Endoscopic Stapler Research Articles

Audit of pharyngeal pouch surgery in derby from 2007–2014, are we following nice guidance?

Audit of pharyngeal pouch surgery in derby from 2007–2014, are we following nice guidance?

Electrothermal bipolar vessel ligation improves operative time during laparoscopic total proctocolectomy: a large single-center experience.

Laparoscopic total proctocolectomy (TPC) with or without ileoanal pouch is a major operation for which the traditional benefits of laparoscopy were not immediately apparent, in part due to the longer operating times. The use of energy devices has been shown to improve operative outcomes for patients who undergo laparoscopic segmental colectomies, but there are limited data for laparoscopic TPC (LTPC). All patients who underwent LTPC between January 2002 and July 2011 were identified from a prospectively maintained institutional-review-board-approved database. Univariate and multiple linear regression analyses were performed to assess the impact of electrothermal bipolar vessel sealers (EBVS) for vessel ligation on operative time. Secondary outcomes included vessel ligation failures, estimated blood loss, and other intra- and postoperative outcomes. One hundred and forty-five patients underwent LTPC, including 126 restorative ileoanal pouch and diverting ileostomy operations and 19 TPC and end ileostomy procedures. Fifteen percent of LTPCs were totally laparoscopic, 45% were laparoscopic-assisted, 32% were hand-assisted, and 8% were laparoscopic-converted cases. Laparoscopic vessel ligation was performed using EBVS (76%), endoscopic staplers (12%), or hybrid techniques (12%). Vessel ligation groups were similar in demographics, body mass index, surgical indication, immunosuppression, and prior surgery. EBVS were associated with shorter median operative times (247 vs. 290 vs. 300min, p=0.018) and fewer vessel ligation failures (1 vs. 11 vs. 12%, p=0.027) compared with endoscopic staplers and hybrid techniques, respectively. There were no differences in estimated blood loss and intra-operative complications among the three groups. Length of stay, 30-day morbidity, and 30-day re-operation rates were also similar. On multiple linear regression analysis, EBVS were a significant predictor of operative time (p=0.019). Routine use of electrothermal bipolar vessel ligation for LTPC is associated with shorter operative time and fewer vessel ligation failures without higher risk of complications than other vessel control methods.

The role of flexible endotherapy for the treatment of recurrent Zenker's diverticula after surgery and endoscopic stapling.

Currently there are three main treatment options for Zenker's diverticulum (ZD): surgery, rigid endoscopy and flexible endoscopy. After primary success, recurrence can be as high as 19% for surgery, 12.8% for rigid endoscopy and 20% for flexible endoscopy. Flexible endoscopy may represent an ideal treatment option for recurring ZD. The aims of this paper are to evaluate the efficacy and safety of flexible endotherapy for recurring ZD after surgery and/or endoscopic stapling and to compare the treatment outcome between naive and recurring patients. Data on patients that underwent flexible endotherapy for ZD between January 2010 and January 2015 were collected. Patients were divided into those with recurrences after surgery and/or endoscopic stapling and those who did not have previous treatments. Dysphagia, regurgitation, and respiratory symptom severity before the procedure were graded. The outcome parameters were: complications, symptom improvement after the first treatment, number of treatment sessions, rate of complete remission and relapses. These parameters were then compared between patients groups. Twenty-five recurring patients were included. Treatment was carried out successfully in all patients. Two adverse events occurred; they were successfully managed conservatively. After the first treatment, there was a significant reduction in dysphagia, regurgitation and respiratory symptoms scores. The median number of treatments was 1 (IQR 0.25, range 1-3): symptom remission was achieved in 84% patients and partial improvement in 16%. Relapsing symptoms occurred in 20% patients; they were successfully managed with an additional treatment session. Results were compared with data on 34 consecutive naive patients treated within the same time span; no differences of the outcome parameters were revealed. Flexible endotherapy for ZD recurrences after surgery and endoscopic stapling appears to be safe and effective, and its efficacy and safety profile seems to be comparable between recurring and naive patients.

Electrocautery device does not provide adequate pulmonary vessel sealing in transumbilical anatomic pulmonary lobectomy

Safe pulmonary vessel sealing device plays a crucial role in anatomic lung resection. In 2014, we reported high rates of massive bleeding complications during transumbilical lobectomy in a canine model due to difficulty in managing the pulmonary vessel with an endostapler. In this animal survival series, we aimed to evaluate the outcome of pulmonary vessel sealing with an electrocautery device to simplify the transumbilical thoracic surgery. Under general anesthesia, a 3-cm longitudinal incision was made over the umbilicus. Under video guidance, a bronchoscope was inserted through the incision for exploration. The diaphragmatic wound was created with an electrocautery knife and used as the entrance into the thoracic cavity. Using the transumbilical technique, anatomic lobectomy was performed with electrosurgical devices and endoscopic vascular staplers in 15 canines. Transumbilical endoscopic anatomic lobectomy was successfully completed in 12 of the 15 animals. Intraoperative bleeding developed in three animals during pulmonary hilum dissection, where one animal was killed due to hemodynamic instability and the other two animals required thoracotomy to complete the operation. There were five delayed bleeding and surgical mortality cases caused by inadequate vessel sealing by electrosurgical devices. Postmortem examination confirmed correct transumbilical lobectomy in the twelve animals that survived the operations. Transumbilical anatomic lobectomy is technically feasible in a canine model; however, the electrosurgical devices were not effective in sealing the pulmonary vessel in the current canine model.

Effect of Tri-Staple™ Technology and Slow Firing on Secure Stapling Using an Endoscopic Linear Stapler

Aim: To evaluate the effect of Tri-staple™ technology and slow firing using the Endo-GIA™ endoscopic linear stapler. Methods: The cardiac and pyloric portions of porcine stomachs were divided using the endoscopic linear stapler with different reload types. A total of 8 min of waiting time was employed during firing in the slow-firing group and no waiting time was employed in the normal-firing group. The shape of the staples was then evaluated. The length of the staple line and serosal laceration was also determined. Results: There was a moderate negative correlation between tissue thickness and secure staple formation. Tri-staple™ reloads (purple, black) offered more secure staple formation compared with Universal green reload. Although slow firing enhanced secure staple formation, its effect was greater when using green reload, compared with Tri-staple™ reloads. Significantly shorter staple line length and longer serosal laceration was observed in the thick tissue. Although the cartridge type did not influence lengths of the staple line or serosal laceration, both were better in the slow-firing group. Conclusions: Tri-staple™ reloads offered more secure staple formation compared with the Universal reload. Although slow firing improved staple line shortening and serosal laceration, its effect on secure stapling was relatively small when using Tri-staple™ reloads.

Multicenter prospective evaluation of a new articulating 5-mm endoscopic linear stapler

Background The objective of this study was to evaluate the safety and efficacy of a novel 5-mm laparoscopic linear stapler in clinical gastrointestinal surgical applications.Methods A prospective, single-arm study with an open enrollment of subjects requiring stapling of the gastrointestinal (GI) tract was performed. The study endpoints were the number of complications and technical failures associated with the use of a novel stapler when compared to similar events with conventional staplers as described in the medical literature.ResultsSeven centers enrolled 160 subjects, 150 of which were followed up to at least 30 days postoperatively. Intraoperative success: In 423 deployments, there were two staple line leaks and five staple line bleeds, all of which were intraoperatively resolved. In addition, incomplete staple lines were noted as a result of user error (n = 15) or device-related issues (n = 22), all of which were immediately resolved and none of which resulted in a complication or a change of the surgical procedure. Late outcomes: A total of 13 surgical complications in 160 patients were related to a GI transection or anastomosis, 12 of which related to a hand-sewn anastomosis or use of other commercially available staplers. One event (1/153, 0.065 %) on POD 1, involving bleeding of the staple line, was felt to be related to the use of the new stapler.ConclusionThe study confirmed that the new device was user-friendly (9 % incidence of problems firing the device), reliable (3 % device failures) and safe (<1 % complication rate related to the stapler). Based on these results, it would seem that this new 5-mm stapler is a safe and effective alternative to standard 12-mm staplers.

Long-Term Outcome of the Treatment of Zenker’s Diverticulum

Treatment of Zenker's diverticulum can be accomplished by use of a transcervical myotomy (TCM) with diverticulopexy/diverticulectomy or by the transoral endoscopic stapling (TOS) approach. Our aim was to evaluate the short-term and long-term outcomes of these two techniques. A retrospective review was performed to identify all patients who had received either treatment for Zenker's diverticulum from July 1998 to August 2013. Telephone interviews were attempted of all surviving patients to assess long-term outcome. There were 77 patients, with a median age of 71 years (range, 37 to 97 years). All patients had dysphagia, and 33 (43%) had regurgitation. TCM was performed in 68 patients, and TOS was done in nine. The median size of the diverticulum was 2.5 cm in the TCM group and 4 cm in the TOS group (p= 0.13). The operation was primary in 66 patients (86%) and a reoperation in 11 patients. The median hospital stay was 1 day for TOS and 3 for TCM (p= 0.0005). The median time to oral intake for both groups was 1 day. There were three adverse events in the TCM group and none in the TOS group. Early outcome was assessed in all 77 patients at a median of 4 months (interquartile range [IQR], 1 to 13.5 months). Symptomatic improvement occurred in all patients, with 55 patients (71%) reporting complete resolution. Long-term symptoms were assessed at a median of 54 months (IQR, 34 to 77 months) in 38 of 59 (64%) surviving patients. Cricopharyngeal myotomy with diverticulopexy/diverticulectomy and TOS are both safe and effective treatments for Zenker's diverticulum. All patients reported improvement in symptoms, with complete resolution in the majority of patients.

Revision endoscopic stapler Zenker's diverticulotomy.

Endoscopic stapler diverticulotomy (ESD) has become an accepted primary treatment for Zenker's diverticulum (ZD). Recurrence of symptoms after surgical treatment of ZD is not uncommon, and traditionally patients with recurrent symptomatic ZD were referred to revision surgery by the transcervical Zenker's diverticulectomy approach. Our objective was to evaluate the technical feasibility, safety and effectiveness of revision endoscopic stapler diverticulotomy (RESD) for recurrent ZD. A case series with chart review study conducted in a tertiary referral center. The records of all patients who underwent ESD at our institute between 2002 and 2013 were retrieved and those who underwent RESD were identified and screened for primary surgical history, symptoms of recurrent ZD, time to recurrence, intraoperative and postoperative RESD course, complications and symptom resolution. The surgical history and outcome results of RESD and primary ESD (PESD) patients were compared. Eighty-nine ESDs were performed. Twenty were RESDs for recurrent ZD, and 69 were PESDs. Nine RESDs were performed for recurrent ZD after transcervical Zenker's diverticulectomy, 10 RESDs for recurrent ZD after ESD, and one initial surgical approach was unknown. The mean time from first operation for ZD to RESD was 4.7years. The average RESD surgery time and hospital stay were 21.4min and 2.8days, respectively. Endoscopic stapling of the ZD was feasible in 19 of 20 RESDs. Relief of symptoms without recurrence was achieved after 18 RESDs. Four RESD patients experienced minor postoperative complications. There were no significant differences in operative time, technical feasibility, hospital stay and complication rate between the RESD and PESD groups (P>.05). RESD for ZD is technically feasible, safe and effective. The results are comparable to those of PESD.

PTU-173 Feasibility study of safety and cost effectiveness of using johan forceps as endoloop pushers for laparoscopic appendicectomy

<h3>Introduction</h3> <b>Background</b>: The base of appendix can be secured using endoloops or endoscopic stapler. The authors have reported the use of Johan forceps as endoloop pushers for laparoscopic appendicectomy. <h3>Method</h3> <b>Aims</b>: To evaluate the safety and cost effectiveness of this technique. <b>Patients and methods</b>: A prospectively collected data of all patients who underwent laparoscopic appendicectomy by this technique between 2012 till 2014 was reviewed. Base of the appendix was secured using three standard extra-corporeal endoloops deployed with Johan’s forceps utilising one vicryl tie. Demographics, operative findings, post-operative complications and readmissions were recorded and analysed. <h3>Results</h3> Total number of patients was 120. There were 72 (60%) males while rest were female with an age of *24 (14–77). Grossly inflamed appendix (including perforation, localised abscess) was noted in 76% of cases. No peri-operative complications were reported. The post-op stay was *2 (1–5) days (* represents median). Complications include 7 (5.8%) wound infections which were managed conservatively. 9 patients were re-admitted due to reasons unrelated to the surgical technique. The cost of one vicryl tie was £0.5 Vs £49.80 (for 3 standard endoloops available in the market). The cost analysis showed johan assisted appendicectomy to be 99 times cheaper than the standard marketed endoloops. <h3>Conclusion</h3> Our series involving various surgeons employing the standard technique of using the Johan forceps as endoloop knot pushers shows that it is a feasible and safe technique with promising results. The technique has been practised in various hospitals and provides a cheap and safe alternative to the standard endoloops available in the market. <h3>Disclosure of interest</h3> None Declared.

PTU-013 Is endoscopic full-thickness resection feasible and safe in the colon?

<h3>Introduction</h3> Colectomy for complex colonic polyps and early colonic cancer has increased due to national bowel cancer screening programs. However, traditional radical colonic resection risks substantial morbidity and alternative approaches are required. This review summarises the published methods of colonic endoscopic full-thickness resection (EFTR), examining data on feasibility and safety. <h3>Method</h3> Systematic literature searches identified articles describing EFTR techniques of colon, published between 1990 and 2015 in both experimental and clinical studies. Feasibility and safety were the primary outcomes. <h3>Results</h3> Preclinical research reported on three EFTR techniques using endoscopic stapling devices, T-tags or compression device closure for defect closure before (pre-resection) or after specimen resection (post-resection). A total of 103 procedures were performed in 99 porcine models, with an overall success rate of 87% (90/103 procedures). The intraoperative complication rate was 19% (17/90 procedures). Post-resection closure methods more commonly resulted in failure to close the defect and a high incidence of abnormal findings at post-mortem examination. Five clinical studies reported EFTR in 38 patients, with three studies using a compression device for pre-resection closure and one study reporting a post-resection closure technique. EFTR was completed in 33/38 patients without assistance. Only three patients had reported complications. Lateral margin clearance was variably reported and complete full-thickness resection was achieved in only 12/17 patients. <h3>Conclusion</h3> The technique of EFTR is evolving, with only limited clinical evidence to date, but currently pre-resection closure methods should be advocated. Significant technological challenges remain before colonic EFTR can be recommended in clinical practice, including reproducible lateral margin clearance. <h3>Disclosure of interest</h3> None Declared.

PCN139 - The Impact of Endoscopic Linear Stapling Device Stability in Thoracic Surgery: a Delphi Panel Approach

PCN139 - The Impact of Endoscopic Linear Stapling Device Stability in Thoracic Surgery: a Delphi Panel Approach

Pharyngeal pouch: which technique?

Pharyngeal pouches have been recognised as a cause of dysphagia for centuries and have been treated in a variety of ways over that time. This article aimed to analyse the results of surgery by a variety of techniques, as performed by one surgeon. A retrospective analysis of a case series was conducted, analysing the variables of patient age, sex, type of surgery, length of hospital stay, leak, recurrence and other complications. A total of 121 patients were treated by 135 operations. There were no leaks in the group treated by endoscopic stapling and this group also had a significantly shorter hospital stay. As for recurrence, the lowest rate appeared to be in the group treated by excision of the pouch. The techniques used by the author all still seem to have a role in the management of pharyngeal pouch, with the endoscopic stapling approach associated with a low rate of complications and short hospital stay.

A Simplified Approach to Intracorporeal Robot-Assisted Laparoscopic Ileal Conduit Formation

Introduction: During robot-assisted radical cystectomy, urinary diversions are often performed extracorporeally. However, an optimized minimally invasive technique is possible with total intracorporeal urinary diversion. In this video, we provide a step-by-step demonstration of a simplified approach to the intracorporeal robot-assisted laparoscopic ileal conduit with the Wallace and Bricker anastomosis. Methods: A total intracorporeal ileal conduit formation was performed using the da Vinci robotic surgical system. During ureteral dissection and tunneling, the sigmoid colon was retracted using a dual-blade retractor. A 15-cm segment of ileum ~20 cm from the ileocecal valve was used for the conduit. A 60-mm endoscopic stapler was used to staple, transect, and restore the continuity of bowel segments. Both the Bricker and Wallace ureteroileal anastomoses were performed using a 4-0 monofilament absorbable suture on an RB-1 needle in a continuous manner. Results: This technique of robot-assisted total intracorporeal ileal conduit urinary diversion was performed in 11 patients. No patients developed uretero-enteric or entero-enteric anastomotic leak. One patient required re-operation for bowel obstruction. When performed along with robotic assisted cystectomy and lymphadenectomy, mean total operative time was 445 minutes and mean hospital stay was 7 days. Conclusion: Robotic total intracorporeal ileal conduit urinary diversion offers a truly minimally invasive technique that can be performed for a variety of indications, regardless of the need for specimen extraction. While following similar steps to the traditional Bricker or Wallace anastomosis, the robotic intracorporeal approach utilizes precise control of surgical instruments and allows for a meticulous dissection with minimal blood loss. For patients undergoing radical cystectomy, females bore no abdominal incisions other than port sites since the specimen is removed through the vagina. In males, the incision can be limited to ~5 cm and placed either periumbilical or Pfannenstiel. The authors declare that no competing financial interests exist. Runtime of video: 5 mins

Laparoscopic Radical Cystectomy With Intracorporeal Orthotopic Ileal Neobladder: Technique and Clinical Outcomes

To study the feasibility and safety of laparoscopic radical cystectomy with intracorporeal orthotopic ileal neobladder and to evaluate the role of endoscopic stapling in neobladder construction. Fifty-five patients with bladder cancer who underwent laparoscopic radical cystectomy were retrospectively examined. Extended pelvic lymph node dissection was performed before cystectomy. An ileal segment of 50cm was harvested to construct a U-shaped reservoir. The bottom of the reservoir was anastomosed with the posterior urethra. Twenty-five patients underwent neobladder construction by manual suturing and 30 patients by endoscopic stapler suturing. The mean operative time was 346minutes, and mean neobladder construction time was 230minutes. The median estimated blood loss was 500mL, and 17 patients received intraoperative transfusion. Postoperative complications included 2 cases of urine leakage, 7 cases of pyelonephritis, 4 cases of incomplete bowel obstruction, 1 case of anastomotic stricture, and 1 case of death. Endoscopic stapler suturing for neobladder construction took significantly less time than manual suturing. However, neobladder stones were found in 2 patients who underwent operation using endoscopic suturing, and the stones were removed cystoscopically. The functional outcomes of the 2 constructive methods were comparable. Laparoscopic radical cystectomy with intracorporeal orthotopic neobladder is safe and feasible for experienced laparoscopic surgeons. Application of endoscopic stapler simplifies the surgical procedure while increasing the risk of neobladder stone formation.

Lung resection using transumbilical incision: an animal survival study.

Introduction:Transumbilical single-port surgery is a potentially less invasive approach to many types of abdominal surgeries and offers better cosmetic outcomes than conventional 3-port laparoscopic surgery. It avoids the complication of intercostal neuralgia and may reduce the risk of pulmonary complications after video-assisted thoracic surgery. This study evaluated the feasibility of transumbilical lung wedge resection.Methods:Lung resection was performed in 11 beagle dogs weighing 5.9 to 8.5 kg. A 3-cm umbilical incision and one diaphragmatic incision were made, and an endoscopic stapler was used. The diaphragmatic incisions were repaired under video guidance using a V-Loc knotless suturing device (Covidien, Mansfield, Massachusetts). Animals were monitored daily for signs of postoperative infection. White blood cell count, C-reactive protein level, and IL-6 level were measured in all animals. Animals were euthanized 14 days after surgery and underwent necropsy evaluation.Results:Accurate lung resection was achieved in 10 of 11 animals during a median operative time of 98 minutes (range 60–165). In 1 animal, transumbilical lung resection was not possible and was converted to thoracotomy. All animals survived without major postoperative complications. At necropsy, evidence of uneventful healing of the stapled resection margin and diaphragmatic wound were found. There was no evidence of vital organ injury or intrathoracic infection.Conclusion:A transumbilical approach to thoracic cavity exploration and stapled lung resection is technically feasible. Primary suturing of the diaphragmatic incision is a simple and effective means of diaphragmatic wound closure. This may be an alternative to video-assisted thoracic surgery for the management of simple thoracic disease.

Hand-Sewn Running Barbed Suture versus Endoscopic Stapler Closure of the Mesenteric Defects in Retrocolic and Retrogastric RYGB: A Comparative Case-Matched Study

Background: Obesity is nowadays a major health concern in Western countries and the number of bariatric surgical procedures being performed worldwide is vertiginously rising. The Laparoscopic Roux-en-Y gastric bypass (LRYGB) has become the gold standard bariatric procedure. The retrocolic retrogastric approach is closer to normal anatomy and it is associated to a lower rate of anastomotic leak, a lower rate of gastrojejunal stricture and a lower rate of marginal ulcers; therefore the problem of small bowel obstruction due to internal hernia (IH) has to be faced. The meticulous closure of all possible mesenteric defects with running, non-absorbable sutures may reduce the rate of this complication, but it can be challenging for the surgeon and it rises the operating time (OT). This study has conducted in a context of optimization of our “Fast Track-type” recovery protocol and it aims to compare the rate of early IH and the OT difference when mesenteric defects are closed using running non-absorbable barbed suture or an endoscopic stapler. Materials and Methods: From December 2014 to February 2015 a single-surgeon consecutive series of 22 patients undergoing retrocolic restrogastric LRYBP in our high volume obesity centre has been retrospectively extrapolated from our prospective longitudinal database. We recorded the overall OT and relative rate of IH in patients who received a 15-cm non-absorbable V-LocTM1 (group A, 11 patients) or EndopathTM EMS, endoscopic multifeed stapler2 (group B, 11 patients) defect. Results: The mean OT was 77.36 minutes in the group A and 60.90 minutes in the group B (P value 0.066). 0 patients (0%) in the group A versus 4 patients (36.3%) in the group B developed IH within 30 days (two-tailed P value at chi-square test: 0.02). Conclusion: Early rate of small bowel obstruction due to IH is extremely higher with the use of an endoscopic stapler instead of non-absorbable barber suture and there is not significant difference in the OT; more prospective randomized trials observing bigger series of patients with longer follow-up are needed to validate our study.

Laparoscopic right-sided colonic resection with transluminal colonoscopic specimen extraction.

To study the transcolonic extraction of the proximally resected colonic specimens by colonoscopic assistance at laparoscopic colonic surgery. The diagnoses of our patients were Crohn's disease, carcinoid of appendix and adenocarcinoma of cecum. We preferred laparoscopic total mesocolic resections. Colon and terminal ileum were divided with endoscopic staplers. A colonoscope was placed per anal and moved proximally in the colon till to reach the colonic closed end under the laparoscopic guidance. The stump of the colon was opened with laparoscopic scissors. A snare of colonoscope was released and the intraperitoneal complete free colonic specimen was grasped. Specimen was moved in to the colon with the help of the laparoscopic graspers and pulled gently through the large bowel and extracted through the anus. The open end of the colon was closed again and the ileal limb and the colon were anastomosed intracorporeally with a 60-mm laparoscopic stapler. The common enterotomy orifice was closed in two layers with a running intracorporeal suture. There were three patients with laparoscopic right-sided colonic resections and their specimens were intended to remove through the remnant colon by colonoscopy but the procedure failed in one patient (adenocarcinoma) due to a bulky mass and the specimen extraction was converted to transvaginal route. All the patients had prior abdominal surgeries and had related adhesions. The operating times were 210, 300 and 500 min. The lengths of the specimens were 13, 17 and 27 cm. In our cases, there were no superficial or deep surgical site infections or any other complications. The patients were discharged uneventfully within 4-5 d and they were asymptomatic after a mean 7.6 mo follow-up (ranged 4-12). As far as we know, there were only 12 cases reported yet on transcolonic extraction of the proximal colonic specimens by colonoscopic assistance after laparoscopic resections. With our cases, success rate of the overall experience in the literature was 80% (12/15) in selected cases. Transcolonic specimen extraction for right-sided colonic resection is feasible in selected patients. Both natural orifice surgery and intracorporeal anastomosis avoids mini-laparotomy for specimen extraction or anastomosis.

Modified intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy for gastric cancer: early experience.

PurposeThis study presents findings on the clinical usefulness of an overlap method that is another modification for the currently well-known intracorporeal gastroduodenostomy in totally laparoscopic distal gastrectomy (TLDG).MethodsWe studied 42 patients diagnosed with gastric cancer who underwent TLDG between December 2011 and March 2013. Endoscopic linear staplers were used for intracorporeal anastomosis and patients were observed with endoscopic tracking six months after surgery. We retrospectively reviewed the outcome of the operation, the clinical pathological results, and the endoscopy results.ResultsThe mean duration of the operation for 42 patients was 228.3 ± 42.5 minutes and the mean time to complete the anastomosis was 12.18 ± 2.3 minutes. There were no mortalities and no cases of open conversion. Following the operation, 37 patients had stage IA, 5 in stage IB, and 3 in stage II gastric cancer. Abscesses were seen in 3 patients and 5 cases of stasis during the postoperative period. Duodenoscopy 6 months after the operation showed 11 cases of gastric stasis, 28 cases of bile reflux, and 1 new case of erosive gastritis. We did not observe contraction in any of the patients.ConclusionThe overlap method for intracorporeal gastroduodenostomy, using an endoscopic linear stapler, can be considered a feasible and safe technique for the treatment of stomach cancer. However, a long-term comparative study is required to sufficiently evaluate our findings.

Intestinal Staple Line Reinforcement Using MatriStem

Background: Staple line reinforcement material has been demonstrated to raise the burst pressure threshold after linear intestinal stapling. Numerous bioprosthetic materials have been utilized in surgical practice. Porcine urinary bladder matrix (ACell, Inc.) is an extracellular matrix material derived from porcine bladder used to reinforce surgically repaired soft tissue, and facilitate the body’s regenerative capacity. Objective: This study represents the first evaluation of urinary bladder matrix in gastrointestinal staple line reinforcement. Methods: Pathogen-free pigs underwent midline laparotomy under general anesthesia. Small intestinal division was performed with an endoscopic linear stapler. Nineteen intestinal divisions were performed with urinary bladder matrix staple line reinforcement, and twenty divisions were unreinforced. Staple lines were then subjected to burst pressure analysis by intraluminal infusion of dyed Krebs solution at an infusion rate of 20 ml·min-1 under manometric monitoring. Upon visible staple line extravasation, intraluminal pressure was recorded. Results: Intestinal staple lines reinforced with urinary bladder matrix exhibited significantly higher burst pressure threshold (p

Duodenal lengthening in short bowel with dilated duodenum

Although duodenal dilatation occurs in children with short bowel syndrome (SBS) facilitating dismotility and bacterial overgrowth, the duodenum has been an untouchable intestinal segment for lengthening procedures owing to its close relationship with bilio-pancreatic structures and blood supply shared with the pancreas. Three children (age range, 0.5–7 years) with SBS and dilated duodenum underwent a novel surgical procedure of duodenal lengthening combined with a technical modification of serial transverse enteroplasty (STEP). Pre-STEP, jejunum length was 5, 35 and 45cm, respectively. Duodenal lengthening was performed with sequential transverse applications of an endoscopic stapler on the anterior and posterior wall of the duodenum to avoid bilio-pancreatic structure injury. Two patients underwent 3 duodenal firings (stapler of 35mm) and the third 5 firings (stapler of 45mm). Duodenal firings were 17%, 21% and 83% of the total firings. ResultsNo surgical complications occurred. One patient developed transient episodes of D-lactic acidosis. Two patients (5 and 45cm) were weaned off parenteral nutrition at 12months post-surgery and the remaining patient´s (35cm) parenteral calorie requirements have decreased by 60%. ConclusionDuodenal lengthening is effective since it tailors and increases the absorptive surface of the duodenum, even in cases of extreme SBS.