Sutureless Anastomosis Research Articles

Enhancing long-segmental tracheal restoration: A self-repairing hydrogel loaded with chondrocytokines for sutureless anastomosis and cartilage regeneration

Artificial tracheal substitutes encounter significant challenges during long-segmental tracheal defects (LSTD) reconstruction, notably early postoperative anastomotic stenosis and tracheal chondromalacia. Mitigating early anastomotic stenosis by creating a compliant sutureless substitute is pivotal. Enhancing its chondrogenic capacity is equally critical for sustained healthy tracheal cartilage regeneration. This study proposes a self-healing hydrogel for sutureless tracheal anastomosis to mitigate anastomotic stenosis, enriched with kartogenin (KGN) and transforming growth factor-β1 (TGFβ1) to bolster chondrogenic properties. Initially, two precursor solutions were prepared: 1) aldehyde-modified hyaluronic acid with sulfonation and β-cyclodextrin-CHO loaded with KGN; 2) hydrazide-grafted gelatin loaded with TGFβ1. Coextrusion of these solutions resulted in a gelated G + TGFβ1/sH-CD + KGN hydrogel, characterized by a robust covalent bonding network of acylhydrazones between hydrazide and aldehyde groups, imparting excellent self-healing properties. The G + TGFβ1/sH-CD + KGN hydrogels, showcasing favorable cytocompatibility, excellent injectability, and rapid gelation, were loaded with bone marrow stem cells. These were customized into O-shaped rings and assembled into a malleable tracheal substitute using our established ring-to-tube method. This resultant compliant substitute facilitated sutureless anastomosis of LSTD in a rabbit model, attributed to the Schiff base reaction between the hydrogel's carbonyl group and the tissue's amino group. Notably, the tracheal substitute reduced early postoperative anastomotic stenosis, maintained tracheal patency, alleviated sputum blockage, promoted reepithelization, and increased the survival rate of the experimental rabbits. The sustained release of chondrocytokines resulted in excellent tracheal cartilage regeneration. Employing chondrocytokines-loaded hydrogels with self-healing properties represents a significant advancement in sutureless tracheal anastomosis and tracheal cartilage regeneration, holding promising potential in inhibiting early postoperative anastomotic stenosis and tracheal chondromalacia when treating LSTD.

(Invited) ultrasensitive Low Cost Flexible Sensors and Bioinspired Sutureless Anastomosis Devices

I will present our efforts for investigating flexible electronic sensors for potential health monitoring applications and bioinspired sutureless anastomosis devices for easier, faster, and safer surgery.Highly sensitive flexible tactile sensors are of continuing interest for various applications including human–machine interface systems, internet of things, and wearable health monitoring devices. Current technologies for high sensitivity piezoresistive sensors tend to rely on costly materials and/or fabrication methods, limiting accessibility and scalability. Here, we report a facile sacrificial casting–etching method to synthesize nanoporous carbon nanotube/polymer composites for ultra-sensitive and low-cost piezoresistive pressure sensors. Our synthesis method overcomes the limitations of the traditional solution-dip-coating method for adhering nanoscale conductive materials to the nanoscale porous surface. Importantly, we show ultra-high sensitivity with a strain gauge factor over 300, which is ∼50 times higher than that of traditional CNT-based piezoresistive sensors. For practical tactile sensing applications, we demonstrate that the sensors can detect both gentle pressures (1 Pa–1 kPa) and low pressures (1 kPa–25 kPa) with a fraction of the cost. Our nanoporous polymer composite could contribute to expanding the scope of using nanocomposite sensors for medical applications from its easy tunability for sensing diverse range of tactile signals.Anastomosis, the surgical connection of adjacent tubular organs is a foundational surgical skill for many surgical procedures. The current standard of anastomosis is manually suturing two tubular structures together around an opening with fine sutures. However, it requires several years of surgical training, a long time (60 to 90 minutes per anastomosis) for procedure, and, at times, specialized equipment, facility and staffs. Thus, it is an expensive (up to $35,000 per procedure).Moreover, even in the hands of skilled surgeons, the anastomosis can be complicated by leakage or thrombosis. To address current challenges, we investigated a sutureless anastomosis device inspired by rose prickles. I will present our approach to design, fabricate, and test devices. Our device showed the failure force comparable to that of the handsewn suture (4.9 N) and no leakage up to 45 mL/min flow rate, well above the physiologic blood flow rate. Compared with handsewn anastomosis, the device resulted in minimum deformation of the anastomotic site. From in-vivo non-survival porcine studies, the device showed successful anastomosis (< 5 min per anastomosis) with no leaking for both arterial and venous anastomoses. We envision our findings can contribute to enabling easier, faster, and safer anastomosis, and making anastomotic techniques more accessible to a broad range of clinicians, researchers, and patients across the world.

A Novel Sutureless Anastomotic Device in a Swine Model: A Proof of Concept Study

IntroductionVascular reconstruction requires technical expertise and is often time consuming. As a novel alternative to traditional hand-sewn vascular anastomoses, the VasoLock (VL), is a nonabsorbable, sutureless anastomosis device with traction anchors designed to hold free artery ends together. These anchors do not penetrate the vessel wall but adhere by leveraging the elasticity of the vessels to fasten blood vessels together. This pilot study assesses the performance and patency of this novel device in a porcine model of femoral artery injury. MethodsFemale swine (n = 7) underwent femoral artery exposure for a total of 10 VL implanted. Study animals underwent hemodilution to a target hematocrit of 15% and ROTEM was used to assess coagulopathy, followed by an arterial injury via transection. The VL was inserted without any sutures. Flow-probe monitors were positioned proximal and distal to the device and flow rates were measured continuously for a total of 90 min. Flow was analyzed and presented as a ratio of distal to proximal flow with the slope of this ratio across time subsequently determined. Angiographic assessment was completed to evaluate for patency and technical complications after 90 min of implant. ResultsThe average animal weight was 44.1 ± 3.2 kg. The average mean arterial pressure at the time of implant was 51.2 ± 7.8 mmHg, median heart rate was 77.4 (IQR = 77.25-157.4) beats per minute, and average temperature was 36.1 ± 1.5°C. The baseline hematocrit was 13.5 ± 3.0%, average pH was 7.20 ± 0.1, average clotting time was 154.1 ± 58.7 s and average clot formation time was 103.4 ± 10.9 s all demonstrating the acidotic, hypothermic, and coagulopathic state of the swine at the time of insertion. During the 90-min observation period, the average flow gradient identified across the VL was 0.99 ± 0.24, indicating no significant change in flow across the VL. The average slope of the gradients was 0.0005 (P = 0.22), suggesting the ratio of proximal and distal flow did not change over the 90 min. Following 90 min of dwell time, all VL were patent without technical complication. Angiographic assessment at 90 min demonstrated no evidence of dissection, device migration, arterial extravasation, or thromboembolism with any of the 10 devices. ConclusionsThis pilot study demonstrated technical feasibility of the novel VL device over a 90-min observation period. All VL were patent and no negative events or complications were identified. This technology demonstrated significant promise in a coagulopathic state: additional investigation, involving long-term survival, is warranted for further validation.

The feasibility of debranching aortic arch and visceral arteries with sutureless telescoping anastomoses during open aortic aneurysm repair.

Open repair of aortic aneurysms frequently requires reimplantation of major aortic vessels. Traditional techniques can be time consuming, require meticulous hemostasis, and risk aneurysmal patch degeneration, which can require a challenging reoperation. We describe our experience using a stent graft to create a sutureless anastomosis that obviates these drawbacks. Between April 2018 and March 2021, all consecutive adult patients who underwent open repair of the aorta with at least one supra-aortic trunk or visceral vessel reimplanted using the sutureless anastomotic technique were included. Anastomoses were constructed by bridging a branch graft and the target artery with a Viabahn self-expanding stent (W.L. Gore & Associates, Flagstaff, AZ). Clinical information and perioperative outcomes for the patients were collected and analyzed. Among 26 patients, 50 individual aortic vessels were debranched using sutureless self-expanding stent anastomoses, including 42 visceral vessels and 8 supra-aortic trunk vessels. Technical success was 100%. The median time to complete the anastomosis was 3minutes, 12seconds (range, 2-6minutes). Perioperative mortality was 15% (n= 4). No stent-related complications, such as occlusion, bleeding, stroke, renal failure requiring hemodialysis, bowel ischemia, or the need for anastomotic reintervention, occurred. Follow-up imaging at 1 year revealed a 100% patency rate and no anastomotic stenosis, misalignment, or kinking. The sutureless anastomosis technique to debranch the aorta during open aortic aneurysm repair is technically feasible and reliably hemostatic and does not require early reintervention. The operative outcomes have been acceptable, and the short-term follow-up imaging findings demonstrated excellent patency without anastomotic kinking. In select cases, sutureless anastomoses are a possible alternative to traditional sutured anastomoses during aortic debranching. Further research is needed to compare the operative times and long-term patency of sutureless anastomosis to those of traditional sutured techniques.

Viabahn-assisted sutureless anastomosis (VASA) repair of a complex internal carotid artery aneurysm.

Extracranial carotid artery aneurysms (CAAs) are extremely rare and often require surgical intervention to avoid complications such as local compression symptoms and thrombo-embolization. We present the case of a 63-year-old man with a history of hypertension, meningioma, and an incidental finding of a right saccular internal carotid artery aneurysm at the base of the skull. He underwent open surgical repair; nonetheless, end-to-end anastomosis was not feasible. As bailout, the internal carotid artery was successfully reconstructed with a novel Viabahn-assisted sutureless anastomosis technique (GORE, Viabahn). Postoperative clinical assessment revealed no complications, postoperative computed tomography angiography revealed a patent reconstruction, and the patient was discharged home uneventfully with 1-year clinical and computed tomography angiography follow-up without remarks. Hybrid procedure is a viable option for technically challenging carotid anastomoses near the skull base.

Evaluation of fibrin, cyanoacrylate, and polyurethane-based tissue adhesives in sutureless vascular anastomosis: a comparative mechanical ex vivo study

The stability of a microvascular anastomosis is an important prerequisite for successful tissue transfer. Advances in tissue adhesives are potentially opening new avenues for their use in sutureless microsurgical anastomosis, however they have not yet gained clinical acceptance. In this ex vivo study, a novel polyurethane-based adhesive (PA) was used in sutureless anastomoses and its stability compared with that of sutureless anastomoses performed with fibrin glue (FG) and a cyanoacrylate (CA). Stability was assessed using hydrostatic (15 per group) and mechanical tests (13 per group). A total of 84 chicken femoral arteries were used in this study. The time taken to create the PA and CA anastomoses was significantly faster when compared to the FG anastomoses (P < 0.001): 1.55 ± 0.14 min and 1.39 ± 0.06 min, respectively, compared to 2.03 ± 0.35 min. Both sustained significantly higher pressures (289.3 mmHg and 292.7 mmHg, respectively) than anastomoses using FG (137.3 mmHg) (P < 0.001). CA anastomoses (0.99 N; P < 0.001) and PA anastomoses (0.38 N; P = 0.009) could both withstand significantly higher longitudinal tensile forces compared to FG anastomoses (0.10 N). Considering the background of an in vitro study, the PA and CA anastomosis techniques were shown to be similar to each other and superior to FG, due to their stability and faster handling. These findings need to be validated and confirmed in further in vivo studies.

Evaluating the Arteriotomy Size of a New Sutureless Coronary Anastomosis Using a Finite Volume Approach.

The ELANA® Heart Bypass creates a standardized sutureless anastomosis. Hereby, we investigate the influence of arteriotomy and graft size on coronary hemodynamics. A computational fluid dynamics (CFD) model was developed. Arteriotomy size (standard 1.43mm2; varied 0.94-3.6mm2) and graft diameter (standard 2.5mm; varied 1.5-5.0mm) were independent parameters. Outcome parameters were coronary pressure and flow, and fractional flow reserve (FFR). The current size ELANA (arteriotomy 1.43 mm2) presented an estimated FFR 0.65 (39mL/min). Enlarging arteriotomy increased FFR, coronary pressure, and flow. All reached a maximum once the arteriotomy (2.80 mm2) surpassed the coronary cross-sectional area (2.69 mm2, i.e. 1.85mm diameter), presenting an estimated FFR 0.75 (46mL/min). Increasing graft diameter was positively related to FFR, coronary pressure, and flow. The ratio between the required minimal coronary diameter for application and the ELANAarteriotomy size effectuates a pressure drop that could be clinically relevant. Additional research and eventual lengthening of the anastomosis is advised.

Total Anomalous Pulmonary Venous Connection Repair: Single-Center Outcomes in a Lower-Middle Income Region.

The management of total anomalous pulmonary venous connection (TAPVC) in neonates and infants is resource-intensive. We describe early and follow-up outcomes after surgical repair of isolated TAPVC at a single institution in a resource-limited setting. The data of 316 consecutive patients with isolated TAPVC undergoing repair (January 2010-September 2020) were reviewed. The study setting was a tertiary hospital in southern India that provides subsidized or charitable care. Standard surgical technique was used for repair, circulatory arrest was avoided, and suture-less anastomosis was reserved for small or stenotic pulmonary veins. Surgical and postoperative strategies were directed toward minimizing intensive care unit (ICU) stay. 302 (95.6%) patients were infants and 128 patients (40.5%) were neonates; median weight was 3.3 kg (IQR 2.8-4.0 kg). Obstruction of the TAPVC was seen in 176 patients (56%) and pulmonary hypertension in 278 patients (88%). Seventeen (5.4%) underwent delayed sternal closure. The median postoperative ICU stay was 120 h (IQR 96-192 h), mechanical ventilation was 45 h (IQR 24-82 h), and hospital stay was 13 days (IQR 9-17 days). There were three in-hospital deaths (0.9%). Over a median follow-up period of 53.3 months (IQR 22.9-90.4), pulmonary vein restenosis was seen in 32 patients (10.1%) after a mean of 2.2 months (1-6 months). No perioperative risk factors for restenosis were identified. Using specific perioperative strategies, it is possible to correct TAPVC with excellent surgical outcomes in low-resource environments. Late pulmonary vein restenosis remains an important complication.

Comparison of sutureless anastomosis with hybrid vascular graft to standard graft for the hypogastric preservation during open aortic surgery

article: Comparison of sutureless anastomosis with hybrid vascular graft to standard graft for the hypogastric preservation during open aortic surgery - Italian Journal of Vascular and Endovascular Surgery 2022 June;29(2):45-51 - Minerva Medica - Journals

Sutureless neurorrhaphy system using a macrophage-polarizing in situ visible light-crosslinkable adhesive protein hydrogel for functional nerve regeneration

Surgical intervention after traumatic peripheral nerve injury relies heavily on sutures. While the suture method often burdens functional nerve regeneration by causing secondary traumatic damage and eliciting prolonged inflammatory immune responses, replacing sutures has rarely been considered because secure anastomosis between severed nerve ends has been the utmost priority in neurorrhaphy. In the present work, a macrophage-polarizing sutureless neurorrhaphy system was proposed by using an in situ visible light-crosslinkable protein-based bioadhesive hydrogel containing a functional neurotransmitter peptide. The efficacy of the proposed bioadhesive hydrogel as a successful sutureless neurorrhaphy system was intensively evaluated in vitro and in vivo. Using a rat sciatic nerve defect model, our findings suggested that this macrophage-polarizing bioadhesive hydrogel offered effective sutureless anastomosis and the capability to induce M2 macrophage polarization for effective tissue remodeling, significantly enhancing functional nerve regeneration compared with conventional sutures. Taken together, these results suggest that our macrophage-polarizing functional bioadhesive hydrogel system can be utilized as a promising alternative to surgical sutures for nerve regenerative medicine applications.

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.

Sutureless versus Hand-Sewn Coronary Anastomoses: A Systematic Review and Meta-Analysis.

Background: Sutureless coronary anastomotic devices are intended to facilitate minimally invasive coronary artery bypass grafting (MICS-CABG) by easing and eventually standardizing the anastomotic technique. Within this systematic review and meta-analysis, we aim to determine patency and to evaluate safety outcomes for the sutureless anastomoses. Methods: CENTRAL, MEDLINE, and EMBASE were searched from database start till August 2021 in a predefined search strategy combining the key concepts: ‘coronary artery bypass grafting’, ‘sutureless coronary anastomoses’, and ‘hand-sewn coronary anastomoses’ by the Boolean operation ‘AND’. Study characteristics, patient demographics, interventional details, and all available outcome data were extracted. A meta-analysis was performed on patency at longest follow-up. Safety outcomes were presented. Results: A total of eleven trials towards six sutureless anastomotic devices were included, comprising 3724 patients (490 sutureless and 3234 hand-sewn). There was no significant difference in patency at a mean follow-up duration of 546.3 (range 1.5–2691) days, with a risk ratio of 0.77 (95% CI 0.55–1.06). MACE was reported in 4.5% sutureless and 3.9% hand-sewn patients, including all-cause mortality (resp. 1.3 vs. 1.9%), myocardial infarction (resp. 1.6 vs. 1.7%), and coronary revascularization (resp. 1.8 vs. 0.5%). Incomplete hemostasis occurred in 24.8% of the sutureless anastomoses. Intra-operative device failure forced conversion to hand-sewn or redo-anastomosis in 5.8% of the sutureless cases. Conclusion: Based on the systematic review and meta-analysis including six devices, we conclude that sutureless coronary anastomotic devices appear safe and effective when used by well-trained and dedicated surgical teams.

A Novel Method of End-to-Side Microvascular Anastomosis Using T-Shaped Metal Stents: A Porcine Study.

End-to-side anastomosis requires highly specialized techniques. An easy end-to-side anastomosis technique enables anastomosis of vessels with different diameters and under various situations. We invented T-shaped metal stents and evaluated novel methods of end-to-side sutureless anastomosis, confirming their safety, effectiveness, and operability. We performed 8 end-to-side sutureless anastomoses in 4 7- to 11-month-old, male Mexican hairless piglets. After induction of anesthesia, the left femoral artery was resected by approximately 8 cm, and the superior and posterior stumps of the resected femoral artery underwent an end-to-side anastomosis with the right femoral artery by the placement of the metal stents with subsequent use of adhesive for the circumferential area. The patency of blood vessels and the presence of thrombosis were evaluated by ultrasonography or contrast-enhanced computed tomography and histology 4 weeks postoperatively. All the animals survived the procedure; no thrombosis was identified in any of the 8 anastomosis sites according to imaging studies performed 4 weeks postoperatively. Histological examination confirmed the probe patency of blood vessels and neointimal cell proliferation around stent branches. End-to-side anastomosis is possible with T-shaped metal stents. In the future, we aim for the practical application of these stents by improving their operability.

Mechanical strength and hydrostatic testing of VIVO adhesive in sutureless microsurgical anastomoses: an ex vivo study

Conventional anastomoses with interrupted sutures are challenging and inevitably associated with trauma to the vessel walls. The goal of this study was to evaluate a novel alternative adhesive-based suture-free anastomosis technique that uses an intraluminal stent. Overall, 120 porcine coronary vessels were analyzed in an ex vivo model and were examined for their mechanical (n = 20 per cohort) and hydrostatic strength (n = 20 per cohort). Anastomoses were made using the novel VIVO adhesive with an additional intraluminal nitinol stent and was compared to interrupted suture anastomosis and to native vessels. Sutureless anastomoses withstood pressures 299 ± 4.47 [mmHg] comparable to native vessels. They were performed significantly faster 553.8 ± 82.44 [sec] (p ≤ 0.001) and withstood significantly higher pressures (p ≤ 0.001) than sutured anastomoses. We demonstrate that the adhesive-based anastomosis can also resist unphysiologically high longitudinal tensile forces with a mean of 1.33 [N]. Within the limitations of an in vitro study adhesive-based suture-free anastomosis technique has the biomechanical potential to offer a seamless alternative to sutured anastomosis because of its stability, and faster handling. In vivo animal studies are needed to validate outcomes and confirm safety.

Usefulness of internal organ retractors in making sutureless delta-shaped intracorporeal anastomosis during laparoscopic colectomy.

Usefulness of internal organ retractors in making sutureless delta-shaped intracorporeal anastomosis during laparoscopic colectomy.

CYANOCRYLATE ADHESIVES IN FORMATION OF COLORECTAL ANASTOMOSIS

Data of foreign literature concerning sutureless formation of the colorectal anastomosiswith the help of cyonocrylate adhesives are presented in the article. These are quick acting glues, available on the Ukrainian market, and may be used by Ukrainiansurgeons in implementation of their ideas as to the sutureless connection of organs in theexperimental and clinical investigations.12 different types of cyanocrylate adhesives as to their resistance to the rupture of theconnected by them large intestine segments, were studied. Questions of the technicalformation of the sutureless anastomoses were considered. When substantially newtechnical devices for gluing together the organs are absent, progress is hardly possible.Objective – to acquaint the domestic surgeons and oncologists with modern achievementsof foreign scientists in the field of sutureless colorectal anastomosis formation by meansof cyanocrylate adhesives.Conclusions. For some time past foreign surgeons the problems of colorectal anastomosesintensively develop the problems of colorectal. This is due to the fact that indices ofcolorectal anastomosis insufficiency remain on high levels. Unfortunately, the hopesthat the introduction of modern advanced stapler anastomotic techniques can radicallyreduce the frequency of this complication were not justified.

Long-term feasibility of the new sutureless excimer laser-assisted non-occlusive anastomosis clip in a pig model

BackgroundHigh flow bypass surgery can be a last resort procedure for patients suffering from complex neurovascular pathology. Temporary occlusion of a recipient artery in these patients could result in debilitating neurological deficits. We developed a sutureless, mechanical anastomotic connection device, the SELANA clip (Sutureless Excimer Laser-Assisted Non-occlusive Anastomosis clip: SEcl). In the present study, we aim to determine the long-term non-inferiority of the SEcl technique compared with historical data of the conventional ELANA anastomosis technique.MethodsA total of 18 SEcl bypasses were created on the carotid artery in a porcine model in 6 different survival groups. Mean application times, flap retrieval rates, hemostasis, patency, flow, endothelialization, and remodeling were assessed.ResultsThe mean application time of the SEcl anastomoses was 15.2 ± 9.6 min, which was faster compared with the conventional ELANA anastomoses. The flap retrieval rate of the SEcl anastomoses was 86% (32/37). Direct hemostasis was achieved in 89% (33/37) SEcl anastomoses. Patency in all surviving animals was 94% (17/18). Bypass flow after six months was 156.5 ± 24.7 mL/min. Full endothelialization of the SEcl pins was observed after 3 weeks.ConclusionThe SEcl technique is not inferior to the ELANA technique regarding patency, flap retrieval rate, flow, and endothelialization. On the basis of a significantly shorter application time and superior hemostasis, the SEcl technique could be preferable over the ELANA technique. A pilot study in patients is a logical next step based on our current results.

Percutaneously created sutureless anastomosis.

An 80-year-old male diabetic patient with end-stage renal disease was evaluated for decreasing access flow and difficult cannulation of his established percutaneous arteriovenous fistula (pAVF), created 6 months ago with the Ellipsys vascular access system (Avenu Medical, San Juan Capistrano, Calif).1Mallios A. Jennings W.C. Boura B. Costanzo A. Bourquelot P. Combes M. Early results of percutaneous arteriovenous fistula creation with the Ellipsys Vascular Access System.J Vasc Surg. 2018; 68: 1150-1156Abstract Full Text Full Text PDF PubMed Scopus (54) Google Scholar, 2Mallios A. Fonkoua H. Allouache M. Boura B. Percutaneous arteriovenous dialysis fistula.J Vasc Surg. 2020; 71: 1395Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar, 3Mallios A. Bourquelot P. Franco G. Fonkoua H. Allouache M. Boura B. et al.Mid-term results of percutaneous arteriovenous fistula creation with the Ellipsys vascular access system, technical recommendations and an algorithm for maintenance.J Vasc Surg. 2020 Apr 7; ([Online ahead of print])Abstract Full Text Full Text PDF Scopus (26) Google Scholar The patient's ipsilateral hand was cool without distal pulses. Percutaneous transluminal angioplasty of the pAVF anastomosis had only modestly improved access flow because of significant diffuse arterial calcifications. Bilateral distal arterial occlusions were present and the pAVF remained dysfunctional. Further and more aggressive attempts with percutaneous transluminal angioplasty were thought likely to result in severe hand ischemia (steal syndrome); therefore, arterial inflow proximalization was established using a 4- to 7-mm graft (W. L. Gore & Associates, Flagstaff, Ariz) with a lateral axillary artery anastomosis and an end-to-end outflow anastomosis to the mature cephalic vein, ligating the distal pAVF inflow site. An excellent thrill was recovered immediately over the entire length of the cephalic vein in the arm. Distal circulation improved substantially. A/Cover, B, and Video 1 show a perioperative view of the percutaneously created Ellipsys anastomosis between the proximal radial artery and perforating vein of the elbow. To our knowledge, this is the first direct visualization of an Ellipsys pAVF anastomosis in a human. The anatomic configuration and natural course of the pAVF are apparent along with the absence of suture or fibrosis, yielding a shape similar to surgical proximal radial artery AVFs described by Jennings et al.4Jennings W. Mallios A. Mushtaq Proximal radial artery arteriovenous fistula for hemodialysis vascular access.J Vasc Surg. 2018; 67: 244-253Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar C (medial view), D (anterior view), and Video 2 show the ligated pAVF anastomosis. Need for ligation of a pAVF has been a concern of some critics because of the multiple venous branches. This report demonstrates that in the rare case in which ligation is necessary, an Ellipsys pAVF may be easily ligated without consequence or technical challenges. The patient's informed consent was obtained before submission of this manuscript. eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiJkM2YxZjljYzQzMTczOTJhZDVmYzdiMjVmYjJmMDc3YSIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjU5NjgwMTEyfQ.P2iwekbqoGENyxeFwVBltgYalZQe974yt_1Pylg0oqw2wFHO3H5CWSPevIxJUo12W3mIV07CWaNMIpXXz890jVkEezWvpGPFAxKusFybJG_J-dUhtw2jZOOPABJPZG57mLmCApG-jTPEMAHW9pySwjjAkCUSrKAtXkkDyhYRg9KC4hAUWNilnBi-_azL08GN--bXaVldB4WfATLWRNN0AD8X_3mTXzlx_QakMBjMTbIc_JlN1rqNjO2zj3X2xxIyscs4nu7HNDe4Yl8ALcJg4rbz3dXNZm9xYBzLti2FU-yetHtrydtcxMLAVp3Fyk5IF4QMtPBmJ6GImX4mAYjwgg Download .mp4 (0.98 MB) Help with .mp4 files Video 1Perioperative view of the percutaneously created Ellipsys anastomosis between the proximal radial artery and perforating vein of the elbow.eyJraWQiOiI4ZjUxYWNhY2IzYjhiNjNlNzFlYmIzYWFmYTU5NmZmYyIsImFsZyI6IlJTMjU2In0.eyJzdWIiOiI4Yjk0MWI1ZWQwOTI1YzFjNmE0ZTAyMTJkN2YyODFjNiIsImtpZCI6IjhmNTFhY2FjYjNiOGI2M2U3MWViYjNhYWZhNTk2ZmZjIiwiZXhwIjoxNjU5NjgwMTEyfQ.HCPbtwp0lEn6tVnP5ipUjgo9Onu8BqDai6EaTcoSnwhdy1nK0swZeXM-bhdYhkOHKJoygNoK2-KvvS0ogyTxmhdk4F4pH_uKLQ0aBVKS1U7mXOouNT7J4OYjQRKkWFFxHaJWdePogqOgipV0cU_g0q4Mvzdqrwz-NM5QJTjg-rCAciba72xGohrwgvkUD24fZ21KOdzuGHnQD3HJlUmu5pbDBMCl6oLq5Uq970eaiRxZt66Y9ky_xXvbywthSc5h81x5QAqsGyLpDWA7oyrVn61ol7zdANzYpKlKsL9YKEgXAoBS8SNAMubTKpBlYIGCQrUtMDl602MclcggLFcrRA Download .mp4 (0.63 MB) Help with .mp4 files Video 2Ligated percutaneous arteriovenous fistula anastomosis.

Application of magnetic compression anastomosis technique in pediatric surgery

Malformation of digestive tract is common in neonates. Esophageal atresia (EA) comprises a group of congenital abnormalities defined by discontinuity of the esophagus. EA with communication with the trachea is known as tracheoesophageal fistula (TEF). For the repair of EA, it is needed to establish an anastomosis between two structures that may be significantly spaced apart, such as in long-gap EA (with a gap >3 cm). The repair across a long-gap can induce tension on the anastomosis, leading to dehiscence, anastomotic leak, or procedure failure. In neonatal patients with long-gap EA with TEF, the complications of significant gastroesophageal reflux, or anastomotic leaks and severe refractory esophageal stricture after surgery are common, which remains challenging for pediatric surgery. There are multiple options for lengthening and approximating the ends in long-gap EA such as myotomies, Gough flap, or the Foker technique. The treatment of long gap EA usually requires thoracotomy or thoracoscopy to place traction sutures on each esophageal in multiple stage operations, the treatment period of which is long. Esophageal stricture is the most common complication following EA repair. Refractory esophageal anastomotic stricture after repair of EA in infants is a challenging surgical problem. In general, these strictures can be successfully managed using endoscopic techniques including bougie and balloon dilation, stenting, and chemotherapeutic agents. If these techniques are unsuccessful, treatment options are limited to surgical resection of the strictured segment and reanastomosis, or esophageal replacement. Magnetic compression anastomosis (MCA) has been introduced for several decades. Recently, rare-earth magnets have been employed to create solid anastomosis for long-gap EA and refractory esophageal stricture in children. In MCA, a sutureless anastomosis of the gastrointestinal tract can be formed using two magnetic Harrison rings. Magnetic compress has been shown to be effective for the treatment of long-gap EA in children. MCA can be conducted during the same stage surgery of ligating the TEF with customized magnetic rings. Under the magnetic force, the two magnetic rings pull along the gastric tube to achieve anastomosis. Once the postoperative permanent suction of these two pouches is instituted, spontaneous growth can be awaited. MCA has been shown to be effective in anastomosis of stomach, small bowel and colon in both experimental and clinical cases. The magnets are most commonly made of neodymium-boron or samarium-cobalt, which can display strengths significantly greater than those of ferrite. Magnetic compression has been used to treat biliary strictures in adult patients who have undergone liver transplantation, as magnetic connectors for coronary surgery, and for the functional undiversion of ileostomy in pediatric patients. Reports also describe the use of magnetic compression in restoring patency of anastomotic strictures of the alimentary tract in patients who have undergone surgery for esophageal, gastric, and rectal cancer. Yamanouchi and colleagues have published many papers on their experience with Samarium cobalt magnets. They even used them to treat recurrent anastomotic strictures after initial MCA. It has been reported that in conditions such as congenital oesophageal atresia or rectal atresia in children, and also is a safe, minimally invasive way to gradually refunctionalize the excluded distal bowel after previous diverting ostomy. MCA using mated magnets with their interposed compressed tissue may result in serosa-to-serosa apposition. At present, MCA for the treatment of EA patients is restricted to gross type A (without TEF) and anastomotic stenosis without thoracotomy. Magnamosis offers a minimally invasive technique for repair of this congenital anomaly. This is particularly helpful in those patients who cannot undergo initial or repeat thoracotomy or thoracoscopy due to anatomic considerations or overall severity of illness. Translumenal digestive tract anastomosis using the constant magnetic field is reliable and feasible as a minimally invasive technique to treat congenital esophageal and anorectal abnormalities. Magnamosis is technically feasible for esophago-esophageal anastomoses. In anorectal malformations with favorable anatomy, this procedure may avoid an operative repair such as posterior sagittal reconstruction. We propose that magnamosis can be considered as an alternative for the treatment of rectal atresia in certain children.

Hybrid fluorescent magnetic gastrojejunostomy: an experimental feasibility study in the porcine model and human cadaver.

Laparoscopic gastrojejunostomies are time consuming and require a specific training. Alternatively, sutureless anastomosis can be achieved using endoscopically delivered magnetic rings. Our aim was to assess the feasibility and reproducibility of an endo-laparoscopic gastrojejunostomy technique, using a pair of magnets coated with a near-infrared fluorescent biocompatible polymeric material. Five pigs (3 acute and 2 survival models) and one human anatomical specimen were included. In the survival models, the distal ring was inserted into the duodenum endoscopically, and it was fixed to a thread clipped to the gastric mucosa. Twenty-four hours later, a two-port laparoscopy was performed using a near-infrared (NIR) laparoscope. The magnet position in the jejunum was detected with the transluminal fluorescence of the dye. Magnetic interaction with the metallic tip of the laparoscopic grasper allowed to capture the ring and bring the bowel loop to the future anastomotic site on the gastric wall. The proximal magnet was inserted into the stomach endoscopically and released when magnetic interaction started, allowing for a precise connection with the distal ring. The animals were followed up for 12days and underwent control endoscopies and radiograms. In the acute animals, the anastomotic procedure was repeated 24 times. Finally, the procedure was performed in the human anatomical specimen. There were no technical problems, and magnetic connection could be precisely directed at both the anterior and posterior gastric walls. No complications occurred during the survival period and the anastomoses were patent on day 5. Transluminal fluorescence enabled a rapid detection of the magnet. Hybrid-reduced port magnetic gastrojejunostomy using a pair of fluorescently coated magnetic rings was feasible, reproducible, and easy to perform in both porcine and cadaver models.