Endoscopic Gastrointestinal Anastomosis Stapler Research Articles

Feasibility of laparoscopic stapled partial cystectomy in canine cadavers.

To describe a technique for laparoscopic partial cystectomy and evaluate sealing of canine urinary bladder tissue with an endoscopic stapler. Prospective, cadaveric study. Eleven canine cadavers. Laparoscopic partial cystectomy was performed with an endoscopic gastrointestinal anastomosis (GIA) stapler. Leak testing and urodynamic evaluation was performed to measure intravesical pressure at initial leakage and catastrophic failure or the maximum pressure at which intravesical pressure plateaued. Surgical time, complications, and site of leakage were also recorded. Laparoscopic partial cystectomy was successfully performed in 10 of 11 cadavers. Median procedure time was 13.6 min (10.1-15.2 min). Median intravesical pressure at initial leakage was 31 mmHg (28-56 mmHg) with a median increase from initial pressure of 15 mmHg (11-37 mmHg). No catastrophic failure of the cystectomy site was observed during leak testing. Intravesical pressure plateaued at a median of 52 mmHg (39-73 mmHg), which was a median of 13 mmHg (8-23 mmHg) higher than intravesical pressure at initial leakage. The median total volume infused at the time of plateau of intravesical pressure was 89 mL (58-133 mL). Laparoscopic stapled partial cystectomy was feasible in canine cadavers. Endoscopic GIA staplers appear to seal the canine urinary bladder with minimal leakage. Use of an endoscopic GIA stapler may provide a minimally invasive option for partial cystectomy in dogs. Further evaluation for application to clinical cases is warranted.

The First Documented Case of High-Grade Synovial Cell Sarcoma of the Rectum

A patient presented with signs and symptoms of tenesmus, urgency, and rectal bleeding that she had been experiencing over the course of several months. Full endoscopic evaluation showed a 6-cm submucosal mass approximately 10 cm from the dente line projecting as an endoluminal mass with a large broad base. An initial endoscopic resection was attempted but aborted because of significant hemorrhage, and surgical oncology was consulted. After stabilization, the patient underwent a transanal resection of the mass the following day. An endoscopic gastrointestinal anastomosis stapler resulted in a margin-negative complete resection of what was later determined to be a high-grade synovial cell sarcoma. This case report presents the first known documented case of synovial cell sarcoma of the rectum.

Epicardial Radiofrequency Pulmonary Vein Isolation Combined with Left Atrial Appendage Resection for the Treatment of Atrial Fibrillation: Early Results of a New Minimally Invasive Approach

Background: Minimally invasive approaches for surgical ablation of atrial fibrillation have gained attraction for years due to potential benefits of maximizing the efficacy of surgery and minimizing the complexity of conventional Cox-Maze procedure. Methods: Five patients underwent bilateral pulmonary vein isolation using an epicardial bipolar radiofrequency ablation device (Cardioblate Gemini System, Medtronics, USA) combined with left atrial amputation using an endoscopic gastrointestinal anastomosis stapler. For three patients whose indication for surgery was lone atrial fibrillation, the surgery was performed through bilateral mini-thoracotomy incisions without pump assist, whereas other two patients underwent standard sternotomy for concomitant aortic valve replacement. Radiofrequency ablation was performed for four-to-seven times to confirm the entrance and exit block. Results: All patients restored normal sinus rhythm intraoperatively. There were no mortality or operative complications. Baseline rhythm at discharge was normal sinus rhythm in 4 and atrial fibrillation in one. Two patients who had baseline sinus rhythm showed paroxysmal atrial fibrillation or flutter on 24-hour Holter monitoring. At three months, four patients showed sinus rhythm without anti-arrhythmic medications whereas one had atrial fibrillation. Conclusion: Epicardial bipolar radiofrequency pulmonary vein isolation combined with left atrial appendage resection is safe and feasible. This approach may be a good alternative to catheter ablation for patients with lone atrial fibrillation.

Extraluminal Laparoscopic Wedge-Resection of Submucosal Tumors on the Posterior Wall of the Gastric Fundus Close to the Esophagocardiac Junction

Laparoscopic resection of submucosal tumors in the gastric fundus, especially in the posterior wall near the esophagocardiac junction (ECJ), is difficult and time consuming and is and likely to cause esophageal stenosis and splenic injury. In this article, we report an extraluminal laparoscopic wedge-resection (ELWR) that minimizes these problems. Thirty-seven patients with submucosal tumors in the posterior wall of the gastric fundus received ELWR. The operation consisted of four steps: 1) localization of the tumor, 2) dissection of the omentum, 3) mobilization of the gastric fundus/upper pole of the spleen and exposure of the ECJ, and 4) resection of the gastric fundus with a linear endoscopic gastrointestinal anastomosis stapler. None of the cases needed conversion to open surgery. Mean postoperative hospital stay was 5.5 +/- 1.0 days. The distance between the tumor and the incision margin ranged from 0.7 to 2.5 cm toward the ECJ. Pathologic examination revealed 7 cases of leiomyomas, 29 cases of stromal tumors (4 were low-grade malignant tumors), and 1 case of neurofibroma. There was no recurrence, metastasis, esophageal stenosis, or any other severe adverse event during the follow-up period (52 +/- 3.1 months). ELWR is a safe, effective treatment for submucosal tumors in the posterior wall of the gastric fundus.

Retrospective Study of 28 Cases of Cholecystoduodenostomy Performed Using Endoscopic Gastrointestinal Anastomosis Stapling Equipment

Medical records were reviewed of 24 dogs and four cats that underwent cholecystoduodenostomy to relieve extrahepatic biliary obstruction. These procedures had been performed using a 30-mm endoscopic gastrointestinal anastomosis stapler. At presentation, most animals had clinical signs of vomiting and anorexia, and total bilirubin was elevated in both dogs (n=21) and cats (n=4). Pancreatitis (n=13), cholangiohepatitis (n=7), and neoplasia (n=6) were the most common underlying conditions. Sixteen dogs and two cats survived to their 2-week reevaluation. The most common cause of death was euthanasia (n=9) secondary to neoplasia (n=4), peritonitis (n=3), or respiratory arrest (n=2).

Laparoscopic radical nephrectomy for cancer with level I renal vein involvement.

Venous involvement develops in 5% to 10% of patients with renal cell carcinoma and is generally considered a relative contraindication to laparoscopic radical nephrectomy. To our knowledge we report the initial clinical series of laparoscopic radical nephrectomy for renal cell carcinoma associated with level I renal vein thrombus. At our 2 institutions 8 patients each underwent laparoscopic radical nephrectomy for level I microscopic renal vein thrombus (group 1) and level I gross thrombus (group 2). In all 8 group 2 patients the level I thrombus was preoperatively diagnosed by computerized tomography. Mean renal tumor size in groups 1 and 2 was 7.8 and 12.4 cm., respectively. After controlling the renal artery the renal vein was secured by firing an endoscopic gastrointestinal anastomosis stapler on its collapsed, uninvolved proximal part adjacent to the vena cava. Intraoperative, postoperative and pathological parameters were assessed in the 2 groups. In group 1 laparoscopic radical nephrectomy was technically successful in all 8 patients. Mean operative time was 3.1 hours, mean estimated blood loss was 382 cc and mean hospital stay was 1.9 days. In 1 patient each a soft tissue and a vascular margin was positive for cancer. At a mean follow up of 19.5 months (range 2 to 36) metastatic disease occurred in 3 cases (38%). In group 2 laparoscopic radical nephrectomy was technically successful in 7 cases with open conversion in 1. Mean operative time was 3.3 hours, mean estimated blood loss was 354 cc and mean hospital stay was 2.3 days. Surgical soft tissue and the renal vein vascular margin of the transected vein were negative for cancer in all 8 cases. At a mean followup of 9.4 months (range 5 to 16) pulmonary metastasis developed in 1 patient (13%). Although it is an advanced procedure, laparoscopic radical nephrectomy in patients with level I renal vein thrombus is feasible, safe and follows established oncological principles.

Thoracoscopic Lung Lobectomy for Treatment of Lung Tumors in Dogs

To report use of thoracoscopic lung lobectomy (TLL) for treatment of lung tumors (LT) in dogs. Retrospective study. Nine dogs. Dogs that had TLL for tumor removal were included. Using general anesthesia and 1-lung ventilation, TLL was performed using a 30-60 mm endoscopic gastrointestinal anastomosis stapler. If the visual field was obscured, lobe resection was completed via thoracotomy. Metastatic and primary LT were resected by thoracoscopic lobectomy in 9 dogs (6 male, 3 female; mean (+/-SD) weight, 29+/-7 kg; mean age, 10.7+/-1.9 years). Six dogs had a solitary mass and 3 dogs had 2 masses within a single lobe. The left caudal lobe was removed in 3 dogs. In 5 dogs, TLL was used alone whereas conversion to thoracotomy was required in 4 dogs because of poor visibility. There were 7 metastatic LT and 2 primary LT. Mean duration of thoracoscopic surgery was 108.8+/-30.3 minutes compared with 150.75+/-55.4 minutes in dogs requiring conversion to thoracotomy. Mean hospitalization was 3.1+/-1.3 days. Provided the visual field is not obscured, TLL can be performed effectively in dogs. Dogs with metastatic or primary LTs should be considered for TLL, particularly for small masses positioned away from the hilus in the left caudal lung lobe.

PURE LAPAROSCOPIC ENTEROCYSTOPLASTY

The realm of laparoscopic surgery has expanded from simple extirpative operations to more complicated reconstructive procedures, such as dismembered pyeloplasty and ileal conduit creation. There has been recent interest in using laparoscopic techniques to augment the bladder with bowel.1, 2 To date only 1 case of enterocystoplasty, using the stomach, has been accomplished entirely by laparoscopy.3 To our knowledge we report the first case of ileal enterocystoplasty performed completely by laparoscopy. CASE REPORT A 31-year-old paraplegic woman with a C6 spinal cord injury developed worsening voiding dysfunction during the 2 years preceding presentation. She had managed previously with clean intermittent catheterization every 4 hours and remained dry. Video urodynamic studies demonstrated detrusor instability at bladder volumes of 40 to 50 ml. and a maximum bladder capacity of 85 ml. The patient did not desire urinary diversion or a continent cutaneous reservoir, and opted instead for laparoscopic ileal bladder augmentation. Mechanical and antibiotic bowel preparation was performed, and externalized ureteral stents were initially placed. The remainder of the operation duplicated open augmentation cystoplasty using an ileal segment. Briefly, 5 ports were used and the ileum was identified 15 cm. from the ileocecal valve. An endoscopic gastrointestinal anastomosis stapler was used to isolate a 15 to 20 cm. segment of ileum, and the mesentery was incised with ultrasonic coagulating shears. Bowel continuity was restored in a side-to-side fashion using a gastrointestinal anastomosis stapler, with the enterotomy closed in a single layer with interrupted 2-zero silk Lembert sutures. Monopolar electrocautery was used to remove the staples from both ends of the isolated ileal segment and detubularize it on its antimesenteric border. The ileum was sutured into a U-shaped configuration using a single layer of running 3-zero polyglactin sutures prior to mid sagittal cystotomy. The ileal patch was sutured to the bladder in quadrants using running 3-zero polyglactin sutures. Drainage was provided by a 20Fr urethral catheter and a 10 mm. Blake drain brought out through a lateral port site. No suprapubic catheter was placed. Watertight closure was confirmed by intraoperative irrigation of the bladder. Estimated blood loss was 100 ml. and there were no intraoperative complications. On the third postoperative day the drain was removed and the patient resumed liquid intake. However, she remained hospitalized due to prolonged ileus for 13 days. She returned to work and normal activity 1 week after being discharged. A cystogram performed 4 weeks postoperatively, at the time of catheter removal, demonstrated a bladder capacity of at least 250 ml. (see figure). Presently, the patient is continent between catheterizations with urinary volumes approximating 400 ml. DISCUSSION

Radical Retropubic Prostatectomy Using Endoscopic Gastrointestinal Anastomosis Staplers

Objective: To investigate whether the use of the endoscopic gastrointestinal anastomosis (GIA) stapler for hemostasis of the dorsal vein complex during radical retropubic prostatectomy saves operation time and blood loss together with therapeutic efficacy. Materials and Methods: From April 1990 to December 1998, a total of 296 patients underwent radical retropubic prostatectomy for prostate cancer in clinical stages T1, T2 and T3. In 157 patients we evaluated the efficacy of the endoscopic GIA stapler in order to minimize blood loss from the dorsal vein complex and to reduce mean operative time. Results: The mean total operative time decreased an average of 35 min and the mean blood loss fell from 850 to 400 cm³ using the stapling technique. Although complications are seen with traditional methods, we noted a net increase in anastomotic strictures with this new technique. Conclusions: Even if this technical trick is effective in reducing blood loss, a higher incidence of anastomotic strictures has to be taken into account when using staplers close to the anastomotic site.

Use of the endoscopic gastrointestinal anastomosis stapler in radical cystectomy.

Use of the endoscopic gastrointestinal anastomosis stapler in radical cystectomy.

Applied Stapling Technique in Radical Retropubic Prostatectomy: Efficient, Effective and Efficacious

Purpose We demonstrated the efficiency, efficacy and effectiveness of the endoscopic gastrointestinal anastomosis (GIA) stapler in radical retropubic prostatectomy. Materials and Methods A total of 21 patients with organ confined prostate cancer on preoperative staging underwent radical retropubic prostatectomy. During these procedures we analyzed the applicability and efficacy of the endoscopic GIA vascular stapler to effect ligation, division and stapling of the dorsal vein complex and lateral pedicles of the prostate. This group was compared to 7 controls in whom we performed surgery for organ confined disease, using the stapler solely for the lateral prostatic pedicles or not at all depending on availability. One patient with localized muscle invasive transitional cell carcinoma of the bladder underwent radical cystectomy using the endoscopic GIA stapler in a sequential fashion to ligate and divide all pedicles of the specimen. Results Mean total operative time was 2 hours (range 1 hour 40 minutes to 2 hours 50 minutes) and average estimated blood loss was 400 cc. All patients were discharged from the hospital on postoperative day 3. To date 17 of the 21 patients are continent and 6 are potent. Conclusions Although not designed to replace the standard approach to radical retropubic prostatectomy, we believe that this technique makes the procedure easier and more approachable in the hands of the less experienced surgeon.