Stapling Device Research Articles

A novel method of anvil placement of circular stapler for esophagojejunostomy in laparoscopic total gastrectomy for gastric cancer: results of consecutive 200 cases.

Laparoscopic total gastrectomy for gastric cancer is still a demanding operation because of technical difficulties, especially of intracorporeal esophago-jejunal anastomosis. We introduced a newly designed method of anvil placement of circular stapling devices (CS) for laparoscopic esophagojejunostomy (EJS). A small incision was made on the anterior wall of the stomach, from which the anvil was inserted into the stomach and proceeded to the thoracic esophagus. Then, the abdominal esophagus was transected by a linear stapler, and the anvil into the esophagus was drawn back to the esophageal stump by pulling out the cotton tape pre-attached to the anvil. Intracorporeal EJS by Roux-en-Y reconstruction was performed by CS inserted into the abdominal cavity from the umbilical wound. A total of consecutive 200 gastric cancer patients underwent laparoscopic total gastrectomy using this method. There was no operative mortality. Anastomotic complications occurred in 12 cases (6.0%): 9 cases of stenosis (4.5%) and 3 cases of bleedings (1.5%). Anastomotic leakage was not observed. As for non-anastomotic complications, there occurred 2 pulmonary complications (1.0%), 3 pancreatic leakages (1.5%), and 8 bowel obstructions due to internal hernia (4.0%). With a median follow-up period of 47.1months, 5-year overall survival for assessable patients (n = 193) was 60.3% (95% CI 52.6-67.2). The total rate of peritoneal recurrence was 9.8%. Our new method of anvil placement for laparoscopic EJS with CS is safe and feasible with favorable survival outcomes. It eliminates the need for suturing, and will promote the clinical application of laparoscopic total gastrectomy for gastric cancer. UMIN000046119.

Recurrent appendiceal intussusception mimicking ileocecal invagination in a 7-year-old girl

Appendiceal intussusception in children is a rare entity characterized by the invagination of the appendix into the cecum. The early diagnosis and optimal surgical management of appendiceal intussusception have not been achieved because of its rarity. Here, we report a case of a 7-year-old girl with appendiceal intussusception presenting with recurrent ileocecal invagination. She was treated by simple appendectomy without using a stapling device. The imaging findings in patients with appendiceal intussusception were reported, and the optimal surgical treatment for appendiceal intussusception was discussed.

P8.001: Robotic-Assisted Living Donor Nephrectomy: High Technology Incorporated for Patient Benefit

Background: Kidney transplantation (KT) provides increased survival for patients with end-stage renal disease (ESRD). Living donation (LD) is a cornerstone in the increase of the pool of donors available, especially due to recipients requiring less time on the waitlist and need for ongoing dialysis along with evidence for longer graft survival. One of the barriers for LD is the burden of the procurement surgery, that has traditionally been performed by open or laparoscopic hand-assisted technique. We report here a case series of 22 patients submitted to robotic-assisted left donor nephrectomy. Methods: Prospectively collected data of patients submitted to robotic-assisted left donor nephrectomies at the Jackson Memorial Hospital, University of Miami, Miami Transplant Institute, in the period of Aug-2021 to Mar-2022, during the first phase of implantation of the Transplant Robotic Program. Data relative to the pre-operative, intra-operative and post-operative periods were collected, including clinic-demographic characteristic of the patients, surgical metrics, and pathology findings. Continuous variables were analyzed with Student t-test, categorical variables were analyzed with chi-square test. A p-value of less than 0.05 was considered to be statistically significant. Results: 22 patients were included, of those 10 (45.5%) were male. The median age was 40 (30-49.3) years old. Of all cases analyzed, 16 (72.7%) donated the kidney to a related family member. The donor kidney graft anatomy was conventional (single artery, single vein, single ureter) in 19 (86.4%) of the cases. There was 1 (4.5%) case with multiple arteries that was successfully reconstructed in the back-table operation. There were anatomical technical difficulties in 5 (22.7%) cases. A Pffanenstiel incision was used in 10 (45.5%) cases for graft extraction from the abdomen. The median extraction time was 90.5 (IQR 56.5-225.2) seconds. The median intra-operative robotic console time was 102 (IQR 89.8-119.2) min. Robotic stapler devices were used in 21 (95.5%) cases. Foley catheter was removed in the operating room in 21 (95.5%) cases. The median length of stay was 1.23 (IQR 1.0-1.4) days. Graft function was immediate in 20 (90.1%) of the cases, and slow in 2 (9.9%) cases. Macroscopic procurement damage was appreciated in 5 (22.7%) cases. There was 1 (4.5%) postoperative readmission, 4 (18.2%) postoperative complications, and no surgical re-intervention needed. None of the patients had to be converted to laparoscopic or open operation associated to the procedures. There was no statistically significant difference between the groups analyzed. Conclusion: Robotic-assisted left donor nephrectomy is a safe procedure associated with minor risk of complications, and should be stimulated in the transplant centers where robotic surgery is available.

A COMPARATIVE STUDY OF STAPLERS VERSUS HAND SEWN ANASTOMOSIS IN INTESTINAL SURGERIES

INTRODUCTION: Intestinal anastomosis is a surgical procedure to establish communication between two separated portions of the intestine. This procedure restores intestinal continuity after removal of a pathological condition affecting the bowel. Intestinal anastomosis can be performed by a hand-sewn technique using absorbable or non-absorbable sutures, mechanical stapling devices. Sutured anastomosis (hand-sewn technique) is the commonly used method. The newer stapling devices for intestinal anastomosis has provided an alternative option to perform rapid anastomosis.1 Various studies have contradictory results in terms of duration of procedure, post operative recovery and anastomotic leak. There are insufcient evidence to demonstrate superiority of either technique and more studies are needed to demonstrate the superiority of either technique. AIM MATERIAL AND METHODS:: To study and compare the effectiveness of staplers vs hand sewn anastomosis in Intestinal surgeries. A comparative observational study Consists of patients presenting with need of bowel resection and anastomosis inclusion criteria at Apollo Hospital Gandhinagar, Gujarat. The patients who are admitted for elective as well as emergency resection & anastomosis of small and large intestines for various illnesses are selected after thorough clinical examination and investigations to conrm the diagnosis co- morbid conditions. Details were recorded in the proforma prepared. : 62.5% complications in comorbid subjects and 37.5% complications in non comorbid subjects.RESULTS The mean of anastomotic time for hand sewn group was 27.8 minutes whereas for the stapler group it was 9.0 minutes mins .With respect to return of bowel sounds, mean time was 46.32 hours in the hand sewn group and 35 hours in the stapler group Mean day of hospitalization was 8.16 days in hand sewn and 7.8 days in stapler technique. mean time taken for resumption of oral feeds the was 66.96 hours in hand sewn group and was 59.52 hours in stapler group .hand sewn group had total ve complications(20%), whereas stapler group had three complications(12%) Both the groups did not have any mortality. The mean cost of hand sewn anastomosis is 717.4 Rs which is signicantly less than mean cost of stapled anastomosis which is 33,754 Rs. : Stapler anastomosis signicantly reduces operative time and time taken for return of normal bowel sounds.CONCLUSION Because of the shortened total operating time in the stapled anastomosis .There is increased risk of overall complications in patients having co- morbidities in both hand sewn and stapled anastomosis. Mechanical staplers are far more costly than suture materials. Stapling technique can be used safely and effectively

Robotic-assisted colorectal surgery - initial results.

The mini invasive procedure in colorectal surgery is gaining ground as an alternative to conventional surgery. Colorectal surgery has significantly evolved since the advent of the automatic stapler devices and subsequently with the minimally invasive approach. The next logical step - the robotic assisted surgery was developed to satisfy surgeons' needs to the area of colorectal surgery and to offer a new and safer method to patients. The evidence for benefits of its use in this area appears to be promising.

Meckel's Diverticulum: Role of Small Bowel Exploration in Patient Presenting with Abdominal Pain

A 37-year-old woman with a history of endometriosis presented with ongoing pelvic pain. She had undergone multiple previous surgeries at an outside facility for evaluation and treatment including total hysterectomy, bilateral salpingo-oophorectomy, sigmoid diverticulectomy, and excision of pelvic and abdominal wall endometriosis. She continued to experience severe dyspareunia, constipation, and right periumbilical pain that radiated to her right flank. Preoperative magnetic resonance imaging showed areas concerning deep infiltrating endometriosis with no evidence of diverticulum. Repeat surgical exploration and possible excision of endometriosis were recommended. Intraoperatively, the pelvic peritoneum visually and histologically revealed fibrosis with no evidence of endometriosis. Laparoscopic inspection of the small intestine revealed a 2.5 cm Meckel's diverticulum (MD) (Fig. 1). Given the patient's abdominal pain, visualization of MD, and no significant pelvic pathology, a decision was made to perform thorough exploration of the small bowel via a minilaparotomy at the umbilicus. MD was resected using a stapling device (Fig. 2). Postoperatively, the patient reported complete resolution of periumbilical pain and improvement in constipation. These improvements persisted at the time of last follow-up (7 months postoperatively). Lack of sexual activity prevented assessment of changes in dyspareunia.

The Learning Curve of an Absorbable Subcuticular Stapling Device in Plastic and Reconstructive Surgery.

Background:Learning curves can reflect a surgical trainee’s rate of progress and competence in acquiring new skills. The INSORB subdermal staple device has been well established to facilitate decreased closure time across various surgical procedures, with similar cosmesis, healing, and consistency as those of standard subdermal sutures. This study is unique, as it demonstrated an observable learning curve with this device when used by a junior surgeon.Methods:Sixty-six patients underwent a cosmetic procedure during the second half of 2019 under the care of a single plastic surgeon in Melbourne, Australia. This corresponded to 254 unique linear incisions. Subdermal closure was done either with interrupted 3-0 Monocryl sutures or with the INSORB device. The consultant closed the incisions on one side, with the contralateral incision closed by the assistant using the same closure method. Data were then compared retrospectively, and closure times were compared over the ensuing 6 months.Results:Overall, consultant closure speed is 25% faster than assistant speed. When using 3-0 Monocryl, the difference is 33%, whereas the difference is reduced to 21% when using the INSORB. Furthermore, a mild learning curve could be appreciated with the assistant’s use of the INSORB over the comparatively short 6-month study period.Conclusions:In addition to improved speed, cost, outcome, and ergonomics, subdermal absorbable staples may also garner a faster learning curve than standard closure with 3-0 Monocryl. This study supported the learning curve of a surgical device as another innovative benefit and an important aspect of developing surgical technology.

Hepatic and portal vein transection by vascular stapler in open living donor hepatectomy – A retrospective cohort study

BackgroundIn an effort to increase donor safety in living donor liver transplantation, the utilization of vascular staplers for the division of the right portal and hepatic veins in patients undergoing right lobe liver donation for living donor liver transplantation (LDLT) was implemented. In here we report our experience with vascular staplers in patients undergoing LDLT and evaluate the subsequent feasibility and safety for donors. Material and methods17 cases of living donor liver transplant were retrospectively analyzed. The right portal vein was transected directly at the bifurcation of the main portal vein, the right hepatic vein was resected directly at the wall of the inferior vena cava using a vascular stapler device. ResultsWe registered a complication rate of 41.2% (7 donors). According to the Clavien-Dindo classification, grade II and grade III complications were each observed in 5.9% and grade IIIb complications in 29.4%, whereas catastrophic bleeding, complications with residual disability or the necessity of re-laparatomy did not occur. Upon 6 weeks, all donors were able to return to their previous occupation in fully recovered condition. ConclusionsThe utilization of vascular staplers in donors during open LDLT presents an encouraging alternative to manual over-sewing of vascular stumps. Apart from its timesaving aspect, the technique reduces the potential risk of life-threatening clamp slippage with subsequent uncontrolled blood loss.

Initial Airtightness of the Lung Parenchyma After Transection of the Interlobar Fissure – Monopolar Cutter, Stapler Versus Nd: YAG Laser

IntroductionEvery lobectomy requires the transection of the interlobar fissure. Resection surfaces must be airtight in order to avoid leakage and infection. Using an ex vivo model based on porcine lung, we compared three techniques with respect to initial airtightness at different inspiratory pressures. Materials and methodsIn the first technique (group 1), we transected the interlobar fissure with a monopolar cutter and overstitched the edges of the resection area with a monofilament thread. In the second technique (group 2), the interlobar fissure was cut with a stapling device. In the third technique (group 3), the interlobar fissure was cut using a laser fibre connected to an Nd: YAG laser. The resection areas were not overstitched; 15 transections were performed in each group. ResultsIn group 1, three parenchymatous bridges leaked starting at a pressure of 25 mbar. In the other two groups, all preparations were airtight at this pressure. If the ventilation pressure was increased up to 40 mbar, all seams in group 1 were leaky at a pressure of 35 mbar. Four staple seams were airtight at a pressure of 40 mbar. In group 3, 11 preparations (73.3 %) were airtight up to a pressure of 40 mbar. ConclusionsBased on our results, the use of an Nd: YAG laser is suitable for the transection of the interlobar fissure. In effect, this technique compares well with the other techniques examined.

V13-10 LINEAR STAPLING DEVICE IN LAPAROSCOPIC PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA IN MULTIPLE ENDOCRINE NEOPLASIA TYPE 2B

You have accessJournal of UrologyCME1 May 2022V13-10 LINEAR STAPLING DEVICE IN LAPAROSCOPIC PARTIAL ADRENALECTOMY FOR PHEOCHROMOCYTOMA IN MULTIPLE ENDOCRINE NEOPLASIA TYPE 2B Patricio Garcia Marchiñena, Andrés Germán Alfieri, Facundo Barbagallo, Ricardo Hosman Basto, and Alberto Jurado Patricio Garcia MarchiñenaPatricio Garcia Marchiñena More articles by this author , Andrés Germán AlfieriAndrés Germán Alfieri More articles by this author , Facundo BarbagalloFacundo Barbagallo More articles by this author , Ricardo Hosman BastoRicardo Hosman Basto More articles by this author , and Alberto JuradoAlberto Jurado More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002646.10AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Solitary adrenal glands, bilateral adrenal tumors or hereditary syndromes are indications of partial adrenalectomy to avoid the need for lifelong corticosteroid replacement. Laparoscopic partial adrenalectomy (LPA) is a safe and effective method in order to provide complete removal of small adrenal lesions, as well as preservation of normal glandular parenchyma. Our objective is to describe a LPA using a linear stapling device in a hereditary pheochromocytoma. METHODS: We present the case of a 29-year-old male with hypertension, anxiety and heart palpitations due to pheochromocytoma caused by multiple endocrine neoplasia type 2B. Urinary catecholamine levels were four times higher than normal. CT scan revealed a 33 mm hypermetabolic right adrenal mass. Transperitoneal LPA was performed with the patient in left lateral decubitus. Four trocars were placed as the described technique parallel to the costal line. Right adrenal tumor was resected using a vascular linear stapling device. To preserve the blood supply of the remnant adrenal gland, it was not extensively dissected and the main adrenal vein was totally preserved. RESULTS: The patient had uneventful postoperative recovery. Surgical time was 90 minutes. Patient was discharged on the 2nd day. Pathology confirmed a 3.5 cm benign composite pheochromocytoma-ganglioneuroma with negative surgical margins. After surgery the patient achieved a complete clinical and biochemical response. During a follow-up of 6 months, no biochemical or radiological recurrence was observed. CONCLUSIONS: LPA using a linear stapling device is a valid alternative to total adrenalectomy when normal adrenal tissue has to be preserved. Source of Funding: No source of fundings © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e1034 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Patricio Garcia Marchiñena More articles by this author Andrés Germán Alfieri More articles by this author Facundo Barbagallo More articles by this author Ricardo Hosman Basto More articles by this author Alberto Jurado More articles by this author Expand All Advertisement PDF DownloadLoading ...

MP32-15 MORTALITY RELATED TO THE USE OF STAPLER DEVICES AND CLIP APPLIERS: ANALYSIS OF THE FDA MAUDE DATABASE

You have accessJournal of UrologyCME1 May 2022MP32-15 MORTALITY RELATED TO THE USE OF STAPLER DEVICES AND CLIP APPLIERS: ANALYSIS OF THE FDA MAUDE DATABASE Balaji Reddy, Shirin Razdan, and Sanjay Razdan Balaji ReddyBalaji Reddy More articles by this author , Shirin RazdanShirin Razdan More articles by this author , and Sanjay RazdanSanjay Razdan More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000002581.15AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Surgical staplers and clip appliers are commonly used. These devices have a potential to malfunction, which may result in serious injury or death. This study characterizes mortality related to surgical stapler and clip applier failure reported in the FDA’s MAUDE database. METHODS: The FDA’s MAUDE database was reviewed between 1992 and 2016 based on the following product codes: GAG, FZP, GDO, GDW, KOG and GCJ. Adverse events including death and the type of device failure were reviewed. Temporal trends in reported deaths related to device failure were analyzed and the Healthcare Cost and Utilization Project database was used to adjust for annual surgical case volume using linear regression analysis. We identified temporal trends in mortality associated with surgical stapler and clip applier malfunction. RESULTS: A total of 75,415 malfunctions, 21,115 injuries, and 676 deaths were associated with the use of surgical stapler and clip applier devices. Most deaths occurred post-operatively (N=516, 76.3%) and were due to infection/sepsis (N=89, 17.2%) or vascular injuries (N= 110, 21.3%). Intra-operative mortality (N=79, 11.69%) was primarily due to vascular injuries (N=73, 92.4%). Device failures resulting in death were recognized both intra-operatively (N=268, 39.6%) and post-operatively (N=325, 48.1%). In post hoc root cause analysis, a surgical stapler and clip applier device problem was the most common attributed cause of death (N=238, 65%). In the linear regression analysis, there was a significant increase in the mortality from device failure in recent years after adjusting for annual surgical volume (p <0.01). CONCLUSIONS: Mortality related to the use of surgical stapler and clip applier is increasing. Most deaths occurred post operatively, and an increased awareness of potential life threatening complications is warranted when these devices are utilized. Source of Funding: None © 2022 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 207Issue Supplement 5May 2022Page: e537 Advertisement Copyright & Permissions© 2022 by American Urological Association Education and Research, Inc.MetricsAuthor Information Balaji Reddy More articles by this author Shirin Razdan More articles by this author Sanjay Razdan More articles by this author Expand All Advertisement PDF DownloadLoading ...

Robotic NICE Procedure Using Handsewn Technique.

INTRODUCTION:In 2018, we described a robotic natural orifice-assisted left-sided colorectal resection with intracorporeal anastomosis and transrectal extraction of the specimen and termed it the natural orifice intracorporeal anastomosis with transrectal extraction procedure. More recently, we have explored the feasibility, safety, and utility of performing total handsewn intracorporeal anastomosis. We present a technical video and initial experience depicting the unique steps to accomplish this procedure with colorectal end-to-end handsewn anastomosis.TECHNIQUE:Twenty natural orifice intracorporeal anastomosis with transrectal extraction procedures with end-to-end handsewn intracorporeal anastomosis were performed. A video depicting the essential steps with 2 variations of the handsewn techniques is presented along with short-term outcomes.RESULTS:The most common indication was complicated diverticulitis followed by rectal cancer and deep infiltrative endometriosis of the rectum. The mean operative time was 235 minutes (99–294 min), and there were no intraoperative complications or conversions. Handsewn end-to-end intracorporeal anastomosis was successful in all patients. Natural orifice transrectal extraction was successful in 17 of 20 (85%) patients. The mean postoperative length of stay was 2.1 days (±1.05 SD). There were 3 major complications. One patient developed a deep surgical site infection, and another patient had an organ space abscess. Both patients required readmission and were treated with antibiotics alone. One patient, who had a diverting ileostomy performed at the time of the index procedure, developed subclinical dehiscence of the anastomosis, which healed without intervention but resulted in a delay in ileostomy reversal. There were no additional readmissions and no reoperations or mortalities.CONCLUSIONS:Robotic natural orifice intracorporeal anastomosis with transrectal extraction procedure and colorectal end-to-end handsewn anastomosis was feasible and safe in this initial series. This technique can be successfully performed in a total intracorporeal manner without the need for an abdominal wall extraction incision or any circular stapling devices.

Dynamic Tendon Grip (DTG\u2122) novel knot array compared to traditional sutures for zone two flexor tendon injury \u2013 a biomechanical feasibility study

BackgroundFlexor tendon injuries pose many challenges for the treating surgeon, the principal of which is creating a strong enough repair to allow early active motion, preserving a low-profile of the repair to prevent buckling and subsequent pulley venting. A main concern is that a low-profile repair is prone to gap formation and repair failure. The Dynamic Tendon Grip (DTG™) all suture staple device claims to allow a strong and low-profile repair of the flexor tendon. The purpose of this study is to test the effects of the DTG™ device in early active motion simulation on range of motion, load to failure and gap formation and to compare it to traditional suturing technique.MethodsTwelve fresh-frozen cadaveric fingers were assigned to two groups: DTG™ device (n = 9) and traditional suturing (double Kessler 4-core suture and a peripheral suture, n = 3). The deep flexor was incised and repaired in zone 2, and active motion simulation was carried out with a cyclic flexion–extension machine. Finger range of motion and gap formation were measured, as well as load to failure and method of repair failure.ResultsFollowing motion simulation, ROM decreased from 244.0 ± 9.9° to 234.5 ± 5.8° for the DTG™ device compared to 234.67 ± 6.51° to 211.67 ± 10.50° for traditional suturing. The DTG™ repair demonstrated gap formation of 0.93 ± 0.18 mm in 3 of 8 specimens after applying 1 kg load, which negated after load removal. Load to failure averaged 76.51 ± 23.15 N for DTG™ and 66.31 ± 40.22 N for the traditional repair. Repair failure occurred as the suture material broke for the DTG™ array and at the knot level for the traditional repair.ConclusionsThe DTG™ all-suture stapling concept achieved a strong low-profile repair in zone 2 flexor tendon injury after active motion simulation. Further clinical studies will be needed to determine the effectiveness of this device compared to traditional techniques.

The 12 steps to a thoracoscopic anterior segment segmentectomy: Oncologically safe and sound.

The 12 steps to a thoracoscopic anterior segment segmentectomy: Oncologically safe and sound.

Evaluation of sutureless anastomosis after ileostomy takedown using the self-forming magnet anastomosis system in a porcine model.

Current standard of care for creation of small bowel anastomoses after a loop ileostomy reversal includes the use of stapler devices and sutures. Compression anastomosis devices have been used for decades, aimed toward improved outcomes with a "staple free" &amp; "suture free" anastomosis. The self-forming magnet (SFM) device is a type of compression anastomosis device used to safely and effectively create an end-to-end small bowel anastomosis without the localized inflammatory response seen with sutures or staples, as no foreign bodies are left behind. A Good Laboratory Practice preclinical study using a porcine model to evaluate creating an in vivo anastomosis via magnetic compression between two segments of small bowel (jejunum or ileum) was performed. Magnetic anastomoses were compared to stapled and handsewn anastomoses. Six animals were used for the magnetic anastomosis and eight for the two control groups for a total of 14 subjects. Mean creation times were 17.1min (SD 6.06) for the SFM group, 10.3min (SD 6.55, CI 95%) for the stapled anastomosis group, and 28.3min (SD 2.63, CI 95%) for the suture anastomosis group, with a statistically significant difference among groups (p &lt; 0.0021). All evaluated SFM anastomosis, stapled anastomosis, and handsewn anastomosis underwent a burst test with a pressure of 1.3 PSI. All six magnets used for anastomoses were naturally expelled. The range of days to expel magnets was 10-17days. Intestinal anastomoses using magnets had considerably less residual scarring and intestinal distortion than anastomoses done with either suture or staples. This preclinical study documents the safety and efficacy of creating end-to-end small bowel anastomoses after ileostomy takedown using a magnetic compression device. The result is an anastomosis free of foreign objects with less inflammation, scarring, distortion, and mural thickening than seen in sutured or stapled anastomoses.

Improved anastomotic technique for esophagojejunal anastomosis using circular stapler.

In total gastrectomy, Roux-en-Y reconstruction with esophagojejunal anastomosis has been widely used in gastrointestinal reconstruction. In the case of anastomotic leakage of RY reconstruction, esophagojejunal anastomosis should be paid attention, and esophageal fragility is considered the reason for the leakage. Here, we introduce an atraumatic and innovative technique for esophagojejunostomy. We prospectively performed routine novel esophagojejunal anastomosis using circular stapler device and reviewed the records of 14 consecutive patients with gastric cancer who underwent open total gastrectomy at Kitasato University Hospital from April 2019 to March 2020. By placing about 10 stay sutures around the entire esophageal stump, the esophageal stump can be opened to the maximum diameter. The forceps grasping the tissue was not necessary for these procedures, consequently preventing either tears the esophageal stump tissue or narrowing the esophageal lumen. These 14 cases were far advanced cases of gastric cancer, 6 cases of splenectomy and 3 cases of distal pancreatectomy. No technical problems such as esophageal tear were observed in all cases. Postoperative complications were observed in 6 patients (42.9%), and their contents varied. However, they all improved conservatively. Regarding anastomotic complications, anastomotic leakage of Clavien-Dindo-II was observed in one case, but it improved conservatively. Our new atraumatic anastomosis technique could abolish problems such as tear of esophagus wall due to introduce a larger-sized anvil, trauma of esophageal wall by grasping with forceps such as Alice or Babcock. Consequently, the atraumatic and innovative technique might make the esophagojejunostomy safe. This method might prevent anastomotic leakage and other complications effectively.

Efficacy of a newly developed bioabsorbable pancreatic clip for distal pancreatectomy in swine.

At present, ≥ 20% of patients experience clinically relevant postoperative pancreatic fistula (POPF) after distal pancreatectomy (DP). We developed a new bioabsorbable pancreatic clip (BioPaC) made of polycaprolactone that does not crush the pancreatic parenchyma during occlusion of the pancreatic stump. We confirmed the efficacy of this BioPac in a porcine DP model and compared it to a linear stapling device (Reinforce®). Pigs were killed at 1month after DP. In the BioPaC group, all swine (n = 3) survived well without POPF. In the Reinforce® group (n = 2), one pig died early at postoperative day 7 with Grade C POPF (amylase 43 700 U/l), and the other survived until 1month at scarification with biochemical leakage of POPF (amylase 3 725 U/l). Pathologically, the main pancreatic duct and pancreatic parenchyma were well closed by BioPaC. The newly developed BioPaC is effective in a porcine DP model.

There is no correlation between a delayed gastric conduit emptying and the occurrence of an anastomotic leakage after Ivor-Lewis esophagectomy

IntroductionEsophagectomy is the gold standard in the surgical therapy of esophageal cancer. It is either performed thoracoabdominal with a intrathoracic anastomosis or in proximal cancers with a three-incision esophagectomy and cervical reconstruction. Delayed gastric conduit emptying (DGCE) is the most common functional postoperative disorder after Ivor-Lewis esophagectomy (IL). Pneumonia is significantly more often in patients with DGCE. It remains unclear if DGCE anastomotic leakage (AL) is associated. Aim of our study is to analyze, if AL is more likely to happen in patients with a DGCE.Patients and methods816 patients were included. All patients have had an IL due to esophageal/esophagogastric-junction cancer between 2013 and 2018 in our center. Intrathoracic esophagogastric end-to-side anastomosis was performed with a circular stapling device. The collective has been divided in two groups depending on the occurrence of DGCE. The diagnosis DGCE was determined by clinical and radiologic criteria in accordance with current international expert consensus.Results27.7% of all patients suffered from DGCE postoperatively. Female patients had a significantly higher chance to suffer from DGCE than male patients (34.4% vs. 26.2% vs., p = 0.040). Pneumonia was more common in patients with DGCE (13.7% vs. 8.5%, p = 0.025), furthermore hospitalization was longer in DGCE patients (median 17 days vs. 14d, p < 0.001). There was no difference in the rate of type II anastomotic leakage, (5.8% in both groups DGCE). All patients with ECCG type II AL (n = 47; 5.8%) were treated successfully by endoluminal/endoscopic therapy. The subgroup analysis showed that ASA ≥ III (7.6% vs. 4.4%, p = 0.05) and the histology squamous cell carcinoma (9.8% vs. 4.7%, p = 0.01) were independent risk factors for the occurrence of an AL.ConclusionOur study confirms that DGCE after IL is a common finding in a standardized collective of patients in a high-volume center. This functional disorder is associated with a higher rate of pneumonia and a prolonged hospital stay. Still, there is no association between DGCE and the occurrence of an AL after esophagectomy. The hypothesis, that an DGCE results in a higher pressure on the anastomosis and therefore to an AL in consequence, can be refuted. DGCE is not a pathogenetic factor for an AL.

Laparoscopic Living-Donor Nephrectomy of a Horseshoe Kidney: A Case Report and Review of the Literature

We present the case of a living-donor nephrectomy of a horseshoe kidney. The recipient was a 33-year-old male with a history of end-stage renal disease secondary to IgA nephropathy. The donor was his 33-year-old partner who on preoperative cross-sectional imaging was found to have a horseshoe kidney with a single artery, vein and ureter. The donor operation was performed using a laparoscopic hand-assisted technique with transection of the interpolar fibrotic band using a stapler device. The backtable organ preparation was performed in a standard fashion with addition of a reinforcing hemostatic suture of the stapled fibrotic band. The donated kidney was transplanted extraperitoneally in the right iliac fossa of the recipient. The patient had an unremarkable postoperative course and was discharged home on post operative day 2 with normalizing renal function. To our knowledge, this is the first living donor nephrectomy of a horseshoe kidney performed using a laparoscopic hand-assisted technique.

188 Right Hemicolectomy with End-To-Side Circular Stapled Ileo-Colic Anastomosis: Evaluation of Outcomes in A Series Of 55 Consecutive Patients

Abstract Background Stapled ileo-colic anastomosis is a well-established alternative to hand-sewn anastomosis after right hemicolectomy. A side-to-side configuration (SSA) is the option commonly practiced. This study describes our experience using a less well described technique, using an end-to-side circular stapled ileo-colic anastomosis (ESSA). Method Consecutive adult patients undergoing a right or extended- right hemicolectomy with ESSA for colonic cancer between July 2013 and March 2020 were included. Perioperative outcomes including anastomotic leak and anastomotic bleeding were extracted from a prospectively maintained institutional database. The Clavien-Dindo classification was used to stratify post-operative complications. Data are presented in medians and IQR. Results Right hemicolectomy with circular stapled ESSA ileo-colic anastomosis was performed in 55 consecutive patients (M:F 26:29) by a single surgeon at a tertiary referral centre. Over half of patients (54.5%, 30/55) were in the 8th and 9th decades of age with a median BMI of 26.5 (IQR:24-30.7). Median postoperative length of stay was 6 days (IQR:4-8) and the overall morbidity rate was 34.5% (19/55). Anastomotic leak and anastomotic bleeding were seen in 5.45% (3/55) and 3.64% (2/55), respectively. None of the patients with leak or bleeding needed a re-operation. Conclusions In comparison to the widely used SSA type of ileo-colic anastomosis, the ESSA configuration using a circular stapling device is a viable option for restoring bowel continuity after right colonic resections with comparable results. Potential advantages of this approach include avoidance of cross stapling and improved ileo-colic anatomical fidelity.