to the talar body which leads to significant problems in fracture healing and integrity. Approximately 39 percent of midfoot and ankle fractures could be missed during initial evaluation due to a lack of adequate radiological and clinical examination. Among these missed injuries approximately 50 percent are talus fractures. A 23-year-old male patient came with complaints of pain over the left foot while walking for 6 months. He had a history of falls from 10 feet height 6 months back. He was conservatively managed in a local hospital without any proper diagnosis. He presented to us 6 months later with chronic, dull aching, continuous pain which aggravates while walking and standing. The diagnosis of the non-union fracture neck of talus was made after radiology and was managed by open reduction and internal fixation with cannulated cancellous screws along with ipsilateral iliac crest cancellous bone grafting. Lack of timely diagnosis escalates the vascular insult, delays timely intervention, and increases morbidity.

P274 The clinical significance of anastomotic ulcers after ileocolic resection to predict postoperative recurrence of Crohn’s disease

Abstract Background The Rutgeerts score (RS) is used to predict postoperative recurrence in Crohn’s disease (CD) patients after ileocolic resection primarily based on endoscopic finding at the neoterminal ileum. However, assessing anastomotic ulcers (AUs) is still a matter of debate. Our aim was to investigate the clinical significance of AUs on endoscopic recurrence in postoperative CD patients. Methods This was a single-centre retrospective study analysing postoperative CD patients with the RS of i0 to i1 at the first ileocolonoscopy within 1 year after ileocolic resection between 2000 and 2016 and those who underwent subsequent ileocolonoscopic follow-up. The study outcome was the clinical significance of AUs predicting endoscopic recurrence (RS ≥ i2b). Results Among 116 patients who were in endoscopic remission at the index postoperative ileocolonoscopy, 84.5% (98/116) underwent subsequent ileocolonoscopies. During the 30.0 months (interquartile ranges, 21.3–53.3) of median follow-up periods after the index ileocolonoscopy, 56.1% (55/98) showed endoscopic recurrence. Furthermore, 65.8% (48/73) with AUs and 75.5% (40/53) with major AUs defined as ulcer occupying ≥ 1/4 of the circumference or ≥ 3 ulcers confined to anastomotic ring, or any ulcers extended to ileocolic mucosa showed endoscopic recurrence. On multivariable analysis, the presence of AUs (adjusted hazard ratio [aHR], 4.33; 95% confidence interval [CI], 1.87–10.0; p &amp;lt; 0.001) and major AUs (aHR, 3.64; 95% CI, 1.95–6.79; p &amp;lt; 0.001) were associated with endoscopic recurrence, respectively. Conclusion AUs are associated with a significantly higher risk of endoscopic recurrence in postoperative CD patient who are in endoscopic remission.

P087 Prevalence and Risk Factors for Developing Anastomotic Ring Inflammation After Ileal Resection and Ileo-Colonic Anastomosis in Patients With Crohn’s Disease

BACKGROUND: The development of early inflammation proximal to the anastomosis in patients with Crohn’s disease that undergo ileal resection has a significant prognostic significance. However, many patients also develop inflammatory changes at the level of the anastomotic ring. The prevalence and significance of this findings is unknown. The aim of this study is to assess the prevalence and risk factors for developing anastomotic ring inflammation (ARI) in patients with Crohn’s disease after an ileal resection and ileo-colonic anastomosis. METHODS: In this retrospective cohort study we analyzed 91 patients with Crohn’s disease (CD) who underwent ileal resection and ileocolonic anastomosis and surveillance colonoscopy within 24 months. The patients were followed from time of surgery through up to four subsequent colonoscopes if applicable. A board certified gastroenterologist reviewed all the endoscopic images for the procedures done. The primary outcome was ARI (partial or full). RESULTS: The cohort population of 91 patients was 51.6% female. Twenty patients had ARI on the first surveillance colonoscopy (4 of the complete anastomotic ring and 16 partial), with an additional 13 developing inflammation at subsequent colonoscopies. The type of surgical anastomosis performed (end to end, end to side or side to side) was not associated with the development of ARI (P > 0.05 for all). There was no difference in time between bowel resection and endoscopic assessment between those patients with and without ARI (12 [IQR: 7-26] and 11 [IQR: 8-18] months respectively [P = 0.62]). There were no differences in median Rutgeerts score or simple endoscopic score (SES-CD) in patients that did present with ARI versus those who did not (median Rutgeerts score of 1 [IQR: 0-2] and 0 [IQR: 0-2] [P = 0.37], and median SES-CD of 2 (IQR: 0-3] and 0 [IQR: 0-4] respectively [P = 0.52]). There was also no association between the presence of ARI and active histologic inflammation in the ileum proximal to the anastomosis (P = 0.23). There was also no statistically significant difference in age at the time of surgery between those patients with and without ARI (median of 35 [IQR:28-42] and 36 [IQR: 27-52] years respectively [P = 0.7]). Starting post-operative prophylaxis for CD recurrence was not associated with a lower prevalence of ARI (OR: 0.26 [95% CI: 0.03-2.1]. P = 0.18). CONCLUSION(S): No demographic or phenotypic variables were associated with development of inflammatory changes at the level of the anastomotic ring. Furthermore, the presence of inflammation did not correlate with endoscopic CD disease activity. Studies looking into the long term clinical significance of ARI are warranted.

P146 AN IMPROVEMENT TO THE CIRCULAR STAPLING ANASTOMOSIS TECHNIQUE DURING MINIMALLY

Abstract Aim The circular stapled (CS) technique with transoral placement of the anvil is commonly used to perform the esophago-gastric anastomosis during minimally invasive esophagectomy (MIE). The procedure is safe, efficient and highly reproducible, however the intersection between the circular plane of the stapler and the linear staple line of the esophageal stump can expose the anastomosis to the formation of dog ears and therefore increase the risk of anastomotic leakage (AL). We describe a simple modification of the CS technique that avoid the formation of staple lines intersection. Background and Methods We prospectively collected data on a small group of patients who underwent MIE for cancer using our modified CS technique. Our technical modification consists in folding the linear esophageal transection line with a stitch around the anvil shaft, in order to include the staple line in the resection during the EEATM firing (figure 1). Feasibility has been evaluated as the percentage of cases in which the improved anastomosis technique has been carried out successfully with the formation of a complete anastomotic ring. Safety has been defined as the absence of procedure related complications. Results MIE was performed in ten patients using our modified CS technique, median age was 55 years. All the procedures were successfully completed with complete resection of the linear esophageal staple line and no intraoperative complication. Only one patient developed a postoperative AL, that was only detected by barium swallow and did not cause any symptom or clinical sign. Conclusions Our modified CS technique is simple, feasible and safe. Further studies are needed to evaluate its efficacy in preventing the occurrence of anastomosis leakage.

A Technical Modification to the Circular Stapling Anastomosis Technique During Minimally Invasive Ivor Lewis Procedure.

Background: The circular stapled (CS) technique with transoral placement of the anvil is commonly used to perform the esophagogastric anastomosis during minimally invasive esophagectomy (MIE). The procedure is safe, efficient, and highly reproducible; however, the intersection between the circular plane of the stapler and the linear staple line of the esophageal stump can expose the anastomosis to the formation of dog-ears and, therefore, increase the risk of anastomotic leak (AL). We describe a simple modification of the CS technique that consists of folding the linear esophageal transection line with a stitch around the anvil shaft, to include the staple line in the resection during the EEA™ firing. Methods: We prospectively collected data on a small group of patients who underwent MIE for cancer using our modified CS technique. Feasibility has been evaluated as the percentage of cases in which the modified anastomosis technique has been carried out successfully with the formation of a complete anastomotic ring. Safety has been defined as the absence of procedure-related complications. Results: MIE was performed in 10 patients using our modified CS technique. All the procedures were successfully completed with complete resection of the linear esophageal staple line and no intraoperative complications. Only one patient developed a postoperative AL that was only detected by barium swallow and did not cause any symptom or clinical sign. Conclusion: Our modified CS technique is feasible and did successfully prevent the occurrence of clinically relevant ALs in this small case series of patients.

Design and development of a hybrid bioartificial water-induced shape memory polymeric material as an integral component for the anastomosis of human hollow organs

A large number of pathologies require the resection of the bowel and anastomoses to rejoin the two remaining stumps to regain lumen patency. Various materials have been used to rejoin one bowel end to the other such as catgut, stainless steel, and absorbable sutures. The present method for anastomosis surgery uses an entero-entero anastomosis (EEA) circular stapler with only a staple line. This method can have some drawbacks, such as intracellular fluid leakage and local inflammations. The aim of this study is to design and develop a novel bioartificial polymer with a ring shape made of polyvinyl alcohol (PVA) and gelatin (80/20 ratio (w/w)) loaded both directly with acetylsalicylic acid and with nanoparticles incorporating the same drug to reduce local inflammation even for a prolonged period of time. A physical method (8cycles freezing/thawing) was used to obtain a crosslinked bioartificial shape memory ring.Mechanical analysis showed a storage modulus having a comparable value with that of the human colon. HPLC analysis pointed out a sustained and prolonged release of the anti-inflammatory drug both immediately after anastomosis surgery and during healing period. Cell culture tests indicated the cytocompatibility of the bioartificial device. A shape memory of the hydrogel prepared in ring form was observed at 37°C after immersion in water. These bioartificial devices can represent a new approach to serve as a multifunctional anastomotic ring.

Experimental Procedure of Compression Anastomosis Using Fragmented Rings: A Porcine Model.

Compression anastomosis has been recently abandoned because of a nonsuperiority compared to stapling anastomosis. Nonremoval of the rings has frequently been reported and this technique does not support a routine use. The aim of this experimental study was to assess the feasibility of anastomosis using compression with a device consisting of fragmented rings. A new compression device, the "Anastocom," was compared to standard double-stapled colocolonic anastomosis in 2 groups of 8 pigs. In each group, colocolonic anastomosis was performed with a circular stapler (DST Series EEA Staplers) in 4 pigs and with the Anastocom device for the other 4 pigs. The anastomotic rings were expelled between postoperative day 7 and day 13 from the 4 animals sacrificed at day 30. The anastomosis was clean and intact in all pigs. After sacrifice, there was no difference in the bursting pressure at day 7 ( P = .226) or at day 30 ( P = .885) between the 2 types of anastomosis. After sacrifice at day 7, the mean bursting pressure values for the Anastocom and EEA anastomoses were 128.6 mm Hg (range 119-143 mm Hg) and 218.9 mm Hg (range 84-240 mm Hg), respectively. After sacrifice at day 30, the mean bursting pressure values for the Anastocom and EEA anastomoses were 111 mm Hg (range 59-234 mm Hg) and 105 mm Hg (range 81-130 mmHg), respectively. No bowel obstruction was observed with Anastocom. This fragmentation mechanism should better prevent nonexpulsion compared to basic compression anastomosis.

Imaging features of surgical complications of Crohn′s disease

Imaging features of surgical complications of Crohn′s disease

Compression versus hand-sewn and stapled anastomosis in colorectal surgery: a systematic review and meta-analysis of randomized controlled trials.

Anastomotic leaks are a feared complication of colorectal resections and novel techniques that have the potential to decrease them are still sought. This study aimed to compare the anastomotic leak rates in patients undergoing compression anastomoses versus hand-sewn or stapled anastomoses. Randomized controlled trials (RCTs) comparing outcomes of compression versus conventional (hand-sewn and stapled) colorectal anastomosis were collected from MEDLINE, Embase and the Cochrane Library. The quality of the RCTs and the potential risk of bias were assessed. Pooled odds ratios (OR) were calculated for categorical outcomes and weighted mean differences for continuous data. Ten RCTs were included, comprising 1969 patients (752 sutured, 225 stapled, and 992 compression anastomoses). Most used the biofragmentable anastomotic ring. There was no significant difference between the two groups in terms of anastomotic leak rates (OR 0.80, 95% confidence interval (CI) 0.47, 1.37; p=0.42), stricture (OR 0.54: 95% CI 0.18, 1.64; p=0.28) or mortality (OR 0.70; 95% CI 0.39, 1.26; p=0.24). Compression anastomosis was associated with an earlier return of bowel function: 1.02 (95% CI 1.37, 0.66) days earlier (p<0.001) and a shorter postoperative stay; 1.13 (95% CI 1.52, 0.74) days shorter (p<0.001), but significant heterogeneity among studies was observed. There was an increased risk of postoperative bowel obstruction in the compression group (OR 1.87; 95% CI 1.07, 3.26; p=0.03). There was no significant difference in wound-related and general complications, or length of surgery. Compression devices do not appear to provide an advantage over conventional techniques in fashioning colorectal anastomoses and are associated with an increased risk of bowel obstruction.