Purse-string Suture Research Articles

Incisional Negative Pressure Wound Therapy Versus Primary Wound Suturing after Intestinal Ostomy Closure: A Systematic Review and Meta-Analysis.

Objective: Wound infection after intestinal ostomy closure is a very common postoperative complication. An alternative to primary wound suturing by single sutures or purse string sutures (PSS) is applying incisional negative pressure wound therapy (iNPWT). The aim of the following systematic review and meta-analysis was to assess and compare clinical outcomes in patients after PSS and iNPWT use. Approach: The aim of the study was to find relevant clinical data comparing outcomes of iNPWT and primary wound closure after intestinal ostomy closure. The search was conducted using the MEDLINE/PubMed, ScienceDirect, EMBASE, Scopus, Cochrane Controlled Register of Trials, SciELO, and Web of Science databases and took place up to November 12, 2022. The authors did not use date or language filters. Statistical analysis was performed using Review Manager 5.4 (The Cochrane Collaboration, 2020, London, UK). The authors conducted a meta-analysis of the following four parameters: wound healing time (WHT), surgical site infections (SSIs), complications, and length of hospital stay (LOS). Odds ratios (OR) and inverse variance (IV) were generated with 95% confidence intervals (CI). The meta-analysis was registered in the International Prospective Register of Systematic Reviews database under registration number CRD42023391640. Results: The analysis revealed that the iNPWT group and the control group did not differ significantly with regard to the WHT parameter (Z = 2,73; p = 0.006; χ2 = 0.37, df = 1, p = 0.54, I2 = 0%). Meta-analysis of SSI incidence revealed a significant difference favoring the iNPWT group over the observational group (OR = 0.42; 95% CI = 0.25-0.72; p = 0.002; I2 = 14%). Patients included in the iNPWT group had a significantly lower pooled incidence of overall complications than the observational group (OR = 0.52; 95% CI = 0.35-0.77; p = 0.001, I2 = 71%). Subgroup analysis limited to randomized studies also presented significant differences favoring the iNPWT group over the observational group (OR = 0.27; 95% CI = 0.14-0.52; p < 0.001, I2 = 67%). Our analysis showed that LOS did not differ significantly between the groups treated with and without iNPWT (IV = 0.19; 95% CI = -0.66 -1,04; p = 0.76, I2 = 0%). In addition, subgroup analysis of randomized studies also did not present a significant difference (IV = 0.25; 95% CI = -0.80 -1,30; p = 0.33, I2 = 10%). Innovation: This study shows that the use of iNPWT can reduce the risk of SSIs with other complications, such as wound hematomas, wound seromas, wound dehiscence, fistulas, and ileus, in patients undergoing intestinal ostomy closure without extended hospital stay. Conclusions: Use of iNPWT can be considered in postoperative care after elective ostomy closure to decrease the rate of the most common complications after ostomy closure.

Endoscopic purse-string suture and naso-jejunal tube feeding for duodenal cutaneous fistula and gastric cutaneous fistula.

The Endoscopic Purse-string Suture (EPSS) technique has gained attention for its potential in closing large defects following gastrointestinal procedures. However, its application in fistula closure is not as widely reported. This study aims to evaluate the safety and efficacy of EPSS and naso-jejunal tube feeding in the closure of duodenal cutaneous fistulas and gastric cutaneous fistulas. This single-center retrospective study, conducted from September 2020 to September 2023 at Tongji University in Shanghai, China, examined the outcomes of EPPS and nasojejunal feeding for patients with gastric and duodenal cutaneous fistulas (n = 10). Demographic data, fistula characteristics, procedure technique and outcomes were evaluated. In this study, the average size of a fistula opening was 7.9 ± 4.6mm. The operations took an average of 25.8 ± 5.6min. Patients typically needed naso-jejunal tube feeding for a median of 14.0days, with an interquartile range (IQR) of 7.7-19.0days. The median duration of hospital stay post-operation was 16.5days, with an IQR of 7.0-25.0days. Nine patients were successful in their initial fistula closure using the EPSS technique. The other patient underwent a second EPSS and, ultimately, all patients experienced complete healing and fully recovered. There were no major adverse events reported. EPSS and naso-jejunal tube feeding are a safe and effective treatment option for duodenal and gastric cutaneous fistulas. Larger, prospective studies are needed to validate these findings and establish the long-term safety and efficacy of this approach.

Hug Flap and Hamdi Hammock: Two Innovative Techniques for Enhancing Aesthetic Outcomes in Deep Inferior Epigastric Artery Perforator Breast Reconstruction.

Achieving optimal aesthetic outcomes in deep inferior epigastric artery perforator (DIEP) flap breast reconstruction remains a challenge, often necessitating additional procedures for refinement. This study presents two innovative techniques (the hug flap and Hamdi hammock) aimed at enhancing breast projection and inframammary fold (IMF) definition in DIEP flap reconstruction. The hug flap technique uses de-epithelialized caudal mastectomy skin to augment breast projection, whereas the Hamdi hammock uses a percutaneous purse-string suture to define the IMF. A retrospective review of 782 patients who underwent DIEP flap breast reconstruction between 2007 and 2023 was conducted. The hug flap group required significantly less additional fat grafting compared to other techniques (11% versus 27% and 22%). No total flap losses occurred in the hug flap group, and fat necrosis rates were low. The Hamdi hammock was used in 405 patients with a mean of two lipofilling sessions. Complications were minor and no stitches required removal. The hug flap and Hamdi hammock techniques offer effective and safe methods for enhancing breast projection and IMF definition in DIEP flap reconstruction. These techniques may reduce the need for additional procedures and improve aesthetic outcomes.

Safety and aesthetic outcomes of double purse-string suture nipple reconstruction in early breast cancer patients undergoing nipple resection and endoscopic skin-sparing mastectomy with breast reconstruction.

The current surgical methods for managing incisions after nipple excision in breast reconstruction patients are limited. However, double purse-string suture (DPS) shows promise in the treatment of nipple excision. This study aimed to investigate the safety and aesthetic outcomes of DPS nipple reconstruction in early breast cancer patients who underwent endoscopic skin-sparing mastectomy (E-SSM) and breast reconstruction. We retrospectively analyzed the clinical data of 87 early breast cancer patients with nipple excision who underwent E-SSM with breast reconstruction. According to the suture methods of nipple incision, all patients were divided into the spindle suture (SS) group, single purse-string suture (SPS) group, and DPS group, with SS and SPS groups combined as the traditional suture (TS) group. Then, we compared the groups' differences in aesthetic outcomes, surgical safety, and oncological safety. A total of 87 patients with 88 breasts were enrolled in this study (SS n=17, SPS n=21, DPS n=50). Patients in the DPS group had significantly better nipple reconstruction satisfaction, Harris scale and any complications incidence than the TS group (all p <0.05). For nipple reconstruction satisfaction and any complication, the adjusted OR (95%CI) of the DPS group were 6.314(1.095-36.415) (p=0.039) and 0.124(0.018-0.863) (p=0.035) compared with the SS group. One patient in the SS group had vertebral metastases, and no recurrence, metastasis, or death has been observed in the other two groups during the follow-up period. DPS is an effective and safe nipple reconstruction procedure for patients undergoing E-SSM with breast reconstruction, delivering excellent aesthetic outcomes.

Robotic purse-string suture technique for intracorporeal anastomosis using double-stapling technique in robotic resection of rectal and sigmoid colon cancer: a propensity score-matched analysis

BackgroundRobotic three-dimensional magnified visual effects and field of view stabilization have enabled precise surgical operations. Intracorporeal anastomosis in right-sided colorectal cancer surgery is expected to shorten operation times, avoid paralytic ileus, and shorten wound lengths; however, there are few reports of intracorporeal anvil fixation for intestinal anastomosis in left-sided colorectal cancer surgery. Herein, we introduce a simple, novel procedure for using robotic purse-string suture (RPSS) in intracorporeal anastomosis with the double-stapling technique in rectal and sigmoid cancer surgery and report short-term outcomes.MethodsFrom September 2022 to April 2024, 105 consecutive patients underwent robotic surgery with double-stapling technique anastomosis for rectal or sigmoid colon cancer at our institution. Their data were retrospectively analyzed. Intracorporeal anastomosis with the double-stapling technique using RPSS was performed in 26 patients (the RPSS group), while the double-stapling technique anastomosis with extracorporeal anvil fixation was performed in 79 patients (the EC group). A 1:1 propensity score-matched analysis was performed (matching criteria: sex, age, body mass index (BMI), tumor location and tumor size) using a caliper 0.3.In the RPSS group, after tumor-specific or total mesorectal excision, specimens were extracted from the umbilical wound with simultaneous anvil placement in the body cavity. The oral colonic stump was robotically excised and robotically circumferentially stitched with 3–0 Prolene in all layers. After anvil insertion into the stump, the bowel wall of the colon was completely sewn onto the central rod of the anvil. Reconstructions were anastomosed using the double-stapling technique.ResultsThe matched cohort contained 23 patients in each group. The RPSS group had significantly less bleeding than the EC group (p = 0.038). Super-low anterior resection (SLAR) in the RPSS group had shorter total operative times than those in the EC group (p = 0.045). The RPSS group experienced no perioperative complications greater than Clavien–Dindo grade III or any anastomosis-related complications.ConclusionsThe RPSS technique can be performed safely without any anastomosis-related complications and reduces the total operative times in SLAR and blood loss through total robotic surgery. This may be a useful modality for robotic colorectal surgery.

Application of endoscopic purse-string sutures in refractory nonvariceal GI bleeding: a multicenter study (with video)

Background and AimsNon-variceal gastrointestinal bleeding is a common medical emergency. Endoscopic hemostasis is recommended and some patients experienced rebleeding after conventional endoscopic hemostasis. Originally, the purse-string suture (PSS) was employed for lesion closure during endoscopic mucosal resection (EMR). We aimed to learn whether endoscopic PSS is effective in controlling the refractory bleeding. MethodsWe retrospectively collected data of patients who underwent endoscopic PSS for refractory non-variceal gastrointestinal bleeding from 3 hospitals. Clinical success was defined as no recurrent bleeding, and patients were discharged according to medical advice. ResultsFrom October 2017 to May 2024, 36 patients who received PSS treatments were included. 83.3% (30/36) of patients achieved clinical success. In refractory upper gastrointestinal bleeding, the clinical success rate was 81.25% (26/32), and it was 100% (4/4) in lower gastrointestinal bleeding. ConclusionThe endoscopic PSS is effective in treating refractory non-variceal gastrointestinal bleeding.

Reconstruction of Chronic Soft Tissue Mallet Fingers: Outcomes of Step-Plasty vs. Purse-String Suture.

After failed conservative therapy or in the absence of any intervention, a rupture of the digital subcutaneous extensor tendon at the distal interphalangeal (DIP) joint, known as mallet finger, may lead to a chronic extension deficit due to excessive scarring and tendon elongation. Various surgical techniques to restore the extension of the distal phalanx have been proposed, but an optimal approach has not yet been established. To tighten the extensor tendon, a purse-string suture can be applied. Although it has shown efficacy, it can result in significant bulging and scar formation. Using the "abbreviato" technique, the elongated part of the extensor tendon is excised, and the tendon is re-sutured. Also, tenodesis has been described, particularly in pediatric cases. In this retrospective follow-up study, we aimed to investigate if the step-plasty procedure previously described by Baumeister provides comparable, if not superior, functional and aesthetic outcomes compared to existing techniques for patients with chronic mallet finger. In this retrospective study, a consecutive series of 68 patients with chronic mallet fingers was enrolled. Patients were treated surgically using step-plasty of the respective extensor tendon. After skin incision and tenolysis, the elongated extensor tendon was incised in a Z-like fashion and stepwise resected in the transverse portion of the Z. The functional and aesthetic effects of this step-plasty technique were compared with results of 44 patients previously treated using purse-string sutures of the extensor tendon and evaluated using Crawford's and Levante's criteria. In all patients undergoing the step-plasty procedure, the extension deficit was significantly reduced from an average of 42 degrees preoperatively to 11 degrees postoperatively. In contrast, the control group treated by purse-string sutures showed a slightly higher postoperative extension deficit of 15 degrees. According to Levante's criteria, the results of our step-plasty procedure were significantly better than those achieved with purse-string sutures. Our study demonstrated that the treatment of older or chronic subcutaneous extensor tendon ruptures using the step-plasty technique led to a significant reduction in extension deficits. According to Levante's criteria, the postoperative outcome was significantly better in comparison to the purse-string suture technique. Additionally, no skin resection was required to improve the extension capability of the distal finger joint, compared to established surgical procedures.

Rationale and tips and tricks for transgastric robotic pancreaticogastrostomy by the double purse-string technique.

Pancreaticogastrostomy (PG) is a viable option for selected patients needing a pancreatic anastomosis. The double purse-string technique can facilitate the construction of transgastric PG but in a minimally invasive approach can lead to complications due to lack of tactile feedback. We present an adaptation of double purse-string PG for the robotic surgery, with several modifications. Firstly, the inner purse-string suture is tied through the anterior gastrotomy to improve the approximation of gastric and pancreatic serosae. Secondly, all-around-the-clock intragastric interrupted mattress sutures of e-PTFE are used to secure the pancreatic remnant to the stomach, enhancing improve hemostasis. Thirdly, e-PTFE sutures precise tension calibration due to their elastic properties and resistance to robotic manipulation. Fourthly, retroperitoneal vessels are preemptively covered by passing the pancreatic remnant through a small opening in the omentum, which is rotated upward in the omental bursa. This technique was employed in 20 PGs with no grade C postoperative pancreatic fistula. It offers a viable option robotic pancreatic anastomosis.

Tips and tricks for transluminal specimen extraction and extra-abdominal sigmoid colon resection.

The purpose of this video is to demonstrate how to achieve adequate length and blood supply of the proximal colon for a perineal pull-through procedure, without splenic flexure mobilization during natural orifice specimen extraction. Key steps of the procedure include lateral mobilization of the colon, D3 lymph node dissection, preservation of the left colic artery, low ligation of the inferior mesenteric vein, ligation and washout of the distal bowel lumen, extra-abdominally proximal resection of sigmoid colon, purse-string sutures on the distal sigmoid colon, and an air leak test. Transluminal specimen extraction with extra-abdominal resection was found to be a cost-effective procedure with good cosmetic effects. Tension-free anastomosis was achieved by preservation of the left colic artery and low ligation of the inferior mesenteric vein. The purse-string sutures were placed on the proximal and distal bowel to avoid crossing the staples line. Transluminal specimen extraction with extra-abdominal resection required minimal manipulation intra-abdominally in comparison with other natural orifice specimen extraction techniques.

Purse-String DIEPplasty: A Technique to Improve Aesthetic Outcome of Autologous Breast Reconstruction.

The purse-string DIEPplasty technique is a method to improve aesthetic outcomes in breast reconstruction using deep inferior epigastric perforator (DIEP) free flaps. Traditionally, DIEP flaps, harvested from the lower abdomen, take on a triangular shape that can lead to sub-optimal aesthetic outcomes with occasionally poor breast projection, irregular contours, or minimal upper pole fullness. The purse-string DIEPplasty technique addresses these issues by using a 0 Polydioxanone continuous purse-string suture through the Scarpa's fascia to modify the harvested flap's shape before inset, giving it a more round base and a central dome-like projection similar to an implant. This method mimics the shape of a breast implant, enhancing the flap's projection, volumetric efficiency, and overall shape, leading to a reconstructed breast with improved aesthetic qualities. This technique represents a potential advancement in reconstructive breast surgery, aiming to reduce the extent of revision procedures and improve patient satisfaction. Further research, however, is needed to validate its effectiveness over time and assess potential complications.Level of Evidence IV This journal requires that authors assign a level of evidence to each article. For a full description of these Evidence-Based Medicine ratings, please refer to the Table of Contents or the online Instructions to Authors www.springer.com/00266 .

Meticulous Closure of Mesenteric Defects Effectively Reduces the Incidence of Internal Hernia After Laparoscopic Roux-en-Y Gastric Bypass.

Internal hernia (IH) after Roux-Y gastric bypass (RYGB) can lead to extended small bowel ischemia if it not recognized and treated promptly. The aim of this study is to show whether improvement in mesenteric defect (MD) closure reduces the incidence of IH. Retrospective analysis of prospectively collected data from our database including all patients who underwent laparoscopic RYGB between 1999 and 2015. The usual technique was a retrocolic/retrogastric RYGB. We divided patients in four groups according to the closure technique for MD and compared incidences of IH between groups. All patients had at least 8years of follow-up. A total of 1927 patients (1497 females/460 males, mean age of 41.5 ± 11years) were operated. A retrocolic/retrogastric RYGB was performed in 1747 (90.7%) and an antecolic RYGB in 180 patients. Mean duration of follow-up was 15 (8-24) years. 111 patients (5.8%) developed IH, the majority through the jejunojejunostomy (JJ, 3.7%) and Petersen (1.7%) defects. With improvement of closure technique, the incidence decreased over time, from 12.9% in the group with separate sutures to 1.05% in the most recent group with running non-absorbable sutures and an additional purse-string at the JJ defect (p < 0.0001). Meticulous closure of MD during RYGB is a very important step that significantly reduces the IH risk after RYGB, even with a retrocolic/retrogastric anatomy. Using running non absorbable braided sutures and an additional purse-string suture at the JJ is the most effective technique, but a small IH risk persists. A high index of suspicion remains necessary in patients who present with acute abdominal pain after RYGB.

Efficacy of a surgical cardiac ablation clamp using nanosecond pulsed electric fields: An acute porcine model

ObjectiveTo examine the effectiveness of a recently developed nonthermal technology, nanosecond pulse-field ablation (nsPFA), for surgical ablation of the atria in a beating heart porcine model. MethodsSix pigs underwent sternotomy and ablation using an nsPFA parallel clamp. The ablation electrodes (53 mm long) were embedded in the jaws of the clamp. Nine lesions per pig were created in locations chosen to be representative of the Cox-maze procedure. Four lesions were intended to electrically isolate parts of the atrium: the right atrial appendage, left atrial appendage, right pulmonary veins, and left pulmonary veins. For these lesions, exit block testing was performed both after ablation and before euthanasia; the time between the 2 tests was 3.3 ± 0.5 hours (range, 2-4 hours). Using purse string sutures, 5 more lesions were created up to the superior vena cava, down to the inferior vena cava, across the right atrial free wall, and at 2 distinct locations on the left atrial free wall. The clamp delivered a train of nanosecond duration pulses, with a total duration of 2.5 seconds, independent of tissue thickness. The heart tissue was stained with 1% triphenyltetrazolium chloride after a dwelling period of 2 hours. Subsequently, each lesion was cross sectioned at 5-mm intervals to assess the ablation depth and transmurality. In some sections, transmurality could not be established on the basis of triphenyltetrazolium chloride staining alone; for these lesions, Gomori-trichrome stains were used, and the histologic sections were evaluated for transmurality. ResultsThe ablation time was 2.5 seconds per lesion, for a total of only 22.5 seconds ablation time to create 9 lesions. A total of 53 lesions were created, resulting in 388 separate histologic sections. Transmurality was established in 386 sections (99.5%). Mean tissue thickness was 3.1 ± 1.5 mm (range, 0.2-8.6 mm). Exit block was confirmed in 23 of the 24 lesions (96%) postablation and 23 of 24 (96%) before the animals were humanely killed. Over the course of the procedure, neither pulse-induced arrhythmias nor any other complications were noted. ConclusionsThe novel nsPFA clamp device was effective in creating acute conduction block and transmural lesions in both the right and left atria in an acute porcine model. This nonthermal energy source has great potential to both shorten procedural time and enable effective ablation in the beating heart.

Double Half Purse-String Sutures Plus "8" Pattern of Stitching for Prevention of Duodenal Stump Fistula after Laparoscopic Gastrectomy.

Background: Duodenal stump fistula represents an infrequent but serious complication after laparoscopic radical gastrectomy with Billroth II or Roux-en-Y reconstruction for gastric cancer. The present study was designed to evaluate the effectiveness of laparoscopic double half purse-string sutures plus "8" pattern of stitching for reinforcement of duodenal stump. Methods: The data of patients undergoing laparoscopic radical gastrectomy with Billroth II or Roux-en-Y reconstruction were retrospectively analyzed between August 2022 and June 2023. According to the different reinforcement methods of duodenal stump, included patients were subdivided into three groups as follows: Group A, duodenal stump was treated with double half purse-string sutures plus "8" pattern of stitching; Group B, duodenal stump was reinforced by continuous suture using a barbed suture; and Group C, duodenal stump without any additional processing. The incidences of duodenal stump fistula between three groups were documented and compared. Moreover, the independent risk factors associated with duodenal stump fistula were analyzed using the logistic regression analysis. Results: No postoperative duodenal stump fistula occurred in Group A, which was significantly different from Group B and Group C (P = .007). In the multivariate analysis, age (odds ratio [OR], 1.191; 95% confidence interval [CI], 1.088-1.303), body mass index (OR, 0.824; 95% CI, 0.727-0.935), and American Society of Anesthesiologists score (OR, 4.495; 95% CI, 1.264-15.992) were the risk factors for duodenal stump fistula. Conclusion: Double half purse-string sutures plus "8" pattern of suture can be conducted in a relatively short operation period and could prevent the incidence of duodenal stump fistula to some extent.

What is the weakest point of a secured aortic cannula in central extracorporeal membrane oxygenation?

The purpose of this study was to compare techniques for securing the aortic extracorporeal membrane oxygenation (ECMO) cannula, using in vitro models. Two models were studied: a tissue model using porcine aortas and a stand model replacing the aorta with a metal stand to study the system independent of the tissue. Interventions in each model were divided into three experimental groups: Group 1 (3-0 Prolene® + 20-French Medtronic Arterial Cannula EOPA™), Group 2 (4-0 Prolene® + 16-French Medtronic Arterial Cannula DLP Pediatric), and Group 3 (5-0 Prolene® + 8-French Medtronic Arterial Cannula DLP Pediatric). In separate experiments, both gradual and rapid forces were applied to the cannulas, starting with 9.8 Newtons and increasing exponentially if the cannula remained secured. Additionally, the method of securing the tourniquet and the number of ties securing the tourniquet to the cannula were evaluated. In the tissue model, even with a minimum force of 9.8 Newtons, the suture pulled through the aortic tissue, leaving sutures and ties intact. In the stand model, two purse-string sutures secured by two ligaclips held the cannula reliably and withstood higher total force. Dislodgement was prevented at forces close to 60 Newtons with only two hemostatic clips included in cannulation. The weakest part of the aortic ECMO cannulation system using in vitro experiments was the tissue. Assuming that these experiments translate in vivo, it is therefore critical to prevent any pull on the cannulas by securing ECMO cannulas and ECMO tubing to both the patient and the patient's bed. Sutures with a larger diameter withstand more force. Two medium hemostatic clips can secure Prolene® sutures within snares as safely as a mosquito hemostat. Two polypropylene purse-string sutures secured by two hemostatic clips were most reliable at greater forces. The rationale for publishing our experiments in this manuscript is to (1) communicate our quantification of possible contributing factors to this rare and likely catastrophic complication of unintended decannulation, (2) increase awareness about this potential complication, and (3) increase vigilance to assure prevention of this dreaded complication.

The bail out option; using endocardial pacing and defibrillation leads epicardially

Abstract Introduction Although transvenous implantation of cardiac pacemakers and defibrillators is technically feasible and less invasive than surgical placement of epicardial leads, certain patients including pediatric patients and patients with complex congenital heart disease will require epicardial pacing and most of them will need pacing throughout their whole life. There are specific leads for epicardial pacing which were developed over time to the currently used bipolar steroid-eluting epicardial leads which may be rarely nationally unavailable. In addition, there are no available dedicated epicardial shock leads (1,2). There is no enough data on the techniques, feasibility, and efficacy of using endocardial leads, including shock leads for epicardial pacing/ defibrillation (3). Purpose We aim to describe our center’s experience in implanting endocardial leads for epicardial pacing or defibrillation and to assess its feasibility &amp; durability. Methods Due to periods of national unavailability of epicardial permanent pacing leads and worldwide unavailability of dedicated epicardial shock leads, a limited cohort of patients requiring urgent epicardial pacing/ ICDs were offered pacing through epicardially implanted endocardial leads. The lead screw is advanced into myocardium, then a purse-string suture is placed around and tied to the lead for fixation. Ventricular pacing lead is fixed to LV apex, while atrial lead is fixed to RA free wall. Shock coils are fixed to LV and RA free walls (Fig. 1). We retrospectively revised our records for these patients &amp; analyzed their clinical data, follow up programming parameters including sensing, pacing thresholds and impedances. Results In the last 8 years, surgeons implanted 9 endocardial leads epicardially. Two were pacing leads implanted for ventricular and atrial pacing in two different pediatric patients, and 7 were shock leads in patients with life threatening VTs despite medical treatment. The patients with ICDs were as follows: one was an adult patient with a Glenn shunt. The other 6 patients were pediatrics with low body weight; 4 of them had long QT syndrome and two had idiopathic VF. The mean follow-up periods were 38 months. Throughout the visits, the pacing thresholds, sensing functions, lead and shock impedances were stable in all patients (Table 1). Two of the patients with epicardial ICDs received appropriate shocks. None received inappropriate shocks. So far, only one patient required battery replacement. Conclusion In view of our findings, using endocardial leads as a bail out alternative to epicardial leads for pacing or defibrillation appears to be safe and effective. This finding is essentially important regarding the shock leads as there are no dedicated epicardial defibrillation leads. It should be noted that these results depend largely on the surgeon’s experience and on achieving acceptable pacing parameters and defibrillation thresholds intraoperatively.Table 1Figure 1

#2923 Intracardiac vascular access as a last resort for hemodialysis in patients with exhausted traditional vascular access: a case report

Abstract Introduction The dysfunction of vascular access (VA) constitutes one of the main problems faced by nephrologists and patients in chronic hemodialysis (HD). This challenge becomes particularly worrying in patients who have depleted their upper extremity venous resources and have no longer arteriovenous fistula available, requiring the placement of a central venous catheters. It leads to an increase in morbidity and mortality and a higher of infections, thrombosis and exhaustion of access points. In such cases, alternatives to conventional VA are limited, with intracardiac access being an emerging option, albeit with very limited documented experience. Case Report We describe the case of a 68-year-old male with a history of hypertension, nasopharyngeal carcinoma in 2012 treated with chemotherapy and radiotherapy. In 2018 he was diagnosed with low-grade urothelial bladder carcinoma (PT1G1) that infiltrated the subepithelial corion while sparing the muscular layer. He also had severe hydronephrosis with impaired renal function, requiring radical cystoprostatectomy with Bricker bladder reconstruction and subsequent bilateral nephrostomy due to persistent dilatation and progressive deterioration of renal function. He began chronic HD in June 2020 through a left femoral catheter due to the inability to access the upper thoracic vascular tree due to stenosing fibrosis from previous radiotherapy. He was placed on the waiting list for a kidney transplant (KT) in the right iliac fossa but experienced multiple catheter dysfunction episodes, requiring the placement of a right femoral venous catheter to continue with his HD sessions. Additionally, peritoneal dialysis was not considered due to previous urological surgery. Considering the limitation of VA and the possibility of KT as its best alternative, we opted for the insertion of a tunnelled intracardiac catheter at the right atrium. This procedure was conducted by the Cardiac Surgery Department on 03/12/2021 through a median sternotomy in the 4th intercostal space. A permanent hemodialysis catheter was inserted in the right atrium through the 3rd intercostal space and fixed with a purse-string suture. It was then tunnelled under the breast to the 2nd intercostal space through a counter-incision. The cuff was appropriately placed in the subcutaneous tissue (Figs 1 and 2). The intervention proceeded without any complication and the catheter exhibited normal functionality. After that, the patient received anticoagulation with enoxaparin the days between dialysis sessions. Consequently, the right femoral catheter was safely removed. Two weeks later, the patient successfully received a KT from a deceased donor. He was discharged on the day 11st post-KT with any complication and maintains a good renal function after 2 years of follow-up with a serum creatinine 1.7 mg/dL (eGFR: 39 ml/min). The intracardiac catheter was removed one month later through a mini-thoracotomy. Conclusions Intracardiac VA is an unusual and high-risk resource that seems an alternative in patients with exhausted VA with no alternative emergency renal replacement therapy, so it should be considered as the last resort. In the case of our patient, the implantation of this catheter allowed for the continuation of dialysis and access to KT.

Safety and Effectiveness of Brachial Artery Preclosure by Purse-String Suture Technique for Left Subclavian Artery Revascularization in Stanford B Aortic Dissection.

To assess the safety and efficacy of the combination of brachial artery (BA) cutdown with purse-string suture (PSS) for BA preclosure during fenestrated thoracic endovascular aortic repair (f-TEVAR). We reviewed the consecutive data in our center from January 2022 to May 2023. Clinical data were analyzed retrospectively, including the baseline characteristics, procedural details, complications, and outcomes. Dichotomous data were summarized as absolute values and percentages. Continuous variables were presented as median values and interquartile ranges (IQRs). All patients underwent arterial cutdown with the PSS technique for BA preclosure. The technique was considered successful when complete hemostasis was achieved and confirmed by ultrasonography 24h postoperatively. The patients were followed up 30days postoperatively for access-related complications. Forty-eight patients who underwent f-TEVAR with 48 BA access sites were included [36 males and 12 females; median age: 62 (IQR: 30-78) years]. The median body mass index was 27.3 (IQR: 21.2-32.7) kg/m2. The median access establishing and closing times were 7.8 (IQR: 6-9.3) min and 3.7 (IQR: 2.5-5) min, respectively. The median operative time and length of stay were 75 (IQR: 63-87) min and 7 (IQR: 5-9) days, respectively. Although the success rate was 100%, partial numbness in the median nerve distribution was noted in 1 patient in the forearm. This resolved spontaneously and no permanent neurological problem was seen. No other access-related complications were noted, and the total complication rate was 2.1% (1/48). BA preclosure with the PSS technique is safe and effective for left subclavian artery revascularization in Stanford B aortic dissection and can be another option for access closure during f-TEVAR.

Mahamana Technique of Pancreaticogastrostomy: A Safe and Reliable Technique for a Difficult Pancreatic Stump.

Pancreatoduodenectomy is a complex surgical procedure involving three anastomoses. Anastomosis of the pancreatic stump with the gastrointestinal tract is associated with most complications described in the postoperative period. So, there have been multiple attempts to discover safe and sound steps for this particular anastomosis. Pancreaticogastrostomy involves anastomosis between the remaining pancreas and stomach. Since it was first performed, its surgical steps have been modified multiple times, but there is no gold standard method to performit. In this paper, we describethe surgical steps of pancreaticogastrostomy in difficult pancreatic stumps in eight patients using two transpancreatic sutures, one purse string suture, and the incorporation of transpancreatic sutures in the third layer of the gastrojejunostomy anastomosis. Postoperative outcomes of this series have provided encouraging short-term results.

Modified Q-type purse-string suture duodenal stump embedding method for laparoscopic gastrectomy for gastric cancer

ObjectiveThis study introduced the modified Q-type purse-string suture duodenal stump embedding method, a convenient way to strengthen the duodenum, and compared it to the conventional one to assess its efficacy and safety.MethodsThis retrospective analysis examined 612 patients who received laparoscopic gastrectomy for gastric Cancer at a single center. The patients were divided into Not Reinforced Group (n = 205) and Reinforced Group (n = 407) according to the surgical approach to the duodenal stump. The reinforced group was further divided into a modified Q-type purse-string suture embedding method group (QM, n = 232) and a conventional suture duodenal stump embedding method group (CM, n = 175) according to the methods of duodenal stump enhancement. Clinicopathological characteristics, operative variables, and short-term complications were documented and analyzed.ResultsThe incidence of duodenal stump leakage(DSL) in the Not Reinforced Group was higher compared to the Reinforced Group, although the difference was not statistically significant [2.4% (5/205) vs 0.7% (3/407), p = 0.339]. Additionally, the Not Reinforced Group exhibited a higher rate of Reoperation due to DSL compared to the Reinforced Group [2 (1.0%) vs. 0, p = 0.046], with one patient in the Not Reinforced Group experiencing mortality due to DSL [1 (0.5%) vs 0, p = 0.158]. Subgroup analysis within the Reinforced Group revealed that the modified Q-type purse-string suture embedding group (QM) subgroup demonstrated statistically significant advantages over the conventional suture embedding group (CM) subgroup. QM exhibited shorter purse-string closure times (4.11 ± 1.840 vs. 6.05 ± 1.577, p = 0.001), higher purse-string closure success rates (93.1% vs. 77.7%, p = 0.001), and greater satisfaction with purse-string closure [224 (96.6%) vs 157 (89.7%), p = 0.005]. No occurrences of duodenal stump leakage were observed in the QM subgroup, while the CM subgroup experienced two cases [2 (1.1%)], though the difference was not statistically significant. Both groups did not exhibit statistically significant differences in secondary surgery or mortality related to duodenal stump leakage.ConclusionDuodenal Stump Leakage (DSL) is a severe but low-incidence complication. There is no statistically significant relationship between the reinforcement of the duodenal stump and the incidence of DSL. However, laparoscopic reinforcement of the duodenal stump can reduce the severity of fistulas and the probability of Reoperation. The laparoscopic Q-type purse-string suture duodenal stump embedding method is a simple and effective technique that can, to some extent, shorten the operation time and enhance satisfaction with purse-string closure. There is a trend towards reducing the incidence of DSL, thereby improving patient prognosis to a certain extent.

Cytological Analysis of the Surgical Field During Transanal Total Mesorectal Excision for Rectal Cancer: A Prospective Study.

An unexpectedly large number of patients experienced local recurrence with transanal total mesorectal excision in Norway. This appears to be associated with cancer cell spillage during surgery. To investigate the surgical field cytology during transanal total mesorectal excision. This was a prospective cohort study. This study was conducted at a single center between June and December 2020. Forty patients with rectal cancer underwent transanal total mesorectal excision. After irrigation of the surgical field, the water specimens were cytologically evaluated at 6 representative steps. The first sample was used as an initial control. The second, third, fourth, fifth, and sixth samples were collected after the first pursestring suture, rectotomy, the second pursestring suture, specimen resection, and anastomosis, respectively. The clinicopathological features and intraoperative complications of the patients were reviewed. The primary outcome was to evaluate the presence of cancer cells in washing cytological samples. Of the 40 consecutive patients enrolled in this study, 18 patients underwent neoadjuvant chemoradiotherapy. Incomplete first pursestring suture and rectal perforation were observed in 4 (10.0%) and 3 (7.5%) cases, respectively. In the first sample, 31 patients (77.5%) had malignant cells. Malignant findings were detected in 2 patients (5.0%) from the second to fifth samples. None of the sixth sample exhibited any malignant findings. This single-center study had a small sample size. Cancer cells were initially detected by cytology, but only a few were observed throughout the procedure; however, cancer cells were not detected in the final surgical field. Further follow-up and novel studies are required to obtain clinically significant findings using cytology during transanal total mesorectal excision. See Video Abstract . ANTECEDENTES:Un número inesperadamente grande de pacientes experimentó recurrencia local con la escisión total del mesorrecto transanal en Noruega. Esto parece estar asociado con el derrame de células cancerosas durante la cirugía.OBJETIVO:Investigar la citología del campo quirúrgico durante la escisión total del mesorrecto transanal.DISEÑO:Este fue un estudio de cohorte prospectivo.ENTORNO CLINICO:Este estudio se realizó en un solo centro entre junio y diciembre de 2020.PACIENTES:Cuarenta pacientes con cáncer de recto se sometieron a escisión total del mesorrecto transanal. Después de la irrigación del campo quirúrgico, las muestras de agua se evaluaron citológicamente en seis pasos representativos. La primera muestra se utilizó como control inicial. La segunda, tercera, cuarta, quinta y sexta muestras se recolectaron después de la primera sutura en bolsa de tabaco, la rectotomía, la segunda sutura en bolsa de tabaco, la resección de la muestra y la anastomosis, respectivamente. Se revisaron las características clínico-patológicas y las complicaciones intraoperatorias de los pacientes.PRINCIPALES MEDIDAS DE RESULTADO:El resultado primario fue evaluar la presencia de células cancerosas en el lavado de muestras citológicas.RESULTADOS:De los 40 pacientes consecutivos inscritos en este estudio, 18 pacientes se sometieron a quimiorradioterapia neoadyuvante. Se observaron la primera sutura en bolsa de tabaco incompleta y perforación rectal en cuatro (10,0%) y tres (7,5%) casos, respectivamente. En la primera muestra, 31 (77,5%) pacientes tenían células malignas. Se detectaron hallazgos malignos en dos pacientes (5,0%) de la segunda a la quinta muestra. Ninguno de la sexta muestra demostraron hallazgos malignos.LIMITACIONES:Este estudio unicéntrico tuvo un tamaño de muestra pequeño.CONCLUSIONES:Inicialmente se detectaron células cancerosas mediante citología, pero solo se observaron unas pocas durante todo el procedimiento; sin embargo, no se detectaron células cancerosas en el campo quirúrgico final. Se requieren más seguimientos y estudios novedosos para obtener hallazgos clínicamente significativos mediante citología durante la escisión total del mesorrecto transanal. (Traducción- Dr. Francisco M. Abarca-Rendon ).