Gastrointestinal Anastomosis Stapler Research Articles

Stapled functional end-to-end intestinal anastomosis with endovascular gastrointestinal anastomosis staplers in cats and small dogs.

To investigate the use of endovascular gastrointestinal stapling devices to perform intestinal functional end-to-end stapled anastomosis in small dogs and cats. Medical records of dogs (≤10 kg) and cats that underwent intestinal resection and functional end-to-end stapled anastomosis with an endovascular gastrointestinal anastomosis (endovascular-GIA) stapling device at five small animal referral centres between April 2014 and September 2023 were retrospectively reviewed. Data including clinical findings, surgical technique, histopathology and complications were collected. A minimum follow-up of 10 days was required. Patients with follow-up of less than 10 days were included if they developed a major complication. Outcome was obtained from assessing the clinical records and contacting the referring veterinarians or owners. Estimated survival was generated according to the Kaplan-Meier method. Differences between survival curves were tested by log-rank test. Twenty-five patients (10 dogs and 15 cats) were included. The median bodyweight was 4.6 kg (range 2.6 to 10 kg). Nine patients were diagnosed with intestinal neoplasia, 16 with non-neoplastic intestinal disease. The median follow-up was 126 days (range 18 to 896 days). Five patients developed minor postoperative complications, including three superficial surgical site infections. No major postoperative complications were reported. Eighteen patients were alive at the end of the study, one patient was lost to follow-up. Kaplan-Meier estimated median survival time was not reached. Survival was significantly longer for patients with non-neoplastic versus neoplastic intestinal. The study suggests that the use of endovascular gastrointestinal anastomosis staplers is safe and effective to perform intestinal functional end-to-end stapled anastomosis in dogs ≤10 kg and cats.

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.

Laparoscopic management of cholecystoduodenal fistula: A case report

Fistula between gall bladder and gastrointestinal tract occurs anywhere for example stomach, duodenum, and colon. Results of inflammatory reaction adhesion may be occur and between two organs and gall stone’s pressure may be contribute this process. Laparoscopic cholecystectomy has been the most widely accepted modality of treatment for patients with gall bladder disease. With time and increasing experience laparoscopic cholecystectomy is now being successfully attempted to treat almost all benign gall bladder pathology and their complications. One such uncommon infrequent complication of cholecystolithiasis is the cholecystoenteric fistula. Management of cholecystoduodenal fistula was traditionally performed by open method. With increasing newer laparoscopic techniques and advancement in the field, cholecystoduodenal fistula, an uncommon clinical entity is now being successfully treated via laparoscopic approach. It is feasible and safer than the conventional open approach in experienced hands, thus decreasing the overall morbidity and mortality attributed to the condition. We report a case of 55yr old female with cholecystoduodenal fistula treated successfully by laparoscopic approach using an Endovascular Gastro-Intestinal Anastomosis (GIA endo) stapler at H.B.T. Medical College & Dr. R.N. Cooper Municipal General Hospital, Juhu, Mumbai. Keywords: cholecystoduodenal fistula; laparoscopic cholecystectomy.

Single-Incision Transumbilical Laparoscopic Sleeve Gastrectomy with a Stomach Retractor in 20 Superobese Patients-a Video Vignette.

The safety and feasibility of single-incision transumbilical laparoscopic sleeve gastrectomy (SITU-LSG) have been proven in obese patients, with great aesthetics. However, it is not performed in superobese patients (BMI ≥ 50kg/m2). We aimed to introduce the technical details of SITU-LSG with a stomach retractor in superobese patients. Twenty superobese patients with a range of BMI from 50.00 to 55.77kg/m2 underwent stomach retractor-assisted SITU-LSG. An intraoperative laparoscopic video has been anonymized and edited to demonstrate the course of the operation on superobese patient. The stomach retractor has a mini grasper end, which can be opened with external force and closed without force, and it was inserted from a 1.5-mm incision at the left upper abdomen. A Kirschner needle (K-needle) was inserted into the right diaphragmatic crura to retract the liver so that the pylorus and fundus of the stomach could be exposed adequately. Traction on the omentum majus and insertion of 34 Fr. Bougie tube were achieved with the aid of the stomach retractor. When endovascular gastrointestinal anastomosis staplers (Endo-GIAs) were used to resect the stomach, the resected gastric tissue was retracted by the stomach retractor. During the reinforce of staple line, the stomach retractor was used to press the proximal end of staple line into the purse string and immobilize the gastric sleeve. After surgery, the patients underwent uneventful postoperative courses. The stomach retractor facilitates SITU-LSG. The combinatory procedure is safe, feasible, and effective in superobese patients.

Safety and Efficacy of Using Staplers and Vessel Sealing Devices for Laparoscopic Splenectomy: A Randomized Controlled Trial.

Background. Laparoscopic splenectomy (LS) is considered the operation of choice on elective basis for managing patients with certain hematological disorders. Hemostatic control of the splenic pedicle is one of the crucial steps in LS. This study compares the safety and efficacy of using endoscopic staplers and vessel sealing devices to control the splenic pedicle in patients with nonsevere splenomegaly. Methods. Fifty-one consecutive patients with different blood disorders including idiopathic thrombocytopenic purpura (ITP), hypersplenism, and lymphoma were randomized for elective LS. Traditional steps of LS, via lateral approach, were followed, and pedicle control was done with either endovascular gastrointestinal anastomosis stapler (n = 26) or vessel sealing device (Ligasure) (n = 25). Results. No difference was noted with different splenic spans when using either methods of pedicle control (P = .145). The volume of blood loss was higher in the Ligasure group compared to the staplers group (182mL vs 131mL, respectively), but was not statistically significant (P = .249). Conversion to open was notably higher in the Ligasure group (P = .034), but the intraoperative complications were comparable in both groups (P = .357). Conclusion. The use of vessel sealing devices for splenic pedicle control has comparable surgical outcomes compared with the use of endoscopic staplers for LS, but with higher rate of conversion to open surgery.

Comparison of Postradical Cystectomy Ileus Rates Using GIA-80 Versus GIA-60 Intestinal Stapler Device

ObjectiveTo assess the impact on recovery of bowel function using an 80 mm versus 60 mm gastrointestinal anastomosis (GIA) stapler following radical cystectomy and urinary diversion (RC/UD) for bladder cancer. MethodsWe identified 696 patients using a prospectively maintained RC/UD database from January 2006 to November 2010. Two nonrandomized consecutive cohorts were compared. Patients between January 2006- and December 2007 (n = 180) were treated using a 60 mm GIA stapler, and 331 patients between January 2008 and December 2010 were subject to an 80 mm GIA stapler. All patients were treated on the same standardized postoperative recovery pathway. After accounting for baseline patient and perioperative characteristics, using a multivariable logistic regression model, we directly compared rates of postoperative ileus using a standardized definition. ResultsOf 511 evaluable patients, ileus was observed in 32% (57/180) for 60 mm GIA versus 33% (110/331) for the 80 mm GIA. Preoperative renal function, age, gender, body mass index, and type of diversion were comparable between cohorts. On multivariate analysis, stapler size was not significantly associated with the development of ileus (GIA-60 vs GIA-80: OR 1.11; 95% CI 0.75, 1.66; P = .6). Positive fluid balance was associated with an increased risk (P = .019) and female sex a decreased risk (P = .008) of developing ileus compared to patients with negative fluid balance. ConclusionThe size of the intestinal bowel anastomosis (GIA 80 mm vs 60 mm) does not independently impact the time to bowel recovery following RC/UD.

Internal hernia caused by a free intraperitoneal staple after laparoscopic appendectomy

Background: Laparoscopic appendectomy is the gold standard for treatment of appendicitis. Stapled closure of the appendiceal stump is commonly performed and has several advantages. Few prior cases have demonstrated complications from free staples left within the abdomen after the stapler has been fired.Case report: A 29-year-old female underwent laparoscopic appendectomy for acute uncomplicated appendicitis during which the appendix and mesoappendix were divided using laparoscopic gastrointestinal anastomosis (GIA) staplers. Her initial recovery was uncomplicated. She returned on postoperative day 17 with sharp mid-abdominal pain, obstipation, and emesis. Her abdomen was distended, and she had a mild leukocytosis. Computed tomography (CT) demonstrated twisted loops of dilated small bowel in the right lower quadrant with two transition points, suggestive of internal hernia with closed loop bowel obstruction. Diagnostic laparoscopy was performed through the three prior appendectomy incisions. An adhesion between the Veil of Treves and the mesentery of the ileum caused by a solitary free closed staple, remote from the staple lines, had caused an internal hernia. The hernia was reduced, and the small bowel was noted to have early ischemic discoloration. The adhesion was lysed by removing the staple from both structures. The compromised loops of bowel began to show peristaltic movement and color returned to normal, and the procedure was concluded without resection. She was discharged home the following day.Conclusions: Gastrointestinal staplers are commonly used due to ease of use and low complication rate. It is not uncommon to leave free staples in the abdomen as retrieval can be difficult and time consuming. Our case is only the second in the literature reporting an internal hernia with closed loop bowel obstruction as a complication of retained staples. Choosing the most appropriate size staple load to reduce the number of extra staples, removing free staples, or the use of an endoloop can prevent potentially devastating complications.

Subcutaneous Emphysema following Endoscopic Zenker's Diverticulum Repair and Postoperative Continuous Positive Airway Pressure Use

Objective. We report a complication of endoscopic Zenker’s diverticulum repair after postoperative continuous positive airway pressure (CPAP) use. Study design. Case report and literature review. Results. Patient presented for Zenker’s diverticulum repair. He was treated endoscopically with gastrointestinal anastomosis stapler and carbon dioxide laser myotomy. He inadvertently resumed CPAP use early on postoperatively and subsequently presented with dysphagia. Imaging revealed subcutaneous emphysema. Conclusion. It is important to understand the implications that CPAP can have on recovery from Zenker’s diverticulum repair. It is reasonable to screen all surgical candidates for CPAP use and ensure they understand instructions regarding safe postoperative use.

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.

Use of cecal bypass via side-to-side ileocolic anastomosis without ileal transection for treatment of ileocecal intussusception in a Vietnamese pot-bellied pig (Sus scrofa)

A 5-year-old castrated male Vietnamese pot-bellied pig (Sus scrofa) was evaluated because of anorexia, vomiting, diarrhea, and weight loss. Hypermotile gastrointestinal sounds were noted on abdominal auscultation. An inflammatory leukogram, dehydration, prerenal azotemia, hyponatremia, hypochloremia, hyperproteinemia, hyperglobulinemia, hypomagnesemia, and high γ-glutamyl transpeptidase activity were identified. Transabdominal ultrasonography revealed distended loops of small intestine. IV fluid therapy and analgesic treatment were unsuccessful in the resolution of clinical signs. Exploratory laparotomy revealed an ileocecal intussusception involving the distal portion of the ileum. Distal ileal and cecal bypass were achieved via side-to-side anastomosis of the proximal portion of the ileum and spiral colon with a gastrointestinal anastomosis stapler. Ileal transection or occlusion was not performed. Postoperative complications were minimal, and the pig was clinically normal 15 months after surgery and required no special care or diet. Distal ileal and cecal bypass without ileal transection have not been described previously in Vietnamese pot-bellied pigs. Anastomosis of the proximal portion of the ileum to the spiral colon without major complications represents a novel, technically simple approach to bypass of the distal portion of the ileum and cecum.

Laparoscopic Button Loop Feed Jejunostomy

Purpose: The purpose of this procedure is to provide a minimally invasive feeding access technique in patients in whom oral or intragastric nutrition is not an option. Surgically placed feeding jejunostomies allow patients to receive postpyloric enteral nutrition in a tolerable and safe manner. At our institution, we designed a minimally invasive technique to place feeding jejunostomies that is not only simple but also more importantly safe and effective. This 2-minute video demonstrates the technique for placing a button loop-feeding jejunostomy in the pediatric population. Methods: The surgical technique entails accessing the abdomen with a 3/5-mm scope at the umbilicus, placing a 12-mm port in the right side of the abdomen, and placing a second working 3/5-mm port in the right-lower quadrant. The right side of the abdomen is chosen as most of our patients have a gastrostomy tube in the left-upper abdomen. The patient is placed in reverse trendelenberg, and the small bowel is displaced into the lower abdomen. The transverse colon is elevated, allowing identification of the ligament of treitz. Approximately 15 to 20 cm from the ligament of treitz, the jejunum is exteriorized through the 12-mm-port site. The jejunum is folded onto itself. Guy sutures are placed distally. A purse-string suture is placed at the apex. An enterotomy is made. An endoscopic stapler is inserted into the limbs of the jejunum. If an endoscopic stapler is used, two staple fires should be utilized to ensure an adequate channel length. If a gastrointestinal anastomosis stapler is utilized, a single cartridge may be utilized. An extracorporeal side‐to‐side anastomosis is performed. A MicKey button is inserted, and the purse-string suture is secured. Anchor sutures are placed onto the peritoneum and secured in the same manner as a Stamm gastrostomy tube. Results: Tube feeds are initiated in 8–12 hours and increased to goal volume within the first 24 hours. The first tube change may be performed on the same schedule as that of a Stamm gastrostomy tube. Conclusion: We believe that our laparoscopically placed loop-feeding jejunostomy tube is a safe and effective means of establishing a permanent feeding access in patients who are unable to tolerate oral or intragastric feeds. This technique may reduce the risks of bowel obstruction and intussusceptions. It allows for safer access by our interventional radiology colleagues in the event of premature tube dislodgement. It also obviates tube complications such as tube migration and occlusion. No competing financial interests exist. Runtime of video: 2 mins

V875 REPAIR OF VESICO-UTERINE FISTULA BY SINGLE INCISION LAPAROSCOPIC SURGERY

You have accessJournal of UrologyOncology (TCC & Adrenal) & Teaching Techniques1 Apr 2012V875 REPAIR OF VESICO-UTERINE FISTULA BY SINGLE INCISION LAPAROSCOPIC SURGERY Rajinder Yadav, Manish Kulshreshtha, Nitin Sharma, and Vipul Agrawal Rajinder YadavRajinder Yadav New Delhi, India More articles by this author , Manish KulshreshthaManish Kulshreshtha New Delhi, India More articles by this author , Nitin SharmaNitin Sharma New Delhi, India More articles by this author , and Vipul AgrawalVipul Agrawal New Delhi, India More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2012.02.969AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES Since the first laparoscopic surgery in urology in 1990s, it has been used for treatment of a variety of urologic disorders. The benefits are well recognized & known to everyone. A number of papers & case series have been published on Single Incision Laparoscopic Surgery (SILS) extirpative surgery, especially nephrectomy. Applicaltion of SILS for management of complications of previous surgery is limited to occasional case reports. We present a case of 38 yr female with Vesicouterine fistula following complicated Caesarian Section. Fistula was associated with bilateral vesicoureteric reflux with Rt nonfunctioning kidney, managed by SILS repair of fistula with subtotal hysterectomy & Rt nephro-ureterectomy. METHODS With patients in lithotomy, Lt side was stented as fistula was close to Lt ureteric orifice. After a 2cm periumblical incision was taken, a Size 7 surgical glove was inserted. Three 5mm ports were introduced through the fingers of the glove. The procedure was carried out using laparoscopic working instruments, scope & camera. After identifying the fistula tract, subtotal hysterectomy and closure of cervix was done. This was followed by repair of fistula and omental transposition. Then pt was taken in 70o lateral position for Rt nephro-ureterectomy. We required a rescue port during fistula repair, which was later used for keeping drain. RESULTS The duration of surgery was 320 min. The blood loss was 100ml. No blood transfusion was required. The drain was removed on POD3. She was in hospital for 5 days. Foleys was removed after 6 wks and stent removed after 3 months. CONCLUSIONS Single Incision Laparoscopic Surgery (SILS) is an emerging sub-specialty of Lap-urology gaining acceptance & popularity very quickly. Till date, publications have shown acceptable results of SILS in urology, which are comparable to standard laparoscopic surgery. SILS techniques are still in the early stages of development and additional studies with larger cohorts are required to more accurately determine its role in the field of urologic surgery. Further technological advances with regards to instrumentation and retraction should facilitate implementation of this surgical platform, especially in management of complicated cases like genito-urinary fistulas. © 2012 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 187Issue 4SApril 2012Page: e356 Advertisement Copyright & Permissions© 2012 by American Urological Association Education and Research, Inc.MetricsAuthor Information Rajinder Yadav New Delhi, India More articles by this author Manish Kulshreshtha New Delhi, India More articles by this author Nitin Sharma New Delhi, India More articles by this author Vipul Agrawal New Delhi, India More articles by this author Expand All Advertisement Advertisement PDF DownloadLoading ...

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.

Stapled Intestinal Anastomosis in Neonates: Validation of Safety and Efficacy

The safety and effectiveness of a stapled intestinal anastomosis in adults and children is well documented. However, the role of this technique in neonates is not well validated. We report our experience with stapled intestinal anastomoses in the neonate at the University of Mississippi Medical Center. All patients from the neonatal intensive care unit who had a stapled intestinal anastomosis between February 2007 and May 2008 were identified. A stapled side-to-side functional end-to-end intestinal anastomosis was performed in all patients using a gastrointestinal anastomosis stapler. Demographic, management, and outcome data were collected via chart review. Variables collected included: birth weight, estimated gestational age at birth and surgery, weight at surgery, the use of vasopressors, associated diagnoses, location of the anastomosis, and postoperative clinic visits. A total of 18 patients were identified during the study period. Nine had small bowel to small bowel, eight had ileum to colon, and one had a colon to colon anastomosis. The average weight at time of operation was 2.8 kilograms (Kg) and the average estimated gestational age at surgery was 38.7 weeks. The only complication reported was a partial small bowel obstruction on postoperative day 12, which was successfully treated nonoperatively. Two patients died from problems not associated with the anastomosis. There were no anastomotic leaks or strictures. The literature regarding the use of stapled bowel anastomoses in neonates is scant. Stapled intestinal anastomoses can be performed safely in neonates without a high rate of complication. The long-term effects of stapled intestinal anastomoses in the neonate are unknown. Future areas of interest would include effects on postoperative feeding and operative time.

Extraluminal laparoscopic wedge resection of gastric submucosal tumors: a retrospective review of 84 cases

Laparoscopic resection of gastric stromal tumors is being performed with increased frequency. This study aims to evaluate the feasibility and safety of the extraluminal laparoscopic gastric wedge resection (ELWR) technique. Clinical data of 84 patients who underwent ELWR for gastric submucosal tumors between September 2000 and December 2007 were reviewed and analyzed retrospectively. The operation includes: localization of the tumor, dissection of the omentum, mobilization of the upper stomach and the upper pole of the spleen, exposure of esophago-cardiac junction (ECJ), and wedge resection of the upper part of gastric body and/or the gastric fundus with endoscopic gastrointestinal anastomosis (Endo GIA) stapler. All of the procedures were performed successfully, with mean operation time of 62.6 +/- 8.9 min and mean intraoperative blood loss of 86.2 +/- 8.1 ml. Through extraluminal laparoscopic wedge resection, complete R0 resection was achieved for all tumors. All surgical margins were negative microscopically. No lesions were missed, nor were there any significant postoperative complications or intraoperative conversions to open surgery. A total of 78.6% of the patients recovered their gastrointestinal functions and began to eat and ambulate within 36 h of the operation. The smallest surgical margins were 0.7-2.5 cm, with a mean distance of 1.4 +/- 0.5 cm. Of the 84 cases of gastric submucosal tumors, 29 cases were leiomyomas, 51 cases were various types of stromal tumors, and 4 other cases were neurofibromas. Mean follow-up duration was 51 +/- 4.3 months (overall follow-up rate 73.8%, 62/84 cases), during which no recurrences or metastases were found. ELWR is a safe, simple, and effective procedure for treating submucosal tumors in the upper part of the stomach. It can avoid intraperitoneal contamination, possible tumor spillage, and postoperative esophageal stenosis, and provides unlimited scope for gastric resection.

Endostitch-assisted endoscopic Zenker's diverticulostomy: a tried approach for difficult cases

The aim was to describe a tried approach to endoscopic Zenker's diverticulostomy, especially in those patients with unfavorable anatomy or smaller pouches who may otherwise be relegated to open repair. The study design was a retrospective case series The setting was an urban, tertiary care university medical center There were seven patients, both inpatient and outpatient, with chief complaints of dysphagia. All had a documented Zenker's diverticulum (ZD) on barium swallow. All of the patients were deemed by the primary surgeon to have some anatomic factor that limited exposure of the diverticulum. The patients underwent Endostitch-assisted endoscopic Zenker's diverticulostomy. Records were retrospectively reviewed, including preoperative and postoperative swallowing status, radiographic findings, operative findings, and follow-up results. Seven patients were reviewed, each of whom had successful endoscopic treatment of ZD. Notably, in each case, an anatomical factor precluded the seating of the gastrointestinal anastomosis (GIA) stapler on the cricopharyngeal bar without the use of endoscopic retention sutures. The majority of the patients were discharged on postoperative day one. All but one patient noted a marked improvement in swallowing function immediately following the procedure and at their outpatient follow-up visit. Endoscopic Zenker's diverticulostomy has been well-described and established as a reliable technique in a majority of cases. We report on our experience using a previously described technique specifically for difficult, unfavorable, or contraindicated cases and suggest the employment of this technique as an alternative method to facilitate endoscopic repair and possibly limit the need for an open approach.

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.

Endostitch‐Assisted Endoscopic Zenker's Diverticulostomy: A tried approach for difficult cases

SUMMARY The aim was to describe a tried approach to endoscopic Zenker's diverticulostomy, especially in those patients with unfavorable anatomy or smaller pouches who may otherwise be relegated to open repair. The study design was a retrospective case series The setting was an urban, tertiary care university medical center There were seven patients, both inpatient and outpatient, with chief complaints of dysphagia. All had a documented Zenker's diverticulum (ZD) on barium swallow. All of the patients were deemed by the primary surgeon to have some anatomic factor that limited exposure of the diverticulum. The patients underwent Endostitch-assisted endoscopic Zenker's diverticulostomy. Records were retrospectively reviewed, including preoperative and postoperative swallowing status, radiographic findings, operative findings, and follow-up results. Seven patients were reviewed, each of whom had successful endoscopic treatment of ZD. Notably, in each case, an anatomical factor precluded the seating of the gastrointestinal anastomosis (GIA) stapler on the cricopharyngeal bar without the use of endoscopic retention sutures. The majority of the patients were discharged on postoperative day one. All but one patient noted a marked improvement in swallowing function immediately following the procedure and at their outpatient follow-up visit. Endoscopic Zenker's diverticulostomy has been well-described and established as a reliable technique in a majority of cases. We report on our experience using a previously described technique specifically for difficult, unfavorable, or contraindicated cases and suggest the employment of this technique as an alternative method to facilitate endoscopic repair and possibly limit the need for an open approach.

Endoscopy-assisted Transanal Division of an Apical Pouch Bridge After Restorative Proctocolectomy With a J-shaped Ileal Pouch

Restorative proctocolectomy and J-shaped ileal pouch-anal anastomosis have been performed as a standard operation for ulcerative colitis. However, functional problems are sometimes troublesome in the postoperative period. The J pouch was constructed from 2 ileal limbs using the gastrointestinal anastomosis (GIA) stapler. A residual mucosal bridge remained because the stapler had a safety margin at the top of the cartridge. Apical pouch bridge is a residual septum above the ileoanal anastomosis. There are several reports of so-called apical pouch bridge syndrome due to outlet obstruction of the J-shaped ileal pouch by an apical bridge. Division of this septum can resolve the outlet obstruction. We describe a successful endoscopic procedure for division of an apical pouch bridge. An Endo-GIA stapler was introduced into the ileal pouch alongside the endoscope, and division of the apical bridge required a few firings of the Endo-GIA stapler under transanal endoscopic guidance. The symptoms related to the apical pouch bridge were resolved completely without creation of an ileostomy.

Utility of the Endovascular Stapler for Right-Sided Laparoscopic Donor Nephrectomy: A 7-Year Experience at Mayo Clinic

Management of the renal vasculature during right laparoscopic donor nephrectomy (LDN) to maximize vessel length has been controversial. The endovascular gastrointestinal anastomosis (GIA) stapler has been used for renal vascular control for our donors since the inception of our LDN program. We evaluated and compared the outcomes of right and left LDNs using a single method for hilar control. A retrospective review was performed of the first 400 LDNs and respective recipients at our institution. Patient demographics, perioperative variables, graft function, and complications were analyzed. Four hundred LDNs were performed between 1999 and 2007. Forty-one were on the right. There were no statistically significant differences between the donor groups or their respective recipients. There were 4 (1%) stapler malfunctions, all occurring on the left side; 2 of these procedures were converted to open to obtain hemostasis. There were nearly equal rates of vascular complications, 4.9% and 4.7%, in the right and left groups, respectively. The overall immediate graft failure rate was 2.3%. Right and left recipient creatinine levels up to 24 months demonstrated no statistically significant differences. We propose that the endovascular GIA stapler for left and right laparoscopic donor nephrectomy is safe for the donor. It standardizes the process, minimizes the need for additional maneuvers in securing the renal hilum, and produces similar outcomes for the recipient. The transplant team also plays an equally large role in favorable graft outcomes.