Hand-sewn Anastomosis Research Articles

Comparative retrospective study on surgical outcomes of hand‐sewn anastomosis versus stapling anastomosis for colectomy using a nationwide inpatient database in Japan with propensity score matching

AbstractBackgroundIntestinal anastomosis is performed by two main methods: hand‐sewn anastomosis (HA) and stapling anastomosis (SA). Studies on anastomosis are still being reported and are an ongoing area of interest. The aim of this study was to evaluate the characteristics of each by comparing them with description and statistical analysis using a nationwide inpatient database.MethodsWe collected data for colon cancer patients who underwent colectomy between April 2014 and March 2022 using the Diagnosis Procedure Combination (DPC) database. In the descriptive analysis, we described the background of the study population and the number of each method. In the statistical analysis, we used propensity score matching to achieve balanced covariates and showed the results of the comparative study using risk ratios and risk differences.ResultsA total of 232 155 cases were selected (HA group: 40 764; SA group: 191 391). SA was performed more frequently than HA during the study period, with the proportion of SA increasing over the last few years (~80% in 2015 and 85% in 2021). We obtained 40 760 pairs through propensity score matching. The comparison of postoperative events varied by outcome (reoperation: 517 [1.27%] vs 380 [0.93%]; risk ratio [RR]: 1.36 [95% confidence interval [CI], 1.19 to 1.55], endoscopic intestinal hemostasis: 17 [0.04%] vs 80 [0.20%]; RR: 0.21 [95% CI, 0.13 to 0.36]).ConclusionSA is becoming more common in colectomy. The risk of reoperation could be higher in the HA group, while the risk of postoperative endoscopic intestinal hemostasis could be higher in the SA group.

A Comparative Study of Hand-Sewn and Stapled Anastomosis in Gastrointestinal Surgeries.

Background Bowel anastomosis is a key part of gastrointestinal surgery where two sections of the intestines are connected. It is a critical step as it restores the digestive tract's continuity after removing damaged or diseased bowel. Stapler devices are a new method that helps connect bowel loops faster and with less tissue damage. This study aimed to evaluate and compare the safety and effectiveness of stapled anastomosis versus hand-sewn anastomosis in surgeries involving the bowel. Methods In this prospective non-randomized study, the study population included 60 patients with various gastrointestinal surgeries admitted to our institution from August 2022 to June 2024 within a single unit. The inclusion criteria included all patients aged over 18 years who underwent surgeries such as gastrojejunostomy, hemicolectomy, and small bowel resection with anastomosis. The exclusion criteria were age under 18, pregnancy, and immunocompromised states. Patients were divided into two groups based on how their digestive tract was reconstructed: 28 had stapled anastomoses and 32 had hand-sewn anastomoses, either as elective or emergency surgery. We examined multiple outcomes such as surgery duration in hours, time until bowel function returned post surgery, length of hospital stay in days, anastomotic leak rate, albumin levels to leak rate, post-surgery pain, and surgical site infection (SSI) rate for the two groups. Southampton wound grading system and the visual analog scale (VAS) were used to assess the SSI and pain score, respectively. Results When comparing the operation time for the suture and staple groups among the elective cases, the p-value was significant (0.02), with 15 patients having prolonged surgery in the suture group compared to only five in the staple group. Regarding the time until the return of bowel sounds post surgery, the p-value was significant (0.02) for elective cases in the two groups, with nine patients having their bowel sounds returning after the third postoperative day (POD) in the suture group. When comparing the duration of stay in the hospital for elective cases for the staple and suture groups, the p-value was significant (0.04), with eight patients staying after the seventh POD in the suture group. When comparing the leak rates for the two groups for elective cases, the p-value was significant (0.04), with four leaks in the suture group and no leaks in the staple group. On comparing the association between the albumin level and anastomotic leak, the p-value was significant at 0.001 and 0.0006 for the suture and staple groups, respectively, with more leaks associated with an albumin level of <3 mg/dl. When comparing pain scores of the suture and staple groups separately in elective and emergency settings, the p-values were both 0.4, which is not significant. Among the elective cases comparing SSIs for the suture and staple groups, the p-value was significant (0.04), with six patients having SSIs in the suture group compared to one patient in the staple group. Among the emergency cases, when comparing SSIs for the suture and staple groups, the p-value was not significant (0.1). Conclusion In elective surgeries, stapled anastomosis reduces surgery time, accelerates bowel function recovery, enables earlier discharge, and lowers anastomotic leak rates compared to sutures. The staples group showed no difference from sutures in the leak rate to albumin levels and pain while offering superior SSI prevention.

A Comprehensive Review of the Literature: Does an Optimal Type of Anastomosis Exist for One Anastomosis Gastric Bypass?

One anastomosis gastric bypass (OAGB) is a popular bariatric procedure known for its efficacy in promoting weight loss and improving metabolic outcomes. However, the optimal anastomotic technique for OAGB remains a subject of debate. This literature review comprehensively examines the three primary anastomotic techniques - linear stapled, circular stapled, and hand-sewn - to determine their suitability for OAGB. Linear stapled anastomosis is favored for its shorter operative time and lower complication rates, such as a reduced incidence of gastrojejunal stenosis. However, its larger anastomotic diameter increases the risk of marginal ulcers due to greater exposure of the gastric mucosa to bile and gastric acids. Circular stapled anastomosis offers a uniform and consistent lumen, which may reduce the risk of postoperative stenosis but is associated with a higher incidence of strictures and ulcers, making it less ideal for use in OAGB. Hand-sewn anastomosis, while time-intensive, provides superior control over anastomotic size and tension, resulting in the lowest rates of strictures and anastomotic leaks, although its effectiveness is highly dependent on surgical expertise. Overall, the current literature lacks large-scale, multicenter studies directly comparing these techniques in the context of OAGB. Future research should focus on randomized controlled trials to establish the most effective and safe anastomotic method for this procedure. Understanding the nuanced benefits and drawbacks of each technique is crucial for optimizing clinical outcomes in OAGB.

Intestinal Anastomosis During Enterostomy Takedown Using a 5 mm Miniature Endostapler Compared to Conventional Handsewn Technique

AimEnterostomy takedown is common in neonates with Hirschsprung’s disease, anorectal malformations, or necrotizing enterocolitis. Stapled bowel anastomosis has become routine in adults, but size of up to 12 mm diameter precludes performing enterostomy takedown in young infants using regular intestinal staplers. After the introduction of miniature (5 mm diameter) staplers, we increasingly used them for enterostomy takedown. This study compares enterostomy takedown using the miniature stapler (MS) to the conventional hand-sewn (HS) technique. MethodsRetrospective review of all children <3 years of age undergoing enterostomy closure at our institution from 2008 to 2023 were retrospectively reviewed. Demographics, operative times, complications, and outcomes were compared between those who underwent the procedure using MS versus HS technique. Data are quoted as median (range). ResultsA total of 102 patients were enrolled, including MS (n = 26) and HS (n = 76) anastomoses. There were no statistical differences in age, sex, or indication for enterostomy. Enterostomy takedown using MS was faster [82.5 (44–218) versus 147 (52–381) minutes, p < 0.001) and associated with earlier commencement of feedings [2 (1–6) versus 4 (1–24) days, p = 0.001], as well as shorter length-of-stay [6 (2–20) versus 17 (3–52) days, p < 0.001), compared to the HS technique. ConclusionsThis is the first study that systematically evaluates the novel 5 mm ministapler for enterostomy takedown in young children. Its use was associated with quicker operative times, earlier feeding and shorter hospital stay. These findings are especially relevant in children with co-morbidities who do not tolerate longer anesthesia times. Randomized, controlled trials should be performed to prospectively confirm these findings. Level of EvidenceLevel III, retrospective comparative study.

The impact of colectomy and restorative procedure on pouch function after ileo-pouch-anal anastomosis in ulcerative colitis. The icon fun study on behalf of the Italian Society of Colon and Rectal Surgery (SICCR) Inflammatory Bowel Diseases committee

BackgroundAvailable guidelines lack in indications on surgical standard in Ulcerative Colitis (UC) AimsTo determine the role of surgical strategies of colectomy and proctectomy with pouch-anal-anastomosis (IPAA) on functional outcomes in a nationwide population multicenter study. The secondary aims consisted of perioperative outcomes and complications. MethodsData on 379 patients who underwent total abdominal colectomy and proctectomy with ileo-pouch-anal-anastomosis (IPAA) with or without diverting ileostomy were retrospectively collected in a red cap multicenter-database searching for variables that could impact on pouch outcomes as cuffitis, pouchitis, anastomotic stenosis, pouch stenosis, failure or pathological Low-Anterior-Resection-Syndrome (LARS) score. ResultsMesocolic dissection sealing vessels at major trunks and from medial to lateral are associated with better outcomes. Laparoscopy is associated with lower rate of cuffitis over time (p = 0.028). Mesentery lengthening is associated with higher pouchitis rate (p = 0.015) and earlier failure (p < 0.0001). Hand-sewn IPAA results in early anastomotic stenosis (p = 0.00011). The Transanal-Transection and Single-Stapling Anastomosis (TTSS) showed to be protective against pouchitis. Extended dissection of adhesions correlates with lower rate of pouchitis-episodes (p = 0.0057). ConclusionsThe study highlights advantages of laparoscopy. New techniques such as TTSS promise further improvements. Mesentery lengthening correlates with high risk of pouch-failure and pouchitis, hand-sewn anastomosis increased risk of stenosis.

Modified stapled hemorrhoidopexy for lower postoperative stenosis: A five-year experience.

Stapled hemorrhoidopexy (SH) is currently a widely accepted method for treating the prolapse of internal hemorrhoids. Postoperative anal stenosis is a critical complication of SH. A remedy for this involves the removal of the circumferential staples of the anastomosis, followed by the creation of a hand-sewn anastomosis. Numerous studies have reported modified SH procedures to improve outcomes. We hypothesized that our modified SH technique may help reduce complications of anal stenosis after SH. To compare outcomes of staple removal at the 3- and 9-o'clock positions during modified SH in patients with mixed hemorrhoids. This was a single-center, retrospective, observational study. Patients with grade III or IV hemorrhoids who underwent standard or modified SH at our colorectal center between January 1, 2015, and January 1, 2020, were included. The operation time, blood loss, length of hospital stay, and incidence of minor or major complications were recorded. Patients with grade III or IV hemorrhoids who underwent standard or modified SH at our colorectal center between January 1, 2015 and January 1, 2020, were included. Operation time, blood loss, length of hospital stay, and incidence of minor or major complications were recorded. We investigated 187 patients (mean age, 50.9 years) who had undergone our modified SH and 313 patients (mean age, 53.0 years) who had undergone standard SH. In the modified SH group, 54% of patients had previously undergone surgical intervention for hemorrhoids, compared with the 40.3% of patients in the standard SH group. The modified SH group included five (2.7%) patients with anal stenosis, while 21 (6.7%) patients in the standard SH group had complications of anal stenosis. There was a significant relationship between the rate of postoperative anal stenosis and the modified SH: 0.251 (0.085-0.741) and 0.211 (0.069-0.641) in multiple regression analysis. The modified SH technique is a safe surgical method for advanced grade hemorrhoids and might result in a lower rate of postoperative anal stenosis than standard SH. The modified SH technique is a safe surgical method for advanced grade hemorrhoids and might result in a lower rate of postoperative anal stenosis than standard SH.

553. CIRCULAR STAPLED CERVICAL ESOPHAGO-GASTROSTOMY, A VALUABLE OPTION AFTER TOTALLY MINIMALLY INVASIVE MCKEOWN ESOPHAGECTOMY?

Abstract Background The optimal choice of anastomotic technique for cervical esophagogastric anastomosis after esophagectomy remains unclear. The incidence of cervical anastomotic leak after esophagectomy can be up to 30%, which is the highest among all types of gastrointestinal anastomosis. Anastomotic stricture is another complication that can decrease the postoperative quality of life with an incidence of 9.1–46.0%. Few studies directly compared circular stapled (CS) and hand sewn (HS) cervical esophago-gastric anastomosis, with mixed results. We aim to compare the two techniques in a pre-post cohort study. Methods Medical record of all patients that underwent minimally invasive subtotal esophagectomy and cervical esophago-gastrostomy in our institution from January 2018 to January 2024 were reviewed from a prospectively collected database. We routinely performed hand sawn anastomoses until February 2022, then switched to circular stapled, with the aim of reducing the incidence of anastomotic leaks. We compared clinical data of patients who received hand sewn cervical anastomosis and circular stapled anastomosis. Primary endpoints were anastomotic leaks and strictures. Results We identified 101 patients who met the inclusion criteria. HS anastomosis was performed in 67 patients, while 34 received CS anastomosis. Anastomotic leak rate was 22.4% in the HS group and 8.8% in the CS group (OR 0.34, p=0.092). Anastomotic stricture rate was 26.9% in the HS group and 14.7% in the CS group (OR 0.47, p=0.17). Median length of stay was 18 (IQR 15-22) days in the HS group and 13.5 (IQR 12-14.5) days in the CS group (p=0.001). Severe complication rate (CD&amp;gt;2) was 16.4% in the HS group and 11.8% in the CS group (OR 0.68, p=0.53). Conclusions In our experience, the introduction of circular stapled cervical esophago-gastrostomy was feasible and safe, and resulted in a lower incidence of anastomotic leak and stricture compared to hand sewn anastomosis, though not statistically significant, possibly because of the small sample size. No difference in other major postoperative outcomes was observed. We found cervical CS anastomosis a reliable, reproducible and technically less demanding procedure, even for very high esophageal cancers. We believe that this anastomotic technique could spread even in Western countries where it has hardly ever been explored.

A novel arterial coupler with non-return snap-fit connection approach optimized arterial end-to-end anastomotic technique: An experimental study

PurposeHand-sewn anastomosis as the gold standard of vascular anastomosis cannot fully meet the requirements of vascular anastomosis in speed and quality. Various vascular couplers have been developed to ameliorate this situation. Most of them are mainly used for venous anastomosis rather than arterial anastomosis, even though it is generally acknowledged that in almost all operations involving vascular reconstruction, it is the arteries that need to be anastomosed faster and more accurately and not the veins. A dedicated device is needed for creating arterial anastomosis in an easy, timesaving, less damaging but reliable procedure. Therefore, we plan to develop a novel arterial coupler device and test pre-clinical safety and effectiveness. MethodsIn this cohort study, the rationality of this novel arterial coupler was preliminarily tested by finite element analysis before it was manufactured. Several factors restrict the use of vascular couplers in arterial anastomosis, such as arterial eversion, fixation, etc. The manufactured arterial couplers underwent in vitro and in vivo experiments. In vitro, isolated arteries of beagles were anastomosed with the assistance of an arterial coupler, and the anastomosed arteries were evaluated through anti-traction tests. In animal experiments, the bilateral femoral arteries of 5 beagles served as a control group. After dissection, the femoral artery on one side was randomly selected to be anastomosed with a quick arterial coupler (QAC) (QAC group), and the femoral artery on the other side was anastomosed by the same person using an end-to-end suture technique with a 6-0 Prolene suture (suture group). The bilateral femoral arteries of 5 beagles were used for coupler-assisted anastomosis and hand-sewn anastomosis in vivo, respectively. Success rate, blood loss, anastomotic time, clamp time, total operation time, and patency rate were recorded. The patency of anastomosed arteries was assessed using vascular Doppler ultrasound, electromagnetic flowmeter, and pathological examination (6 weeks after surgery). ResultsAs a novel arterial coupler, QAC was successfully designed and manufactured by using poly lactic-co-glycolic acid raw materials and 3-dimensions printing technology. Its rationality was preliminarily tested through finite element analysis and related mechanical analysis methods. The isolated arteries were successfully anastomosed with the assistance of QAC in vitro testing, which showed good anti-traction properties. In animal studies, QAC-assisted arterial anastomosis has superior profiles compared to hand-sewn anastomosis in anastomotic time (7.80 ± 1.41 vs. 16.38 ± 1.04 min), clamp time (8.80 ± 1.41 vs. 14.14 ± 1.57 min), and total operation time (46.64 ± 2.38 vs. 51.96 ± 3.65 min). The results of electromagnetic flowmeter, vascular Doppler ultrasound, and pathological examination showed that QAC-assisted anastomotic arteries were superior to hand-sewn arteries in terms of postoperative blood flow (16.86 ± 3.93 vs. 10.36 ± 0.92 mL/min) and vascular patency in 6 weeks after surgery. ConclusionQAC is a well-designed and easily maneuverable device specialized for end-to-end arterial anastomosis. Application of this device may decrease thermal ischemia time and improve the patency of anastomotic arteries, thus, improving outcomes.

374. INCIDENCE AND PREDICTORS OF STRICTURE DEVELOPMENT FOLLOWING ESOPHAGECTOMY: A RETROSPECTIVE ANALYSIS

Abstract Objective Anastomotic stricture (AS) is a well described complication after esophagectomy and not only affects nutritional status but also has a detrimental impact on long-term quality of life. This retrospective study explores the incidence of clinically relevant AS in patients undergoing esophagectomy for cancer and investigates the potentially reversible factors associated with AS. Methods A prospectively entered clinical database of consecutive patients undergoing esophagectomy at a high-volume referral center over a decade (1/2013-12/2022) was queried for the presence of post-operative clinically significant AS, defined as stricture requiring endoscopic dilation. Multiple variables encompassing patient-related risk factors, tumor pathology, prior treatment, operative factors, and post-op complications were included in logistic regression analyses to delineate predictors of stricture formation. Results Of 1015 patients in the database, 115 (11.3%) developed AS requiring at least 1 post-op dilation. Although higher American Society of Anesthesiologists (ASA) grading was associated with elevated AS rate impact with most patients being ASA 2 and 3; 24% and 49% respectfully (p &amp;lt; 0.05). Specific patient factors/comorbidities such as age, peripheral or coronary vascular disease, and diabetes mellitus did not emerge as significant predictors. Surprisingly, neither histology, nor neoadjuvant therapy (chemo or chemoradiation) were associated with AS. Both a cervical anastomosis and a intra-operative pyloromyotomy had a higher AS rate than an intra-thoracic anastomosis (OR 13.3, p=0.006) and patients without a myotomy (p=&amp;lt;0.006). Other operative factors including approach (open vs MIE) conduit type (stomach/jejunum/colon) or width (3/4/5/6 cm) did not impact AS rate. All patients had a hand-sewn anastomosis. No post-operative outcome measures (e.g. leak, epidural use, hypotension) was associated with the development of AS. Conclusion Our results highlight the interplay of patient-related risk factors, tumor pathology, prior treatment, and operative factors in the development of post esophagectomy strictures. Understanding these predictors could potentially influence risk stratification and may facilitate tailored postoperative care strategies for improved patient outcomes.

564. PRONE POSITION THORACOSCOPIC HAND-SEWN ESOPHAGO-GASTRIC ANASTOMOSIS DURING 2-STAGE TOTALLY MINIMALLY INVASIVE ESOPHAGECTOMY FOR CANCER. SURGICAL TECHNIQUE

Abstract Background Minimally invasive esophagectomy has been introduced in the 2000s in an effort to reduce post-operative pulmonary and cardiac complications. 2-stage totally minimally invasive esophagectomy combines laparoscopic abdominal phase followed by thoracoscopic thoracic phase. The rate limiting step of this approach is the construction of esophago-gastric anastomosis. Herein, we aim to present our anastomotic technique on hand-sewn esophago-gastric anastomosis in prone position, utilizing 3D-assisted thoracoscopy. Methods This is prospective analysis of consecutive patients that underwent 2-stage totally minimally invasive esophagectomy for esophageal and gastro-esophageal junction Siewert type I-II cancers from the same surgical team, over a period of 6 years and more than 250 consecutive esophagectomies. All operations were identical in terms of patient positioning, lymphadenectomy and type of anastomosis formed. The anastomosis was hand-sewn in prone position, in 2-layers, using barbed sutures, with utilization of 3D-assisted thoracoscopy. Thorough technique and key steps of this anastomotic technique are provided. Results Median operative time was 280 minutes while median suturing time for the esophago-gastric anastomosis was 45 minutes. Anastomosis was thoracoscopic, hand-sewn constructed in prone position in all cases. There was no conversion to open. Anastomotic leak complicated n=6 patients (2%); n=5 were type I anastomotic leaks, requiring no intervention and n=1 was type II, which was treated with thoracoscopic lavage and chest drains followed by endoVAC therapy. Conclusion Formation of the esophago-gastric anastomosis is the rate limiting step of 2-stage totally minimally invasive esophagectomy. Most surgeons prefer the construction utilizing mechanical staplers. Our anastomotic technique, present a safe and effective anastomosis, with favorable clinical outcomes. It can be reproduced safely and effectively, offering all the advantages of manual anastomosis and significant reduction of devastating post-operative anastomotic leakage. https://wetransfer.com/downloads/bdf3a3496197daf79ccf5b05f71ba64920240309175850/a4da3be742fd3199e102e553c8a4011e20240309175918/c14cc2

491. STEP BY STEP INTRATHORACIC HAND-SEWN ESOPHAGOGASTRIC ANASTOMOSIS DURING TOTALLY ROBOTIC MINIMALLY INVASIVE TWO-STAGE ESOPHAGECTOMY

Abstract Background In every esophagectomy, regardless of the approach, the creation of the anastomosis is a critical step. In minimally invasive esophagectomy, to avoid challenges of thoracoscopic suturing in the upper mediastinum most surgeons use stapling devices or even decide to do a cervical anastomosis. However, in robot-assisted minimally invasive esophagectomy, the surgeon benefits from increased dexterity that facilitates to perform a hand-sewn intrathoracic anastomosis. Methods A 67-year-old man with esophageal adenocarcinoma, staged as a T3N1 underwent neoadjuvant chemotherapy, followed by a fully robotic minimally invasive Ivor-Lewis esophagectomy (robotic surgery during both the abdominal and thoracic phase). For the thoracic phase, the patient was placed in left sided semi-prone position. An 8 mm robotic trocar is inserted in the 6th intercostal space for the camera. Two other 8mm robotic trocars were inserted in the 4th, 8th and a 12mm 10th intercostal space. The anastomosis was constructed at the level, just above the azygos vein. Results The esophagogastric anastomosis was performed with an end-to-end construction. A barbed 3.0 suture was used to close the posterior wall by a single-layer running hand-sewn technique. The esophagostomy and the gastrostomy were performed using vascular scissors. A 36Fr Faucher was placed to expose de inner layer during the esophagostomy. A second posterior continuous full-thickness layer was performed using barbed 3.0 suture. Finally, an anterior wall full-thickness layer was performed using the same suture. To protect the anastomosis an omental wrap was applied. Conclusions Totally robotic minimally invasive esophagectomy for the treatment of esophageal cancer is on the rise. It offers all the advances of minimally invasive techniques, like reduced rates of pulmonary and cardiac complications associated with open thoracotomy and shorter length of stay. Intrathoracic esophagogastric anastomosis still remains challenging and it is considered as the most difficult step of the procedure. Robotic transthoracic manual anastomosis has appeared to overcome this difficulties. https://www.dropbox.com/scl/fi/km4oo66hhnb00k45e7ecq/Stepbystepmanual.mp4?rlkey=eb074cf3sj796byijqza0zoq6&amp;dl=0

409. TWO-STAGE OPERATIVE PROCEDURE FOR A BENIGN, COMPLICATED TRACHEOESOPHAGEAL FISTULA CAUSED BY FOREIGN BODY IMPACTION

Abstract Background Benign Tracheoesophageal fistula (TOF) caused by foreign body impaction is a rare condition requiring technical expertise. There are choices available based on the individual patient's situation, including endoscopic management, local resection and defect closure, and, in rare cases, esophagectomy. Methods A 58-year-old male had a history of artificial tooth dislodgement that got impacted in the esophagus, resulting in dysphagia. Endoscopy showed an impacted denture with an underlying transmural esophageal perforation, closed with clips and an endoloop. Two weeks later, partially covered SEMS was placed. Failure to retrieve the SEMS after repeated attempts due to tissue ingrowths, he was referred for management. CECT showed a stent in situ with a small air-filled cavity left lateral to the tracheal bifurcation. Bronchoscopy revealed the compression of the posterior tracheal wall and the presence of an endoclip in the posterior wall of the left main bronchus (LMB). Results The patient was planned for a two-stage operation. In the first stage, esophagus was mobilized along with the stent and the fistulous tract was excised. The esophagus was divided at both ends in the thorax. Up to this part, the procedure was done with single-port VATS without CO2 and in the left semi-prone position with a bronchial blocker in the right main bronchus. The fistula with the LMB was closed with an intercostal muscle flap and a bovine pericardial patch with transient apnoea. During this part, we extended the incision in the fourth space to raise the flap. Cervical esophagostomy was matured, and a feeding jejunostomy was created. The postoperative phase was uneventful, and he was discharged on the 5th postoperative day. After 4 weeks, we did the second phase of surgery, where we made a 4 cm retrosternal gastric conduit and performed the hand-sewn anastomosis with the cervical esophagus, which was taken down from the skin. The patient had an uneventful postoperative course and was allowed to be taken orally on day five and discharged subsequently two days later. Conclusions TOF demands a multidisciplinary treatment strategy. Successful outcomes are determined by patient triage, delineation of the location and size of the defect, mediastinal contamination, and the availability of expertise.

The impact of anastomotic leakage characteristics on the occurrence of anastomotic stenosis after colorectal resection, a retrospective cohort study.

Anastomotic stenosis (AS) is a common complication after colorectal resection. However, the predisposing factors for stricture formation are not fully understood. Previous studies have shown anastomotic leakage (AL) to be a risk factor for the occurrence of AS. Therefore, we aim to investigate the impact of anastomotic leakage characteristics on the occurrence of anastomotic stenosis after colorectal resection. Consecutive patients with AL following elective, sphincter preserving, colorectal resection, with or without diversion ostomy, between January 2009 and March 2023 were identified from a prospectively collected database. The characteristics of the anastomotic leakage, patient baseline and operative characteristics as well as the postoperative outcomes were analyzed using univariate and multivariate logistic regression to identify factors associated with the occurrence of post-leakage AS. A total of 129 patients developed AL and met the inclusion criteria. Among these, 28 (21.7%) patients were diagnosed with post-leakage AS. There was a significantly higher frequency of patients with neoadjuvant radiotherapy (18% vs 3%; p = .026) and hand-sewn anastomoses (39% vs 17%; p = .011) within the AS group. Furthermore, the extent of the anastomotic defect was significantly higher in the AS group compared with the non-AS group (50%, IQR 27-71 vs. 20%, IQR 9-40, p = 0.011). Similar findings were observed between the study groups regarding age, sex, BMI, ASA score, medical comorbidities, diagnosis, surgical procedure, surgical approach (open vs. minimally invasive), and anastomotic fashioning (side-to-end vs. end-to-end). On multivariate analysis, the extent of the anastomotic defect (OR 1.01; 95% CI 1.00-1.03; p = 0.034) and hand-sewn anastomoses (OR 2.68; 95% CI 1.01-6.98; p = 0.043) were confirmed as independent risk factors for post-leakage AS. No correlation could be observed between the occurrence of post-leakage AS and the ISREC grading of AL, the anastomotic height or the management of AL. Time to ostomy reversal was significantly longer in the AS group (202d, IQR 169-275 vs. 318d IQR 192-416, p = 0.014). The extent of the anastomotic defect and hand-sewn anastomoses were confirmed as independent risk factors for the occurrence of post-leakage AS. No correlation could be observed between the ISREC grading of AL, the anastomotic height or AL management, and the occurrence of post-leakage AS.

Robot-Assisted Microsurgery—what does the learning curve look like?

The introduction of robotic assistance in surgical practice has led to advancements such as the MUSA-2 robotic system that was designed for microsurgical procedures. Advantages of this system include tremor filtration and motion scaling. Initial studies showed promising results in skill acquisition for robot-assisted microsurgery. This study evaluated the learning curve for microsurgical anastomosis with and without robotic assistance among surgeons of varying experience levels. Fifteen surgeons were divided into 3 groups (novice, intermediate, and expert) based on their microsurgical experience. They performed 10 anastomoses by hand and 10 with robotic assistance on synthetic polyvinyl alcohol vessels (diameter of 2 mm) in a laboratory setting. Participants were timed and mistakes such as backwall and leakage were assessed and recorded. Demographic information was collected. Statistical differences were found in manual anastomosis times between the intermediate and novice groups compared to the experts (p < 0.01). However, no statistical difference was found in the mean time between groups for the robot-assisted anastomoses. Novice doctors had the steepest learning curve for hand-sewn anastomosis. Experts had the fastest completion time at the end of the 10th robotic session, finishing at 14 min, compared to 33 min at the 2nd session. All groups reduced their mean time in half through their 10 robotic sessions. This study indicated similarities in the learning curves for robot-assisted anastomosis among surgeons with varied experience levels. Experts excelled technically in manual anastomoses, but robot-assistance enabled novice and intermediate surgeons to perform comparably to the experts. Robotic assistance may aid more novice learners in performing microsurgical anastomosis safely at earlier points in their education.

Long-Term Results of 2-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer

In patients operated on for low rectal cancer, 2-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis provides benefits in terms of postoperative morbidity compared with standard hand-sewn coloanal anastomosis associated with diverting ileostomy and further ileostomy reversal. To compare long-term results of these 2 techniques after ultralow rectal resection for rectal cancer. In this randomized multicenter clinical trial, neither patients nor surgeons were blinded for technique. Patients were recruited in 3 centers. Patients undergoing ultralow anterior rectal resection needing hand-sewn coloanal anastomosis were randomly assigned to 2-stage Turnbull-Cutait pull-through hand-sewn coloanal anastomosis (n = 46) or standard hand-sewn coloanal anastomosis associated with diverting ileostomy (n = 46). All patients underwent ultralow anterior resection. Patients assigned to the 2-stage Turnbull-Cutait pull-through group underwent exteriorization of a segment of left colon through the anal canal. After 6 to 10 days, the exteriorized colon was resected and a delayed hand-sewn coloanal anastomosis performed. For patients assigned to standard coloanal anastomosis, the hand-sewn coloanal anastomosis was performed with diverting ileostomy during the first operation. Ileostomy closure was scheduled after adjuvant treatment was completed in about 6 to 8 months. The study aimed to compare the differences between the 2 groups in terms of long-term surgery-related morbidity, functional, and oncological outcomes at 3 years postoperatively. Data were analyzed from October 1, 2018, through October 31, 2021. The 92 patients randomized in the first study were included for the 3-year follow-up. The overall morbidity rate in the 2 groups showed that 15 patients (16.3%) had complications with a difference of 6.52 (95% CI, -8.93 to 21.79). Nine patients (19.6%) and 6 patients (13.0%) in the 2-stage Turnbull-Cutait pull-through group and hand-sewn coloanal anastomosis group, respectively, had complications without statistically significant differences (P = .57). Oncological results were comparable between the groups. Long-term fecal continence in the CCA and TCA groups, respectively, assessed using the Wexner Incontinence Score was 10.9 (5.50-15.5) vs 13.0 (7.25-16.0; P = .92), Low Anterior Resection Syndrome score was 32.0 (21.0-37.0) vs 34.0 (23.2-38.5; P = .76), and Colorectal Functional Outcome score was 38.5 (23.0-47.1) vs 40.8 (23.3-58.2; P = .30). In this study, after a 3-year follow-up period, 2-stage Turnbull-Cutait anastomosis for ultralow rectal cancer could be considered as a surgical alternative that has the valuable benefit of avoiding a temporary stoma with similar results in terms of morbidity, fecal continence, patient satisfaction, quality of life, and oncological outcomes when compared with hand-sewn coloanal anastomosis with ileostomy. ClinicalTrials.gov Identifier: NCT01766661.

Efficacy and Safety between Stapled Versus Hand Sewn Anastomosis in Anterior Resection for Carcinoma of Rectum

Efficacy and Safety between Stapled Versus Hand Sewn Anastomosis in Anterior Resection for Carcinoma of Rectum

Endoscopic management of patients with familial adenomatous polyposis after prophylactic colectomy or restorative proctocolectomy - systematic review of the literature.

Patients with familial adenomatous polyposis (FAP) develop early colorectal adenomas and if left untreated, progression to cancer is an inevitable event. Prophylactic surgery does not prevent further development of cancer in the rectal remnant, rectal cuff in patients with ileal pouch anal anastomosis (IPAA) and even on the ileal mucosa of the pouch body. The aim of this review is to assess long-term rates of cancer and adenoma development in patients with FAP after prophylactic surgery and to summarise current recommendations for endoscopic management and surveillance of these patients. A systematic literature search of studies from January 1946 through to June 2023 was conducted using the PRISMA checklist. The electronic database PubMed was searched. Fifty-four papers involving 5010 patients were reviewed. Cancer rate in the rectal remnant was 8.8-16.7% in the western population and 37% in the eastern population. The cumulative risk of cancer 30 years after surgery was 24%. Mortality due to cancer in the rectal remnant is 1.1-11.1% with a 5-year survival rate of 55%. The adenoma rate after primary IPAA was 9.4-85% with a cumulative risk of 85% 20 years after surgery and a cumulative risk of 12% for advanced adenomas 10 years after surgery. Cumulative risk for adenomas after ileorectal anastomosis (IRA) was 85% after 5 and 100% after 10 years. Adenomas developed more frequently after stapled (33.9-57%) compared to hand-sewn (0-33%) anastomosis. We identified reports of 45 cancers in patients after IPAA of which 30 were in the pouch body and 15 in the rectal cuff or at the anastomosis. There was a significant incidence of cancer and adenomas in the rectal remnant and ileal pouch of FAP patients during the long-term follow-up. Regular endoscopic surveillance is recommended, not only in IRA patients, but also in pouch patients after proctocolectomy.

A Comparative Study between Stapler and Hand Sewn Anastomosis in Elective Gastrointestinal Surgery in a Tertiary Care Centre

A Comparative Study between Stapler and Hand Sewn Anastomosis in Elective Gastrointestinal Surgery in a Tertiary Care Centre

Stapled versus hand-sewn anastomoses after bowel resection in patients with crohn disease

BackgroundAnastomosis configuration is an essential step in treatment to restore continuity of the gastrointestinal tract following bowel resection in patients with Crohn’s disease (CD). However, the association between anastomotic type and surgical outcome remains controversial. This retrospective study aimed to compare early postoperative complications and surgical outcome between stapler and handsewn anastomosis after bowel resection in Crohn’s disease.MethodsBetween 2001 and 2018, a total of 339 CD patients underwent bowel resection with anastomosis. Patient characteristics, intraoperative data, early postoperative complications, and outcomes were analyzed and compared between two groups of patients. Group 1 consisted of patients with stapler anastomosis and group 2 with handsewn anastomosis.ResultsNo significant difference was found in the incidence of postoperative surgical complications between the stapler and handsewn anastomosis groups (25% versus 24.4%, p = 1.000). Reoperation for complications and postoperative hospital stay were similar between the two groups.ConclusionOur analysis showed that there were no differences in anastomotic leak, nor postoperative complications, mortality, reoperation for operative complications, or postoperative hospital stay between the stapler anastomosis and handsewn anastomosis groups.

Efficacy of staplers in comparison with conventional (Hand-Sewn) anastomosis in gastrointestinal surgery – A prospective and randomized study

Efficacy of staplers in comparison with conventional (Hand-Sewn) anastomosis in gastrointestinal surgery – A prospective and randomized study