Anastomosis Stapler Research Articles

Endoscopic treatment of postoperative colorectal anastomotic strictures.

The postoperative development of benign colorectal anastomotic stricture remains a frequent and unsolved problem. From 1996 until 2002, we analyzed 94 consecutive patients with postoperative colorectal anastomotic stenosis who were treated endoscopically. Sixty-eight patients were initially resected for malignant disease, and 26 patients for benign conditions. Most frequently, hydrostatic balloon dilatation was performed; in selected cases, it was combined with a laser or argon plasma coagulation (APC) incision, or a laser incision only. Dilatation was successful in 59% of patients resected for cancer and 88% resected for a benign condition. Complications developed in 17 patients (benign restenosis, perforation, abscess); they were significantly more frequent after initial cancer resection than after resection for a benign condition ( p < 0.05). High success and low complication rates make endoscopic dilatation the treatment of choice to avoid high-risk reoperations in patients with benign anastomotic stricture. The presence of stapler anastomosis, postoperative leakage, and/or radiotherapy does not significantly impede successful endoscopic dilatation.

Anastomotic leakage after low rectal stapler anastomosis: significance of intraoperative anastomotic testing

Aims: One of the most significant surgical complications following rectal resection with primary anastomosis is anastomotic leakage. The aim of this study was to evaluate the benefit of intraoperative anastomotic testing of stapled anastomoses and the impact on leakage rate.Methods: Between 1987 and 2000, 1360 consecutive rectal resections for carcinoma were performed. In 933 operations rectal resection was completed with either stapled (n=788), handsewn (n=80) or coloanal (n=65) anastomosis. Since 1995 we introduced intraoperative anastomotic testing, routinely. Between 1995 and 2000, 296 patients were treated with stapled anastomosis following rectal resection. Different variables influencing anastomotic leakage were evaluated.Results: Between 1987 and 2000, 68 of 933 patients treated by resection and anastomosis developed a clinically significant anastomotic leak (7.3%) where as between 1995 and 2000 the leakage rate was 9.8% of all patients with stapled anastomosis. There was an increase in resection rate from 62 to 72%. Since 1995 we demonstrated either intraluminal bleeding or leakage in 18.1% of all stapled anastomoses by intraoperative anastomotic testing. The postoperative anastomotic leakage rate was equal in those patients with normal and abnormal findings of anastomotic testing even though 74% of all patients with irregular findings were treated by performing a protective stoma simultaneously. We found no significant risk factor for the development of anastomotic leakage.Conclusion: We recommend a protective stoma with any anastomosis within the lower third of the rectum. Anastomoses within the middle and upper third of the rectum demonstrate a lower risk of anastomotic insufficiency and do not need a protective stoma, routinely.

Laparoscopic linear cutting stapler failure

Objectives. To characterize the frequency and nature of problems with linear cutting staplers to help prevent complications in the future. These devices are often used during laparoscopic urologic procedures. Methods. We retrospectively reviewed the experience with laparoscopic linear cutting staplers at two institutions routinely performing urologic laparoscopy and analyzed the difficulties with any staplers. Data from the Food and Drug Administration Center for Devices and Radiological Health were also examined to determine the prevalence and types of reported problems. Results. In performing approximately 460 laparoscopic cases, we encountered 5 problems (1%) with endovascular gastrointestinal anastomosis staplers. Fifty-five additional cases in 50 patients were documented in the Food and Drug Administration database. Of the 55 patients, 15 (27%) required open conversion to manage the problem, 8 (15%) received blood transfusions, and 2 (4%) died postoperatively. Twenty-two events occurred during 19 laparoscopic donor nephrectomies (35%) without associated graft dysfunction, damage, or loss. All phases of instrument use were subject to problems; however, abnormal firing of the stapler and improper staple formation were the most common and morbid aspects of device malfunction. Conclusions. Despite the general reliability of linear cutting staplers, difficulties were encountered in every step of use. Most situations were successfully managed by prompt identification and appropriate intracorporeal maneuvers. Nevertheless, significant morbidity may occur, and conversion to an open operation should be considered. Many potential problems can be avoided by surgeon and staff education, and one should be aware of the alternative methods of tissue ligation currently available.

Laparoscopic approach to open gastric bypass

Background: Gastric bypass is a successful tool in the treatment of morbid obesity. In recent years, laparoscopic Roux-en-Y gastric bypass has gained popularity. However, open bypass is sometimes more suitable for patients who are “superobese.” Laparoscopic instrumentation can be used during an open gastric bypass to facilitate dissection, formation of the gastric pouch, and creation of the gastrojejunostomy. Methods: We describe the use of laparoscopic ultrasonic coagulating shears for dissection during open gastric bypass. Additionally, laparoscopic gastrointestinal anastomosis and end-to-end anastomosis staplers are used for creating bowel anastomoses. Conclusions: Laparoscopic instrumentation can be useful in the setting of open procedures. Their long handles and jaw design make them ideal for working in the depths of a superobese abdomen.

Hand-assisted laparoscopic autoaugmentation gastrocystoplasty.

Autoaugmentation gastrocystoplasty has been previously performed successfully. This set of experiments was conducted to determine the feasibility of performing autoaugmentation gastrocystoplasty laparoscopically. Hand-assisted laparoscopic autoaugmentation gastrocystoplasty was performed on 15 mongrel dogs. The surgery was carried out with two 10-mm trocars and a 6-cm Pfannenstiel incision. The gastric wedge, supplied by the right gastroepiploic artery, was resected with two applications of an endoscopic gastrointestinal anastomosis (GIA) stapler. The pedicle was demucosalized, and the anastomosis to the bladder was completed through the Pfannenstiel incision. All of the dogs were successfully treated laparoscopically and were eating at 48 h. There was no evidence of anastomotic leak dehiscence at the gastric resection staple line. Hand-assisted laparoscopic autoaugmentation gastrocystoplasty can be performed successfully in dogs. This operation may offer a superior alternative to standard bladder autoaugmentation procedures in children suffering from congenital bladder disorders.

Simultaneous Laparoscopic Management of 3 Urological Malignancies

A 65-year-old male smoker presented with gross hematuria. Transurethral resection of the bladder revealed urothelial cell carcinoma, pT1 grade 3. Despite instillation of intravesical bacillus Calmette-Guerin and a repeat endoscopic resection, muscle invasive bladder cancer subsequently developed with involvement of the prostatic urethra. Computerized tomography also demonstrated a 4 cm. central right renal mass (fig. 1). There was no evidence of metastatic disease or lymphadenopathy. Serum prostate specific antigen and creatinine were 2.9 ng./ml. and 1.5 mg./dl. (normal 0.6 to 1.1), respectively. After a discussion of treatment options the patient underwent laparoscopic nephroureterectomy with en bloc laparoscopic radical cystoprostatectomy. He did not desire a continent urinary diversion. Nephrectomy was performed via a 4-port transperitoneal approach, and the ureter was mobilized below the iliac vessels without division. Three additional ports were placed to facilitate cystoprostatectomy, performed as described previously.3 Vascular pedicles and dorsal vein complex were controlled using a combination of an endovascular gastrointestinal anastomosis stapler and laparoscopic coagulating shears. After apical prostate identification the urethra was transected with an endovascular gastrointestinal anastomosis stapler immediately after removal of the Foley catheter. The specimen was removed intact from the extended infraumbilical trocar site (fig. 2). Lymphadenectomy and ileal conduit construction were performed through the minilaparotomy. Estimated blood loss was 800 ml., and operative time was 11 hours. No intraoperative or postoperative complications were encountered, and the patient resumed oral intake at 4 days and was discharged home at 6 days postoperatively. Pathological examination confirmed 3 separate urological malignancies—clear cell renal cell carcinoma, pT1N0 Fuhrman grade 3; bladder urothelial cell carcinoma, pT2bN0 grade 3; and prostate cancer, Gleason score 3 4 pT2bN0—as well as low grade dysplasia throughout the right ureter. All surgical margins were negative.

PURE LAPAROSCOPIC ENTEROCYSTOPLASTY

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

URETERAL SUBSTITUTION WITH A STAPLED NEOURETER: A SIMPLIFIED BOARI FLAP

We evaluate a new technique that will quickly and easily replace a long segment of ureter by creating a tapered neoureter (Boari flap) with bladder wall and absorbable staples. A neoureter was created in 14 pigs with native bladder and 75 mm. Polysorb gastrointestinal anastomosis staplers (U. S. Surgical, Norwalk, Connecticut). Urine culture and serum creatinine were obtained before neoureter creation. Neoureter length and time to construct were recorded. At 6 weeks serum creatinine was repeated, and ureteral stent removed with evaluation of the staple lines for stones and residual staples. At 4 months intravenous pyelogram, cystogram and serum creatinine were obtained before necropsy. The bladder, neoureter and kidneys were examined grossly and histologically for hydronephrosis, staples, stones and stenosis. Mean neoureter length was 13.4 cm. and mean time to construct was 15 minutes. Laboratory results were unremarkable. Of the 14 pigs 2 died of pneumonia before stent removal, and at autopsy neither had evidence of hydronephrosis nor anastomotic stricture. In the remaining 12 pigs there was no evidence of residual staples or stone formation with mucosa covering the staple line at cystoscopy and necropsy. Successful neoureter substitution was performed in 9 pigs with no gross or histological changes. There were 3 pigs that had evidence of hydronephrosis with histological findings of chronic pyelonephritis and 2 of them appeared atrophic compared to the contralateral kidney. Our study demonstrates a new technique for ureteral substitution with bladder and absorbable staples that may be performed quickly and easily. Furthermore, we show that absorbable staples can be safely incorporated into the urinary tract with minimal worry about encrustation or calculus formation.

Radical Retropubic Prostatectomy Using Endoscopic Gastrointestinal Anastomosis Staplers

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

LAPAROSCOPICALLY ASSISTED VAGINAL RESECTION OF RECTOVAGINAL ENDOMETRIOSIS

In Brief Background We wanted to establish a technique of laparoscopically assisted radical vaginal surgery for deep endometriosis of the rectovaginal septum with extensive rectal involvement. Technique The procedure is started by vaginally excising the involved area which is left on the rectum, followed by bilateral dissection of the pararectal and retrorectal spaces. Para- and retrosigmoido-rectal spaces are developed laparoscopically along the coccygeosacral bone and medially to the pelvic splanchnic nerves toward the para- and retrorectal openings that were made transvaginally. Rectal transection is done with a laparoscopic stapling device caudal to the endometriotic lesion. Using a suprapubic minilaparotomy, the bowel is transected cranial to the lesion and reintroduced into the abdomen, and a transanal circular stapler anastomosis is done. Experience Thirty-four women had this procedure. The mean distance of the anastomosis was 4 cm above the anus. None required ileostomy or colostomy and no major complications were noted. Conclusion The combination of laparoscopic and vaginal approaches is useful for removing extensive endometriotic infiltration of the rectosigmoid; bladder and rectal function and fertility can be preserved. A combined laparoscopic-vaginal approach can be used in surgical treatment of rectovaginal endometriosis.

Estudo comparativo de anastomoses colorretais com anel biofragmentável e com grampeador em cães submetidos à irradiação gama pré-operatória

OBJETIVO: Comparar os resultados precoces entre anastomoses colorretais realizadas com anel biofragmentável e com grampeador circular após irradiação pélvica. MÉTODOS: Foram utilizados 40 cães beagle, em dois grupos de 20 animais, submetidos ou não à irradiação gama pré-operatória, com dose única de 500 cGy. Cada grupo foi dividido em dois subgrupos de dez animais, sendo denominado A o grupo em que se utilizou o anel biofragmentável e B aquele em que se empregou o grampeador. Os animais foram submetidos à secção completa do intestino grosso ao nível da junção retossigmóide, com reconstrução do trânsito sendo efetuada por uma das técnicas, após sorteio. Os animais foram sacrificados no sétimo dia de período pós-operatório. RESULTADOS: Houve dois óbitos antes da reoperação: um em animal do grupo teste, por ruptura da anastomose realizada com anel biofragmentável; outro por peritonite generalizada em animal do grupo controle com anastomose efetuada por grampeador. Aderências e infecções de parede ocorreram de forma similar. A análise histológica convencional e a análise morfométrica realizada por computador das áreas de cicatrização anastomótica identificaram comportamento análogo entre os grupos e subgrupos estudados. CONCLUSÃO: Os resultados precoces das técnicas empregadas para anastomose intestinal foram semelhantes nas condições de risco estudadas.

Vertical division of the rectum by endostapler in very low colorectal anastomosis with a double-stapling technique

SummaryApplication of standard linear staples can sometimes be difficult in a narrow pelvis of small male patients, or in deep colorectal anastomosis, even using improved double-stapling techniques (DST). A modified DST, using an endostapler, by vertical division of the rectum, instead of the usual horizontal division, under a newly devised position, facilitates easy and steady transection of the rectum, even in the narrow pelvis or with very low anastomosis. Vertical transaction of the rectum, followed by circular stapler anastomosis, forms a vertically ellipsoid anastomotic orifice, which might be more physiological to the vertically shaped anal canal, especially in very low anastomosis.

Use of the endoscopic gastrointestinal anastomosis stapler in radical cystectomy.

Use of the endoscopic gastrointestinal anastomosis stapler in radical cystectomy.

Principal modifications of the Duhamel procedure in the treatment of Hirschsprung's disease

In the literature, many articles refer to the DUHAMEL technique or some of its modifications in the treatment of Hirschsprung's disease, however, no complete review of all of them has been published to date. The authors present an analysis of the principal modifications of this technique based on the results of an international retrospective survey that evaluated a series of 2,430 patients as well as data from the literature. The important role of the internal anal sphincter in the physiology of continence is emphasized; understanding its function is an imperative prerequisite for a successful Duhamel procedure. The original technique, which used two crushing Kocher clamps as proposed by Duhamel in 1956, as well as a majority of the modifications with various spur-crushing instruments are no longer in use. At present, surgeons generally use staplers for the colorectal anastomosis.

A Comparison of Stapled and Hand-Sewn Anastomoses in Crohn’s Disease

Sixty-eight patients with Crohn’s disease who underwent intestinal resection were randomly divided into 2 groups: the stapled group (32 patients, 40 anastomoses) with functional end-to-end anastomoses made with linear staplers and with circular stapling anastomoses, and the hand-sewn group (36 patients, 48 anastomoses), with anastomoses achieved by layer-to-layer suturing. There were no significant differences in operative indications, age, sex, blood loss, or length of hospital stay between the groups. The operation times for right hemicolectomy and total colectomy in the stapled group were significantly shorter than those in the hand-sewn group. There were no significant differences in anastomotic dehiscence or recurrence between the stapling and hand-sewn procedures. These results indicate that these stapling techniques, even though producing an everted anastomosis, are not an adverse procedure for Crohn’s disease.

Modified Indiana Pouch: Surgical technique and preliminary results

– Two modified continent Indiana Pouch techniques are presented, one of which using gastrointestinal anastomosis (GIA) staplers. The authors describe their experience with 88 patients who underwent the above operation at the Divisions of Urology in the Maria Vittoria Hospital of Turin and S. Maria Nuova Hospital of Reggio Emilia. Mean follow-up is 18 months (range 4-26). A total of 24 post-operative complications are described: 2 bowel obstructions, 4 strictures of the stoma, 3 parastomal hernias, 1 pouchitis and 1 acute pyelonephritis, 2 cases of incontinence, 2 of over-distension of the pouch, 5 ureteral obstructions and 4 cases of diarrhoea. Neither stones of the pouch nor metabolic acidosis were observed. Using GIA staplers for tailoring the pouch saves 120 minutes operating time for an additional cost of about 600 $.

Laparoscopic creation of a continent cecal tube for antegrade colonic irrigation

Objectives The antegrade continence enema (ACE) procedure has been used for the treatment of overflow fecal incontinence or constipation in patients with spina bifida. The procedure requires an appendiceal reimplantation into the cecum with creation of a continent abdominal stoma for antegrade colonic washout. To preserve the appendix for potential use in urinary diversion, we developed two surgical techniques for tubularizing an antimesenteric cecal segment to use in place of the appendix. Methods The surgery was performed in 6 dogs. The first two procedures used an open surgical technique through a 10-cm midline laparotomy. The cecum was isolated, and a small cecotomy was made. A 10F red rubber catheter was introduced into the cecotomy, and a 4-cm length of cecum was tubularized along its antimesenteric border with a gastrointestinal anastomosis stapler over the catheter. A nipple was created at the base of the tube to enhance continence, and the tubular segment was brought through the lower abdominal wall to create a catheterizable stoma. After our success, four subsequent procedures were performed laparoscopically to create the same tubularized cecal segment. A 4-cm antimesenteric tubularized cecal segment with sufficient lumen to accommodate a 10F to 12F catheter was constructed using a laparoscopic gastrointestinal anastomosis stapler. Rather than creating a nipple at the base of the tubular segment, continence of the stoma was achieved by tunneling the cecal tube through a 2-cm lower quadrant subcutaneous tunnel. A flush stoma was then created and secured to the skin. Results Stoma viability was grossly confirmed in all 6 dogs during the postoperative period, with no incidence of bowel obstruction. Slight fecal leakage through the stoma was observed in 1 dog with a laparotomy but not in those with laparoscopy. Catheterization was easily performed in all dogs with a 10F red rubber catheter during the postoperative period. The dogs were killed on postoperative day 10, and gross anatomic and histologic examination of the cecal segment confirmed luminal patency and viability. Conclusions Open and laparoscopic continent cecostomies were successfully constructed in a canine model and are likely to be applicable to humans with neuropathic constipation.

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

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

The Double Stapling Technique for Low Anterior Resection

Since the introduction of the end-to-end anastomosis (EEA) stapler for rectal reconstruction, we have used a modification of the conventional technique in which the lower rectal segment is closed with the linear stapler (TA-55) and the anastomosis is performed using the EEA instrument across the linear staple line (double stapling technique). Our experience with this procedure includes stapled colorectal anastomoses in 75 patients and is the basis for the report. This review presents the details and advantages of the technique and the results. Complications include two patients with anastomotic leak (2.7%), and two with stenosis that required treatment (2.7%). Protective colostomy was not done in this series. There were no deaths. Our experience and that of others suggests that this modification of the EEA technique can allow a lower anastomosis in some patients, and that it can be done with greater safety and facility.

Safety of EEA staplers for anastomosis between upper esophagus and the gastric tube

The EEA stapling devices used for intrathoracic anastomosis between the upper esophagus and the gastric tube in patients with carcinoma of the thoracic esophagus were evaluated, and the results were compared with those of an antesternally reconstructed esophagus. These approaches were both used by the same surgical team. An intrathoracic anastomosis using the EEA stapler was made in 53 patients with carcinoma of the thoracic esophagus. Minor anastomotic leakage occurred in five patients (9.4%). Good results were obtained with total parenteral nutrition for 2 weeks. Intrathoracic anastomotic complications were never fatal. Among another 106 patients with antesternally reconstructed esophagus, with the EEA stapler there were 28 patients with anastomotic leakage (26.4%) and two operative mortalities (1.9%). Intrathoracic anastomosis with the EEA stapler is recommended because it is secure and the operative procedure is simple and time-saving. For successful use of the instrument, proper technical procedures must be followed.