Anastomotic Technique Research Articles

Anastomotic techniques for small intestinal obstruction in horses. A scoping review.

Small bowel obstruction (SBO) is a significant cause of surgery in adult horses presenting with colic pain. SBOs often require resection and anastomosis. While various techniques for intestinal anastomoses have been developed, it remains uncertain if any fully meet our clinical needs. To conduct a scoping review of publications on anastomosis techniques and outcomes for the treatment of SBO. Scoping review. A literature review was conducted using the CAB, Web of Science, Scopus, and PubMed databases. Peer-reviewed scientific articles in English, published between 1992 and 2023, were included. A quality assessment was performed for potentially eligible articles. Experimental studies, case reports, and case series with less than five cases were excluded and relevant data on study methods and sample size were extracted and charted from remaining articles. Anastomosis type and outcome were reported for articles considered potentially eligible for meta-analysis. Articles in which only overall outcome was reported or details on type of anastomosis were not reported were excluded for the final charting. Of 3024 articles, 210 underwent a quality assessment. The most common study designs were case reports and case series (64.3%), followed by experimental studies (17.1%). After further exclusions, 104 articles met the inclusion criteria. In only 42 articles detailed data on type of anastomosis and relative outcome were reported. A total of 23 anastomosis types were reported for the treatment of SBO, with 6 different outcomes evaluated. Both short- and long-term survival rates consistently exceed 70% for all types of anastomosis (jejuno-jejunal, jejuno-ileal, and jejunocaecal). Non-English language studies and conference proceedings were excluded. The body of literature focused on surgical treatment for SBO exhibits low-quality evidence. Several techniques of anastomosis were described for different pathologies. However, there is a lack of homogeneity in reporting outcome for each surgical technique. Furthermore, outcomes considered varied significantly among studies and were sometimes poorly reported, although success rates are generally high. Overall, there is a need for better-structured studies on existing and commonly used techniques before comparing techniques and exploring other innovative approaches.

Controversies in IPAA for Ulcerative Colitis: A Systematic Review of Different Anastomotic Techniques.

Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these techniques. To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy. Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria. Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis. IPAA technique. Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function). Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques. A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy. Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.

Intracorporeal antimesenteric ancillary trocar: an anastomotic technique facilitating natural orifice specimen extraction in left-sided colorectal surgery.

Natural orifice specimen extraction (NOSE) in left-sided colorectal surgery requires application of the circular stapler anvil to the proximal bowel without exteriorization through an additional abdominal incision. We describe an intracorporeal method to secure the stapler anvil, termed the intracorporeal antimesenteric ancillary trocar (IAAT) technique. The ancillary trocar is attached to the stapler anvil before introduction into the abdominal cavity through the anal or vaginal orifice. The colon is incised before the trocar spike is brought out through the antimesenteric surface 3-4 cm within the cut edge. A linear stapler is used to seal the bowel end. The ancillary trocar is detached and retrieved via the NOSE conduit. Following the NOSE procedure, a side-to-end colorectal anastomosis is performed with the transanal circular stapler. Ten consecutive patients underwent elective left-sided colorectal resection with IAAT for NOSE (seven transanal, three transvaginal) from January to June 2023. Median age and body mass index were 66 (range 47-74) years and 24.3 (range 17.9-30.8) kg/m2 respectively. Two (20%) patients underwent sigmoid colectomy for sigmoid volvulus while eight (80%) underwent anterior resection for colorectal cancer. Median operating time, operative blood loss and postoperative length of hospital stay were 170 (range 140-240) min, 20 (range 10-40) mL and 1 (range 1-3) day respectively. There were no postoperative complications, readmissions or reoperations. Median follow-up duration was 3 (range 1-6) months. The IAAT double-stapling side-to-end anastomotic technique is safe and feasible for patients undergoing left-sided colorectal resection with NOSE, resulting in good outcomes.

OP19 Extended mesenterectomy is not superior to mesenteric sparing resection in primary ileocolic resection for Crohn’s Disease in terms of postoperative endoscopic recurrence – results of an international randomised controlled trial

Abstract Background Extended mesenteric resection has recently been proposed to improve clinical outcomes after an ileocolic resection (ICR) for Crohn’s disease. The aim of this study was to analyse the clinical relevance of extended mesenteric resection, up to the level of the ileocolic trunk (intervention group), compared to conventional mesenteric sparing resection (control group) with regard to postoperative outcomes in patients undergoing primary ICR for Crohn’s disease. Methods In an international randomised controlled trial (RCT), patients ≥16 years, were assigned 1:1 to either the intervention- or the control-group. The anastomotic technique was standardised (side-to-side stapled). To demonstrate a relevant difference of 25% in postoperative endoscopic recurrence (defined as a modified Rutgeerts score ≥i2b, according to central reading) at 6 months, a minimum of 62 evaluable patients per arm were required. Secondary outcome parameters were postoperative morbidity, histopathological outcomes and use of Crohn’s medication postoperatively. Results In total, of the 129 included patients, 56 (43.3%) were male with a median age of 36 (IQR 22-55). There were no statistically significant differences in baseline characteristics between the two groups. There was no difference in endoscopic recurrence rates between the two groups: 27/62 (43.5%) in the intervention group and 27/64 (42.2%) in the control group, (p=1.0) Fig 1. Median time until endoscopy was 6 months (IQR 6-7). More patients received postoperative medical prophylaxis in the intervention group (28% vs 14%). In the control group, more patients started medication after endoscopy (intervention group 20% vs control group 27%). This resulted in a similar number of patients in both groups being on Crohn’s medication after six months, 48% in the intervention group and 41% in the control group. There was no significant difference in length of resection specimen (median length colon 7cm; ileum 22.5cm), blood-loss or operative time. Overall, a postoperative complication occurred in 28%, with anastomotic leakage in 5 (3.9%). Conclusion This is the first RCT to present data on the effect of extended mesenteric resection during ICR for Crohn’s disease. The results of this study showed no superiority of extended mesenteric resection with regard to endoscopic recurrence or other perioperative outcomes.

A modified adventitial inversion with graft insertion technique in acute Type A aortic dissection.

Acute type A aortic dissection may originate from a primary intimal tear located in the ascending aorta and often extends retrogradely into the aortic root. How to prevent bleeding in the aortic root and eliminate false lumen is very important in aortic dissection. We have developed a modified anastomotic technique that involves inverting adventitial and graft into aorta and reinforcing with a felt strip on the external border of the aortic wall. Since 2020, 45 consecutive patients with type A aortic coarctation have undergone this aortic root reconstruction procedure, to date, none have been reopened for bleeding or remnant dissection.

The benefits of R anastomotic technique for Billroth-II reconstruction with Braun anastomosis during totally laparoscopic distal gastrectomy: a propensity score matching analysis.

Currently, there is no consensus on the most appropriate anastomotic site, anastomotic line, and direction for Billroth-II reconstruction with Braun anastomosis (B-II-B anastomosis) during totally laparoscopic distal gastrectomy (TLDG). Herein, the authors presented a novel anastomotic technique called R anastomosis for B-II-B anastomosis and compared it with the conventional B-II-B anastomosis technique to assess its feasibility, safety, and effectiveness. Between March 2019 and September 2022 in our centre, R anastomosis was performed on 123 patients undergoing TLDG for distal gastric cancer. A retrospective review of a prospectively collected database identified patients who underwent TLDG between January 2010 and September 2022. Patients who underwent R anastomosis were matched in a 1:1 ratio with patients who underwent conventional anastomosis using a propensity score based on age, sex, preoperative BMI, American Society of Anesthesiologists (ASA) score, and the history of abdominal surgery. Surgical and postoperative outcomes and clinicopathological data were analyzed for both groups. During the study period, 246 patients were included, 123 in each group. No intraoperative complications associated with digestive tract reconstruction and no cases of conversion to open surgery were reported in either group; furthermore, no incidences of perioperative mortality were noted in either group. The R group had a significantly reduced anastomotic time compared to the control group (30 ± 4.1 vs. 36 ± 5.3 min, P < 0.001). Perioperatively, the incidences of Clavien-Dindo grade II or higher complications were 6.5% (8/123) and 12.2% (15/123) in the R and control groups with no significant difference between the two groups. Postoperative gastric emptying dysfunction was found in five and one patient in the control and R groups, respectively. R anastomosis is a safe and effective technique for B-II-B anastomosis following TLDG. This novel technique enhances the convenience of performing anastomosis and can reduce postoperative gastric emptying dysfunction.

Vascular Anastomosis Course for Core Surgical Trainees (VACT)

Abstract Introduction: On completion of Core Surgical Training, Core Surgical Trainees (CSTs) are expected to have an understanding of emergency and elective vascular conditions as well as practical experience of vascular suturing. A proportion of CSTs will have a vascular rotation and may have been unable to acquire these skills during their placement. We used the postgraduate virtual learning environment (PGVLE) developed by Health Education England West Midlands (HEEWM) in combination with practical sessions to provide a Vascular Anastomosis Course for CSTs (VACT). There are few courses aimed at teaching CSTs the practical skills needed to become a vascular surgeon. VACT aims to improve tissue handling and teach anastomotic technique to CSTs whilst exposing them to the vascular specialty and increasing their knowledge of vascular disease and its management. Methods: VACT is a one-day course consisting of one hour of online material and a one day in-person session. The online content was distributed via the PGVLE platform and included pre-course video tutorials, information and a survey. The in-person portion of the day included two lectures on vascular surgery and trauma and four practical stations covering embolectomy, inlay grafting, end-to-side anastomosis and patch repair. Course feedback was collected anonymously on PGVLE with automated certificate distribution after completion. The results were analysed qualitatively. Results: Thirty East and West Midlands trainees attended the course, of whom 25 (83%) completed the post-course feedback. Three had been on a previous vascular course and 15 would consider applying for higher level vascular training. Eight trainees (32%) self-scored their knowledge of common vascular conditions as good/excellent before the course; this increased to 20 (74%) post-course. The number of trainees self-scoring themselves as confident/very confident with vascular emergencies increased from 0 (0%) pre-course to 15 (56%) post-course. The delivery, content and equipment for the practical stations was rated as excellent/good by all participants in the embolectomy station and by 96% of participants in all other stations. Prior to the course one person (4%) rated their practical skills in vascular surgery as good/excellent. After the course this increased to 14 (56%). In all four practical stations, self-rated confidence levels increased after completing the course.100% of attendees would recommend this course to their colleagues. Conclusion: Feedback from VACT was extremely positive with comments requesting further similar courses. With an increasing need for vascular surgeons, it is essential we provide CSTs with the skills required to complete core surgical training and pursue a career in vascular surgery. VACT could be replicated and adapted to provide vascular training to CSTs across the country.

The Use of the "Flange Joint" Anastomotic Technique for Hepatic Artery Reconstruction in Liver Transplantation

The Use of the "Flange Joint" Anastomotic Technique for Hepatic Artery Reconstruction in Liver Transplantation

Intrathoracic anastomotic techniques in robotic assisted minimally invasive esophagectomy: a narrative review

Intrathoracic anastomotic techniques in robotic assisted minimally invasive esophagectomy: a narrative review

Anastomotic leak after esophagectomy

Background: Esophageal anastomotic leakage (AL) remains a frequent and feared postoperative complication, associated with high mortality and impaired quality of life. The aim of this study was to assess AL rates after esophagectomy with anastomosis at neck for esophageal and gastroesophageal junction cancer (GEJ), and compare the impact of AL on oncological outcome. Methods: Patients with squamous cell carcinoma and adenocarcinoma of esophagus/ gastroesophageal junction who underwent surgery between 2001-2018 were analyzed for cervical anastomotic leak. Results: 419 patients underwent esophagectomy with anastomosis placed at neck during 2001-2018. AL rate was 16%. AL was not found to be associated with anastomotic technique, surgical approach and technique, organ of conduit and route of conduit. A subgroup of patients (n=93) who had undergone neoadjuvant chemoradiation followed by surgery had AL of 30% vs 12% in rest of the treatment modality group (p&lt;0.001). Median survival was 26 months and 34 months in patients with AL and without AL, respectively (p=0.03). AL was managed successfully in all patients. Conclusion: Cervical AL after esophagectomy for cancer of esophagus and GEJ can be treated successfully without major complications.

Safety and effectiveness of totally laparoscopic total gastrectomy vs laparoscopic-assisted total gastrectomy: a meta-analysis.

For gastric cancer with total gastrectomy, the usual laparoscopic surgical approaches are totally laparoscopic total gastrectomy (TLTG) and laparoscopic-assisted total gastrectomy (LATG). Due to its difficult anastomotic technique, the adoption of TLTG is limited. Therefore, surgeons prefer using LATG, which also led to TLTG being somewhat overlooked, so there is no clear conclusion today as to which surgical procedure is more favorable to the patient's recovery. This article aimed to compare the safety and short-term outcomes of the two surgical approaches. Studies comparing TLTG and LATG, published up to December 2022, were searched in PubMed, Web of Science, and Embase databases. The study outcomes, including operative time, blood loss, anastomosis time, number of retrieved lymph nodes, proximal and distal resection margins, time to first fluid and soft diet, hospitalization duration, time to first flatus, and postsurgical and anastomotic complications, were compared between these two different surgical procedures. Statistics were analyzed with RevMan 5.4 and Stata 13.1. Fifteen publications were included in this study. The total sample included 3023 cases. The meta-analysis revealed no significant difference in overall postoperative complications between the two surgical approaches ( P >0.05). Compared with LATG, TLTG led to reduced intraoperative blood loss ( P <0.0001), an increased number of lymphatic node dissections ( P <0.0001), and decreased hospitalization duration ( P =0.002). However, operative time, anastomosis time, pulmonary infection, resection margins, time to first fluid and soft diet, time to first flatus and anastomosis-related complications were no significant difference between TLTG and LATG groups ( P >0.05). TLTG did not lead to an increase in overall postoperative complications, which is a reliable surgical approach for treatment of gastric cancer. Moreover, it may reduce harm to patients and enable them to obtain better surgical outcomes.

OGC P45 Complications in patients undergoing robotic-assisted oesophagectomy at a single centre

Abstract Background Robotic-assisted oesophagectomy is increasingly being utilised in the management of oesophageal cancer. The implementation into practice comes with an inevitable learning curve and it is important to ensure that this does not occur at the expense of poor patient outcomes. This study looks at the complications rates from the implementation of a robotics program at a single centre. Methods A retrospective review of a prospectively maintained database of oesophageal cancer patients treated at a single centre was undertaken. The robotic oesophagectomy program commenced October 2019 and all patients undergoing oesophagectomy to June 2023 were identified. Demographics, operative variables, oncological outcomes, and complications were analysed. Type of operation was robotic when at least one phase was robot-assisted, minimally invasive (MIO) when one phase was thoracosopic or laparoscopic and open when both were open. CUSUM analysis was used to determine the effect of a change in anastomotic technique due to a real time observation of an increase in anastomotic leak rate. Results 229 patients underwent oesophagectomy; 67 robotic, 40 MIO and 122 open. Clinical stage, demographics, and CPEX parameters were similar. There were slightly fewer complications in the robotic group overall (robotic 71.6%, MIO 72.5%, Open 74.2%); this was not statistically significant. There were significantly more anastomotic leaks in the robotic group (19.4%) compared to open (12.9%) which was noted in real time and led to a change in anastomotic technique with CUSUM analysis after this showed a diminished anastomotic leak rate (0/9 cases). Chyle leak occurred in 6% of robotic and 4% of open cases, which was not significantly different. Conclusions We found that the outcomes following robotic oesophagectomy were mostly comparable to conventional techniques. Whilst we found no difference in overall complications, there was a significantly higher anastomotic leak rate observed and identified which led to a change in anastomotic technique. Early results from this indicates a significant reduction in anastomotic leakage. It is crucial that all centres adopting the robotic platform closely monitor outcomes in real-time.

OGC V04 Reconstruction using linear side to side stapled anastomosis following robotic total gastrectomy

Abstract Background Worldwide, gastric cancer is the third most common cause of mortality and is the fourth most commonly diagnosed cancer. Minimally invasive surgery using the robotic platform to perform gastrectomy, is gaining popularity worldwide. It allows for better vision, dexterity, better ergonomics for the surgeon, reduced blood loss and lesser pain. Various anastomotic techniques have been suggested including circular stapler, hand sewn, Pi shaped linear stapler anastomosis. We demonstrate our technique performing a robotic side to side linear stapled anastomosis following total gastrectomy. Methods We detail the steps involved in the procedure, including trocar placement, necessary robotic instruments, and surgical description. 56 year old male patient with a BMI of 40 and PS 1, underwent robotic total gastrectomy after neoadjuvant chemotherapy for mid body diffuse adenocarcinoma. Preoperatively staging investigations included endoscopy, staging laparoscopy, computerised tomography (CT) and positron emission tomography (PET). Fitness was assessed using cardio-pulmonary exercise testing (CPET). Results Patient spend one night in high dependency unit, and was stepped down to ward based care. Enhanced recovery after surgery (ERAS) protocol was followed. There were no complications and patient was discharged after 10 days. Conclusions We demonstrate a safe technique for performing side to side linear anastomosis following robotic total gastrectomy.

HPB P43 Pancreatic Anastomosis Audit (PARANOIA): Initial experience of an international POPF registry

Abstract Background Post-operative pancreatic fistula (POPF) remains the primary determinant of poor outcome following pancreatoduodenectomy (PD) Risk factors are well understood but there is no apparent reduction in incidence. RCT’s are methodologically flawed to investigate POPF. PARANOIA is a registry with two novel outcomes. 1) Surgeons-specific risk-adjusted outcomes: Surgeons will observe in real time how changes to surgical technique impact upon outcomes. By having access to the registry data surgeons can explore technical factors of pancreas surgery that are associated with high or low risk of pancreatic fistula. 2)The registry will serve as a platform for international prospective studies. Methods Core dataset consists of common risk factors found within scores (aFRS, FRS, Roberts’) along with anastomotic technique and adjuncts. Initial prospective studies test topical clinical questions through embedded parallel studies. Using a stepwise approach, the registry and user network will be tested with increasingly complex study designs to determine the functionality of the registry as a novel research tool. Surgeons will have their risk-adjusted outcomes as a CUSUM plot which they can compare against anonymised surgeons by different variables. Results 232 registered surgeons across 56 countries with 776 cases. Majority of surgeons are performing open surgery (open 208 (89.7%) vs laparoscopic (11 (5.2%) vs robotic 11 (5.2%)). End-to-side was the commonest technique (88.8%) with invagination (69%) being used more than duct-to-mucosa (31%). 43.5% of surgeons used an internal stent routinely and almost all used drains (97.8%). 13% used pharmaceutical sealants whereas 28.4% used an autologous barrier. 44% used a somatosatin analogue (SSA). 70.5% reported no POPF whereas 8.4% had a CR-POPF rate. A reduced CR-POPF was associated with use of stent (p=0.008), autologous barrier (p=0.012) and SSA (p=0.049). Conclusions The PARANOIA registry has shown rapid recruitment of surgeons and data entry in pancreatic surgery can not only shorten the timeframe from study conception to dissemination of results but also provide real world data and provide comparison of outcomes between and within geographical regions, a key factor given that some patient and operative variables relevant to POPF vary across the globe. Registry data and the risk-adjusted CUSUMS can be used by surgeons to benchmark themselves against their peers and consider how modifications to their operative technique or perioperative care may affect their outcomes.

IDEAL Stage 2a/b prospective cohort study of transanal transection and single-stapled anastomosis for rectal cancer.

There are several anastomotic techniques available to facilitate restorative rectal cancer surgery after total mesorectal excision (TME), including double-stapled anastomosis (DST) and handsewn coloanal anastomosis (CAA). However, to date no one technique is superior with regard to anastomotic leakage (AL) or functional outcomes. Transanal transection single-stapled anastomosis (TTSS) aims to overcome some of the technical challenges and offer comparable clinical and functional outcomes to traditional anastomotic techniques. The aim of this study was to explore the role of TTSS in modern rectal cancer surgery and to provide comparative clinical and functional outcome data with DST and CAA. A prospective cohort study was undertaken to assess the safety and clinical and patient-reported outcomes associated with the TTSS procedure. All patients undergoing sphincter-preserving surgery for rectal cancer with an anastomosis performed within 6 cm of the anal verge between January 2016 and April 2021 were prospectively enrolled into this study. Clinical and patient-reported outcome data, including low anterior resection syndrome (LARS) assessment, were collected. The primary endpoint was anastomotic leakage within 30 days. A total of 275 patients participated in this study, with 70 (25%) patients undergoing a TTSS, 110 (40%) undergoing a DST and 95 (35%) undergoing a CAA. Patients undergoing a CAA had more distal tumours than those having a TTSS or DST, with a median tumour height of 5, 7 and 9 cm (p < 0.001), respectively. We observed a statistically significant reduction in AL in the TTSS group compared with the DST group, with rates of 8.6% versus 20.9% (p = 0.028). There was no difference in LARS scores between patients undergoing TTSS and DST (p = 0.228), while patients with a CAA had worse LARS scores than TTSS patients (p = 0.002). TTSS is a technically safe and feasible anastomotic technique in rectal cancer surgery as an alternative to DST and CAA. Its advantages over DST are a reduced AL rate and, over CAA, improved function. It should therefore be considered as an alternative technique to improve clinical and patient-reported outcomes in restorative rectal cancer surgery.

Predicting multiple linear stapler firings in double stapling technique with an MRI-based deep-learning model

Multiple linear stapler firings is a risk factor for anastomotic leakage (AL) in laparoscopic low anterior resection (LAR) using double stapling technique (DST) anastomosis. In this study, our objective was to establish the risk factors for ≥ 3 linear stapler firings, and to create and validate a predictive model for ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. We retrospectively enrolled 328 mid–low rectal cancer patients undergoing laparoscopic LAR using DST anastomosis. With a split ratio of 4:1, patients were randomly divided into 2 sets: the training set (n = 260) and the testing set (n = 68). A clinical predictive model of ≥ 3 linear stapler firings was constructed by binary logistic regression. Based on three-dimensional convolutional networks, we built an image model using only magnetic resonance (MR) images segmented by Mask region-based convolutional neural network, and an integrated model based on both MR images and clinical variables. Area under the curve (AUC), sensitivity, specificity, accuracy, positive predictive value (PPV), and Youden index were calculated for each model. And the three models were validated by an independent cohort of 128 patients. There were 17.7% (58/328) patients received ≥ 3 linear stapler firings. Tumor size ≥ 5 cm (odds ratio (OR) = 2.54, 95% confidence interval (CI) = 1.15–5.60, p = 0.021) and preoperative carcinoma embryonic antigen (CEA) level > 5 ng/mL [OR = 2.20, 95% CI = 1.20–4.04, p = 0.011] were independent risk factors associated with ≥ 3 linear stapler firings. The integrated model (AUC = 0.88, accuracy = 94.1%) performed better on predicting ≥ 3 linear stapler firings than the clinical model (AUC = 0.72, accuracy = 86.7%) and the image model (AUC = 0.81, accuracy = 91.2%). Similarly, in the validation set, the integrated model (AUC = 0.84, accuracy = 93.8%) performed better than the clinical model (AUC = 0.65, accuracy = 65.6%) and the image model (AUC = 0.75, accuracy = 92.1%). Our deep-learning model based on pelvic MR can help predict the high-risk population with ≥ 3 linear stapler firings in laparoscopic LAR using DST anastomosis. This model might assist in determining preoperatively the anastomotic technique for mid–low rectal cancer patients.

Can the Single-stapling Technique Following Intersphincteric Resection with Transanal Total Mesorectal Excision Become the New Standard Anastomosis?

For transanal total mesorectal excision (TaTME), the indication for single-stapling technique (SST) has been expanded to include lower anastomosis, even in intersphincteric resection (ISR). We focused on the anastomotic techniques following ISR with TaTME and examined the feasibility and safety of the SST below the anorectal junction (ARJ). Data on postoperative anastomosis-related complications and anorectal function was evaluated in comparison to conventional manual hand-sewn coloanal anastomosis in ISR with TaTME. We examined patients with 3-6 cm tumors from the anal verge who underwent ISR with TaTME between January 2018 and March 2020, and whose anastomotic line was located below the ARJ. Postoperative short-term outcomes and anorectal functions were compared. We also analyzed the effects of various factors on major low anterior resection syndrome (LARS) using multivariate logistic regression analysis. In total, 87 patients-48 in the hand-sewn anastomosis group and 39 in the SST group-were included in this study. SST below the ARJ in ISR with TaTME did not exacerbate surgical outcomes, including anastomosis-related complications. The SST group had a significantly lower LARS score as compared to the hand-sewn anastomosis group, and the proportion of major LARS was significantly lower. Only hand-sewn anastomosis was identified as a statistically significant independent risk factor for major LARS. In TaTME, SST below the ARJ was safe and feasible and had a lower negative impact on postoperative anastomosis-related complications and anorectal function as compared to hand-sewn anastomosis. Thus, SST is a promising anastomotic option for patients with low-lying rectal tumors.

Gastrointestinal thickness, duration, and leak pressure of five intestinal anastomosis techniques in cats.

To compare time to construct completion and resistance to leakage for five intestinal anastomosis techniques in cats and to report normal feline gastrointestinal thickness. Experimental study. Grossly normal intestinal segments (n = 120) from 10 fresh cat cadavers. A total of 8 cm segments of fresh feline cadaveric intestine were collected, and mural thickness was recorded. Segments were randomly allocated between a control group (n = 20 segments) and five treatment groups (20 segments/group with 2 segments/construct = 10 constructs per group): (1) hand-sewn anastomosis - simple interrupted (HSA-SI), (2) hand-sewn anastomosis - simple continuous (HSA-SC), (3) functional end-to-end stapled anastomosis (FEESA), (4) functional end-to-end stapled anastomosis with oversew (FEESA-O), (5) skin stapled anastomosis (SS). Time to construct completion, leakage location, initial leak pressure (ILP), and maximum intraluminal pressure (MIP) were compared. Mean mural thickness ± SD (mm) for the stomach, duodenum, jejunum, and ileum were 1.66 ± 0.28, 2.05 ± 0.18, 2.28 ± 0.30, and 2.11 ± 0.39, respectively. ILPs (mean ± SD) for HSA-SI (165 ± 122 mmHg), HSA-SC (149 ± 83), FEESA-O (63 ± 25, FEESA (84 ± 59), SS (77 ± 56), and control segments (>500) were compared. There was no statistically significant difference in ILP (p > .08) or MIP (p > .084) between any treatment groups. Nonoversewn FEESAs were 2.4 times faster to perform compared to oversewn FEESA and SS groups, and 4.7 times faster than HSA (p < .001). All anastomosis techniques provide resistance to leakage that is supraphysiological to that of the normal maximum intraluminal pressure. HSA take longer to complete than stapled anastomoses. All anastomotic techniques may be appropriate in cats. Hand-sewn anastomoses result in a longer surgical time.

A comparative review of minimally invasive approaches to esophagectomy: technical considerations, variations, and outcomes

Esophageal cancer continues to rise as a public health issue, and esophagectomy remains a mainstay therapy for the disease. Surgical approaches to esophagectomy have evolved over the past few decades with the advent of laparoscopic, thoracoscopic, and robotic technologies. The aim of this review is to identify original articles and perform a comprehensive literature search to provide updates on surgical approaches and technical considerations for esophagectomy. Articles describing the surgical technique specific to robotic-assisted minimally invasive esophagectomy (RAMIE) were reviewed and included. Technical considerations reviewed were comprised of patient positioning, optimal trocar placement, dissection, indocyanine green use, kocherization, pyloric interventions, anastomotic techniques, jejunostomy tube placement, and gastric ischemic conditioning, discussing relevant outcomes for each consideration and approach. Clinical outcomes were also evaluated by comparing RAMIE to open esophagectomy and minimally invasive esophagectomy. Outcomes reviewed included lymph node harvest, intra-operative blood loss, operative times, 30-day readmission, mortality, length of stay, pulmonary complications, recurrent laryngeal nerve injury, anastomotic leak, long-term survival, and disease-free survival.

S53 Impact of Surgical Anastomotic Techniques on the Development of Post-Transplant Biliary Strictures in the Elderly

S53 Impact of Surgical Anastomotic Techniques on the Development of Post-Transplant Biliary Strictures in the Elderly