Anastomosis Technique Research Articles

A Safe and Innovative Method to Apply Venous Coupler in Oncologic Head and Neck Reconstruction.

Venous anastomosis with a coupler device is an effective alternative to the hand-sewn anastomosis technique. Twist in the veins following a coupler anastomosis is a troublesome complication that needs a revision of venous anastomosis. The author proposes a simple technique to reduce the incidence of this complication. This technique is particularly useful in head and neck reconstruction and for beginners in the initial part of the learning curve.

Application of overlap anastomosis in digestive tract reconstruction during minimally invasive Ivor-Lewis esophagectomy.

This study aims to assess the feasibility of the Overlap anastomosis technique in minimally invasive Ivor-Lewis esophagectomy. An accompanying video presentation elucidates our surgical procedures. A retrospective review of 46 patients diagnosed with middle and lower esophageal cancer was conducted. These patients underwent minimally invasive Ivor-Lewis esophagectomy with Overlap anastomosis between January 2019 and December 2020. A consistent team of surgeons performed all procedures. The initial phase involved laparoscopic stomach mobilization, intra-abdominal lymphadenectomies, and preparation of the tubular stomach. Subsequently, with the patient in the left decubitus position, thoracoscopy was used to dissect the esophagus, excise the diseased segment, and conduct mediastinal lymph node dissection. The final stage encompassed the intrathoracic gastroesophageal anastomosis using the Overlap method. All surgeries were completed without converting to an open approach, achieving complete resection. There were no operative fatalities, with an average surgery duration of 259.4min. Average statistics included intraoperative blood loss of 92.3ml, 16.2 lymph nodes dissected, and a postoperative hospital stay of 10.3days. Postoperative complications comprised three instances of hoarseness due to recurrent laryngeal nerve palsy, two cases of aspiration pneumonia, one occurrence of chylothorax, and one gastric emptying disorder. Anastomotic technique-related complications were minimal, with only one patient experiencing an anastomotic leak that resolved spontaneously and two patients facing anastomotic stenosis, which was subsequently alleviated. Our findings posit that the Overlap anastomosis method is safe and efficient for minimally invasive Ivor-Lewis esophagectomy, marked by a notably low rate of anastomosis-related complications. Further evaluation of its long-term implications remains necessary.

A modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement.

One of the crucial aspects of ascending aorta replacement is to achieve hemostasis of the proximal anastomosis. This study aimed to describe a modified prosthesis eversion technique for proximal anastomosis in ascending aorta replacement and compare its operative outcomes with the conventional prosthesis eversion technique. We conducted a retrospective analysis of all consecutive patients who had ascending aortic aneurysm and underwent ascending aorta replacement with the modified or conventional prosthesis eversion technique between January 2019 and December 2022 in our center. A total of 108 patients were included: 55 in the modified group and 53 in the conventional group. The durations of cardiopulmonary bypass, aortic cross-clamping and total operation in the conventional group were longer than those in the modified group. Furthermore, perioperative blood loss and the incidence of re-exploration for bleeding were significantly lower in the modified group. Accordingly, patients in the conventional group accepted more blood transfusion. The modified group had a shorter duration in intensive care unit (ICU) and hospital, and lower total hospitalization costs than those in the conventional group. The modified prosthesis eversion technique is an effective alternative for proximal anastomosis in ascending aorta replacement, with less blood loss, shorter operation time, and lower rate of postoperative complications compared with the conventional technique.

358. CIRCULAR STAPLER METHOD FOR AVOIDING STRICTURE OF CERVICAL ESOPHAGOGASTRIC ANASTOMOSIS, ‘NON-TENSIONING METHOD’

Abstract Background The weakness for the circular stapler technique of esophagogastric anastomosis for esophageal cancer is anastomotic stricture. This study was performed to verify the superiority of a new ‘non-tensioning method’ for avoiding stricture of the cervical esophagogastric anastomosis by circular stapling compared with the conventional method. Methods In 461 patients who underwent McKeown esophagectomy with gastric conduit (GC) reconstruction were reviewed. A GC was pulled up at the cervical site through the retrosternal route. The esophagogastrostomy site of the GC was planned as far caudally as possible on the greater curvature side. In the conventional method, the stapler was fired while pulling the GC to avoid tissue slack. In the new method, the stapler was fired through the natural thickness of the stomach wall. The blind end length was changed from 4 to 2 cm. Anastomotic stricture was compared between the two techniques, and adjustment was performed using propensity score matching. Results The conventional group comprised 315 patients, and the non-tensioning group comprised 146 patients. Anastomotic leakage occurred in 22 (7%) and 6 (4%) patients, respectively (P = 0.211) [and in 9 (3%) and 3 (2%) patients, respectively, if leakage at the blind end was excluded]. Anastomotic stricture occurred in 92 (29%) and 7 (5%) patients, respectively (P < 0.001). The propensity score-matching analysis including 134 pairs of patients confirmed a lower stricture rate in the non-tensioning than conventional group (4% vs. 27%, P < 0.001). Conclusions The non-tensioning technique, the natural thickness of the stomach wall was fired with the stapler, significantly reduced the incidence of anastomotic stricture compared with the conventional technique.

450. LINEAR STAPLED TECHNIQUE FOR ROBOTIC ASSISTED MINIMALLY INVASIVE ESOPHAGECTOMY AND GASTRECTOMY: TECHNIQUE, STEPWISE INTRODUCTION, REPRODUCIBILITY AND OUTCOMES

Abstract Background Robotic-assisted surgery (RAS) for esophagectomy and gastrectomy is gaining in popularity. Compared to open oesophagectomy and conventional minimally invasive techniques, RAS is associated with decreased rates of complications, increased harvested lymph nodes and shorter length-of-stay. However, high anastomotic leak rates (20–27%) have been seen within randomised trials and case series, with up to 50% early in some published series. We present our technique and results of the staged introduction of a linear anastomosis. Methods The technique was initially developed by a single surgeon at open surgery; then adapted to thoracoscopic surgery and finally reproduced at RAS by several surgeons across two centres. Using a prospectively maintained database we reviewed the first forty-two cases utilising a modified linear anastomosis technique for oesophageal anastomosis. Outcomes, with particular focus on the anastomosis were reviewed. We also describe in detail the technical steps involved in our technique for a side-to-side linear semi-mechanical stapled anastomosis using a tri-stapler, with a 2-layer V-lock closure of the common enterotomy, during robotic surgery (video https://www.dropbox.com/s/ljf3zmuy68qry7b/Anastomosis%20technique_Short_Sound.mp4?dl=0). Results Forty patients had a two-stage esophagectomy, one with colonic reconstruction, and two, total gastrectomy. Median age was 62 (range 47–85). 93% (39/42) were adenocarcinomas, the remainder were squamous cell carcinomas. The anastomosis was performed via an open approach in the initial 11, thoracoscopically in 4, then robotically in 27 (including the two gastrectomies). The first 20 anastomoses were performed by one surgeon, who then taught four others. Two grade I anastomotic leaks occurred (4.7%), both were treated conservatively. There was no 30-, 90-day, or in hospital mortality. Non-anastomotic complications occurred in 14/42 (33.3%) of patients, most commonly respiratory (5/42, 11.9%). Conclusion We report a reproducible technique for semi-mechanical linear stapled anastomosis and its safe introduction into esophageal and gastric resections, including RAS. Anastomotic leak rates are below the internationally reported rates, even in the early phase of its introduction in open, thoracoscopic and RAS. With good training and mentorship this may help more centres safely introduce a RAS esophago-gastric programme, improve patient outcomes and reduce length of stay.

181. SAFETY AND TIME USAGE OF CIRCULAR STAPLED ANASTOMOSIS IN THE SHIFT FROM MIE TO RAMIE

Abstract Background Introducing new surgical techniques may increase the potential for adverse events. There is no consensus or evidence on the optimal anastomotic technique in esophageal resection. We used the circular stapled anastomosis (CSA) technique as standard in MIE, and continued this practice during the introduction of RAMIE. Here, we evaluate the early results of reconstruction during Iwor-Lewis esophagectomy using CSA after converting from MIE to RAMIE, with redspect to safety and time usage. Methods The first 27 RAMIEs were included, as well as an equal number of video recorded MIEs immediately preceeding the shift to RAMIE. Patient background and short-term outcomes were recorded prospectively. The duration of the reconstruction, i.e. the time from esophageal transection to transection of the blind limb of the gastric conduit was recorded from operative videos. Both MIE and RAMIE were performed in the prone position using single lumen tube intubation. The robot was not undocked during the reconstruction. Data was registered in a patient registry approved by the Institutional Data Protection Officer with written consent by all patients. Results 27 RAMIEs and 29 MIEs were included. Patient demographics, comorbidity and tumor disease stages were similar between the two groups. There were video recordings of 26 cases in each group. There were no conversions to thoracotomy in either group. All reconstructions were completed using CSA. The median duration of the reconstruction was 40 (range: 26–85) minutes in the MIE group and 46 (35–76) minutes in the RAMIE group (p = 0.02). There were three anastomotic leaks in each group (RAMIE 11% and MIE 10%). One patient died within 90 days of surgery in the MIE group. Conclusion In this study, the use of CSA during RAMIE for the reconstruction in Iwor-Lewis esophagectomy was feasible with comparable anastomotic leak rate as after MIE. The average duration of reconstruction was 6 minutes longer in the RAMIE group.

312. H ANASTOMOSIS IN MECKOWN ESOPHAGECTOMY FOR THE REDUCED ANASTOMOTIC LEAKAGE, OBSTRUCTION, AND GASTROESOPHAGEAL REFLUX

Abstract Background Anastomotic Leakage, obstruction, and gastroesophageal reflux are the major conditions to be taken into account during restoration of alimentary transit in Meckown esophagectomy. There are numerous types of anastomosis techniques to achieve different emphases while the optimal one has not been established. The outcomes of the novel H anastomosis and the conventional end to end layered anastomosis were explored in a prospective cohort study. Methods Patients with resectable esophageal cancer underwent Meckown esophagectomy applying end to end layered anastomosis (Conventional group) or H anastomosis (H group) were included. Besides demographic information, the incidence of anastomotic leakage and other major complications were also recorded. The incidence and severity of postoperative digestive symptoms were assessed by a standard questionnaire including Mellow-Pinkas score for dysphagia and reflux frequency at 6 months after surgery. 24 h-PH and impedance surveillance was also performed on patients receiving H anastomosis. Results Of the 122 eligible patients, 88 received end to end layered anastomosis and 34 underwent H anastomosis respectively. 3(3.4%) patients underwent anastomotic leakage in Conventional group and 1(2.9%) in H group (P = 0.897) The incidences of other perioperative complications were comparable between two groups. The H anastomosis was associated with lower incidence of gastroesophageal reflux (17.2% vs 35.8%, P = 0.117) and higher proportion of patients without food solidity limitation (Mellow-Pinkas score = 0) (79.4% versus 69.1% P = 0.305). The DeMeester score extracted from 24 h-PH and impedance surveillance showed the H anastomosis achieved 70% objective reflux free rate. Conclusion H anastomosis is a refinement of intussusception anastomosis and layered anastomosis to preserve the anti-reflux function of one-direction valve formed by intussuscepted tissues, leakage free from the different locations of layers of anastomosis and obstruction prevention from the removal of intussuscepted muscular layer of esophagus and seromuscular layer of stomach. A multicenter randomized trial comparing the outcomes of the H anastomosis and end to end anastomosis is in process to validate these conclusions.

311. H ANASTOMOSIS FOR LOW INCIDENCE OF ANASTOMOTIC LEAKAGE, OBSTRUCTION AND GASTROESOPHAGEAL REFLUX

Abstract Background End to end intussusception anastomosis is associated with reduced anastomotic leakage for the two layers located at different levels and decreased reflux tends for the intussuscepted structures functioning as a morphological sphincter. Nevertheless, dysphagia often presents due to the anatomy that the inner layer of stomach is larger than its outer layer causing bulge to compress the esophagus below, especially at the sight which gastric wall bends inside. Methods Here we present procedures to perform H Anastomosis which derives from end to end intussusception anastomosis. The critical improvement was the intussuscepted tissue was transformed from the whole layers of esophagus and stomach to the muscular layers of them. The detailed process was shown in the supplementary video which is available at https://1drv.ms/v/s!AmCqlJJZqDPDgzVKV9w4VPd_i72G?e = ubNzUN. Results With removing the intussuscepted seromuscular layer of stomach and muscular layer of esophagus, H anastomosis eliminates the bulge and reduces the thickness of gastric wall covering the esophagus. Postoperative dysphagia is reduced while advantages of intussusception for leakage and reflux control are preserved. These conclusions have been testified by an unpublished prospective cohort study. Conclusion H anastomosis is a novel gastroesophageal anastomosis technique. The preliminary study showed good postoperative outcomes regarding leakage, obstruction and gastroesophageal reflux. Further validation is needed.

Intracorporeal Versus Extracorporeal Anastomoses in Laparoscopic Right Hemicolectomy: A Single-Center Experience.

Right hemicolectomy is a commonly performed procedure for both benign and malignant diseases of the right colon. However, there is marked technical variation in the anastomosis technique used. In our hospital, both intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) are performed. Our study aimed to assess and compare the short-term outcomes following laparoscopic right hemicolectomies, particularly in regard to the anastomosis technique. All consecutive adult (>18 years of age) patients who underwent elective right hemicolectomy from January 2020 to April 2023 at St Richards Hospital, Chichester, University Hospitals Sussex NHS Foundation Trust, UK, were included in our retrospective study. Data, including age at operation, body mass index, American Society of Anesthesiologists (ASA)score, pathology, type of procedure, type of anastomosis, technique of anastomosis, post-operative high-dependency unit (HDU) stay, hospital length of stay, post-operative ileus, anastomotic leak, return to theater, and in-hospital mortality, were extracted. Patients who did not get an ileocolic anastomosis, had a stoma formation, and had an open procedure or conversion to open procedure were excluded. The cases that fulfilled the criteria were shortlisted for analysis. These cases were then divided into two groups: patients who had an IAand those who had an EA. From January 2020 to April 2023, 152 patients underwent right hemicolectomy. A total of 139 patients fulfilled our eligibility criteria and were included in our final analysis. The overall mortality rate was 0.7% (1/139), the return to theater rate was 0.7% (1/139), and no anastomotic leaks were recorded. The overall ileus rate was 16.5% (23/139). The hospital length of stay was significantly longer in the EA group as compared to the IA group (p<0.004). A higher proportion (18.75%, n=21) of the patients had a recorded ileus in the EA group as compared to 7.4% (n=2) in the IA group, but this difference was not statistically significant (p=0.24). We found that the patients who had IA had reduced hospital length of stay. The IA group also had clinically significant reduced rates of post-operative ileus, but this was not statistically significant. However, other short-term outcomes that were measured were similar in both groups.

Microsurgical robotic system enables the performance of microvascular anastomoses: a randomized in vivo preclinical trial

Technical advances in microsurgery have enabled complex oncological reconstructions by performing free tissue transfers, nerve and lymphatic reconstructions. However, the manual abilities required to perform microsurgery can be affected by human fatigue and physiological tremor resulting in tissue damage and compromised outcomes. Robotic assistance has the potential to overcome issues of manual microsurgery by improving clinical value and anastomoses’ outcomes. The Symani Surgical System, a robotic platform designed for microsurgery, was used in this in-vivo preclinical study using a rat animal model. The tests included anastomoses on veins and arteries performed by microsurgeons manually and robotically, with the latter approach using Symani. The anastomoses were assessed for patency, histopathology, and execution time. Patency results confirmed that the robotic and manual techniques for venous and arterial anastomoses were equivalent after anastomosis, however, the time to perform the anastomosis was longer with the use of the robot (p < 0.0001). Histological analysis showed less total average host reaction score at the anastomotic site in robotic anastomosis for both veins and arteries. This study demonstrates the equivalence of vessel patency after microsurgical anastomoses with the robotic system and with manual technique. Furthermore, robotic anastomosis has proven to be slightly superior to manual anastomosis in terms of decreased tissue damage, as shown by histological analysis.

Anti-reflux effects of a novel esophagogastric asymmetric anastomosis technique after laparoscopic proximal gastrectomy.

Reflux esophagitis is a common postoperative complication of proximal gastrectomy. There is an urgent need for a safer method of performing esophageal-gastric anastomosis that reduces the risk of reflux after proximal gastrectomy. We hypothesize that a novel technique termed esophagogastric asymmetric anastomosis (EGAA) can prevent postoperative reflux in a safe and feasible manner. To observe a novel method of EGAA to prevent postoperative reflux. Initially, we employed a thermal stress computer to simulate and analyze gastric peristalsis at the site of an esophagogastric asymmetric anastomosis. This was done in order to better understand the anti-reflux function and mechanism. Next, we performed digestive tract reconstruction using the EGAA technique in 13 patients who had undergone laparoscopic proximal gastrectomy. Post-surgery, we monitored the structure and function of the reconstruction through imaging exams and gastroscopy. Finally, the patients were followed up to assess the efficacy of the anti-reflux effects. Our simulation experiments have demonstrated that the clockwise contraction caused by gastric peristalsis and the expansion of the gastric fundus caused by the increase of intragastric pressure could significantly tighten the anastomotic stoma, providing a means to prevent the reverse flow of gastric fluids. Thirteen patients with esophagogastric junction tumors underwent laparoscopic proximal gastrectomy, with a mean operation time of 304.2 ± 44.3 min. After the operation, the upper gastroenterography in supine/low head positions showed that eight patients exhibited no gastroesophageal reflux, three had mild reflux, and two had obvious reflux. The abdominal computed tomography examination showed a valve-like structure at the anastomosis. During follow-up, gastroscopy revealed a closed valve-like form at the anastomosis site without stenosis or signs of reflux esophagitis in 11 patients. Only two patients showed gastroesophageal reflux symptoms and mild reflux esophagitis and were treated with proton pump inhibitor therapy. EGAA is a feasible and safe surgical method, with an excellent anti-reflux effect after proximal gastrectomy.

Preliminary exploration of modified side overlap with fundoplication by Yamashita (mSOFY) anastomosis technique in laparoscopic proximal gastrectomy

Objective: To discuss the feasibility and safety of modified side overlap with fundoplication by Yamashita (mSOFY) in laparoscopic proximal gastrectomy. Methods: Using the method of descriptive case series study, the clinical data of 9 patients with upper gastric cancer who successfully performed mSOFY anastomosis from March 2022 to October 2022 in the Affiliated Huaian No.1 People's Hospital of Nanjing Medical University were retrospectively analyzed.The reconstruction steps of mSOFY anastomosis are as follows: (1) Make a small incision on the right side of the esophageal stump and in front of the anterior wall of the gastric stump; (2) The 45mm linear cutting stapler is placed into the preset anastomosis of the esophagus and the remnant stomach, and the esophagus is rotated 90° counterclockwise along the axis, so that the right wall of the esophagus is anastomosed with the remnant stomach, and the stomach wall is sutured to the left side of the esophagus; (3) The common opening of esophagus and remnant stomach was sutured with inverted suture; (4)Suture the left and lower sides of the esophagus with the remnant stomach to make the esophagus flat against the stomach wall; (5) Open the sutured common opening: due to the pressure of the false dome, the posterior wall of the lower esophageal segment was compressed into a valve-like structure. We mainly observing the postoperative reflux and nutritional improvement of the patients, and recording the intraoperative situation and postoperative complications. Results: Nine patients with upper gastric cancer who completed laparoscopic proximal gastrectomy (mSOFY anastomosis) did not have conversion to laparotomy or intraoperative / postoperative complications. The operation time was (169.4±10.4) minutes, the anastomotic reconstruction time was (51.7±7.1) minutes, the intraoperative bleeding volume was (98.9±43.4) ml, and the number of lymph nodes dissected was (27.2±6.7). The patient recovered well after operation, without any complaints related to reflux esophagitis. Postoperative gastrointestinal radiography showed that the anastomosis was smooth, without stenosis and leakage. The serum albumin [(41.6±3.4) L vs. (39.9±2.6) L], prealbumin [(211.3±38.6) mg/L vs. (205.3±36.0) mg/L], and hemoglobin levels [(126.7±13.2) g/L vs. (121.0±9.7) g/L] of patients before and one month after surgery have no statistically significant differences (all P>0.05). Conclusion: mSOFY anastomosis can be used as one of the safe and feasible reconstruction methods in laparoscopic proximal gastrectomy.

Comparison of two anastomosis techniques in terms of postoperative pancreatic fistula development: A retrospective cohort study

Comparison of two anastomosis techniques in terms of postoperative pancreatic fistula development: A retrospective cohort study

SP10.8 An overlooked step in colorectal cancer anastomosis: a potentially small step in prevention of exfoliated malignant cells

Abstract Introduction Recurrence after potentially curative surgery has a significant clinical impact with a related poor prognosis. There is an abundance of literature surrounding efficacious techniques for anastomosis. However, to our knowledge comparatively there is minimal evidence reviewing the use of simple anti-septic agents with concurrent cytotoxic properties (ie. betadine or cetrimide) in prevention of anastomotic recurrence. This is despite both historic and newer evidence demonstrating tumour implantation of exfoliated malignant cells (EMCs) at the site of anastomosis leading to recurrence. This is also evident in low grade cancers. Methods A literature search was conducted between January 1980 to January 2022. The studies were to incorporate the use of simple anti-septic agents that were swabbed on the ends of the bowel before anastomosis. The search was restricted to articles published in English. Further more the selected publications were searched for additional studies. Results A result of 243 papers were reviewed, observational studies were found, n- 24. The reported reduction in EMCs was significantly lower at only 2 -7% compared to 16 to 55% in the control groups. Also evidenced were multiple papers providing significant experimental evidence of EMCs on staplers, gloves and the bowel anastomosed. We excluded rectal irrigation from this review article, as it is not employing the method of delivery suitable for all colonic anastomoses. Conclusion These results supporting the theory that cleansing with a cytocidal agent is associated with significantly reduced incidence of local luminal recurrence. We propose that this overlooked step in anastomotic techniques should be revisited.

Dual intravascular stent flipping technique for microvascular anastomosis

The anastomosis of vessels <0.5mm in diameter is challenging. We developed a supermicrosurgical anastomosis technique, the dual intravascular stent flipping technique with a double or single clip (dual flipping technique, double-clip technique, and single-clip technique). In the dual flipping technique, we used a 7-0 nylon intravascular stent and clipped the vessel along with the nylon. The double-clip technique was performed in 10 rats with 20 saphenous and 15 superficial inferior epigastric arteries. Immediate and 1-week patency rates were assessed. Subsequently, we examined ten epigastric arteries in five rats with the single-clip technique. The clinical application was performed in six cases involving finger/fingertip amputations, two cases involving radial artery superficial palmar branch flap, and one case involving superficial circumflex iliac artery perforator flap. Using the double-clip technique, the immediate patency rate was 90% and 93% in the saphenous and superficial epigastric arteries, respectively, whereas the 1-week patency rate was 81%. With the single-clip technique, the immediate patency rate was 100%. The replantation and flaps were successful. The advantages of the dual flipping technique included easy insertion, rare slipping-out possibility, and spontaneous vessel dilation by the flipped nylon. Additionally, the posterior vessel wall could be sutured more easily than could the anterior wall. By using the elasticity of the thread to invert the blood vessel, the posterior wall can be sutured without the double clip. When forceps tip insertion into the lumen is difficult, the dual flipping technique enables a relatively easy anastomosis if the 7-0 nylon is inserted into the vessel lumen.

A simple free flap strategy using end-to-side anastomosis to the main vessels in injured extremity

BackgroundDuring free flap surgery, the surgeon sometimes encounters problems with anastomosis such as intractable arterial spasms or vessel size discrepancy in venous anastomoses. End-to-side (ETS) anastomosis has the advantages of limited chance of vessel spasm and easy handling by adjusting for vessel size discrepancy. We introduced the arterial and venous end-to-side anastomosis (AV-ETS) strategy, which is based on the ETS anastomosis to the main artery and accompanying veins, to avoid intraoperative anastomotic problems when creating a free flap. The aim of this study was to compare flap outcomes and intraoperative anastomotic problems before and after introduction of the AV-ETS strategy in extremity free flap surgery. Materials and methodsWe retrospectively examined 72 consecutive extremity free flaps. Before introducing the AV-ETS strategy, we used the conventional strategy in which the recipient artery was selected according to the number of the remaining main artery and the anastomosis technique was flexibly changed, although the end-to-end (ETE) technique was used in most cases. ResultsThe conventional group had 18 flaps and the AV-ETS group had 54 flaps. The rate of flap survival did not differ between these groups, and there were no cases of flap failure after the introduction of the AV-ETS strategy. The AV-ETS group had significantly fewer flaps that required a change in preoperative planning for the recipient artery or anastomotic site of the artery. ConclusionsThe AV-ETS strategy may facilitate reliable preoperative planning and the performance of stable free flap surgery without requiring a flexible response during surgery.

Advantages of Totally Stapled Collard Over Circular Stapled Technique for Cervical Esophagectomy Anastomosis

BackgroundThe quality of life between the totally stapled Collard (TSC) and circular stapled (CS) techniques from the patient’s perspective has not been assessed. This longitudinal patient-reported outcome and objective data assessment study aimed to compare the effects of TSC vs CS for cervical anastomosis with minimally invasive esophagectomy (MIE) on the quality of life. MethodsThis single-center, retrospective study included patients with esophageal cancer who underwent MIE and cervical anastomosis between April 2019 and February 2021; of whom, 105 and 216 patients received TSC and CS anastomosis, respectively. The objective metrics were evaluated based on postoperative complications. Patient-reported outcomes instruments using the European Organization for Research and Treatment of Cancer modules were assessed preoperatively. The Quality of Life Questionnaire (QLQ) Core 30 and the QLQ-Oesophagus Module 18 assessed the quality of life. Mixed-effects models examined changes in questionnaire scores. ResultsThe stenosis rate in the TSC group was significantly lower than that in the CS group. There were no significant differences in other postoperative complications between the groups. In the QLQ Core 30 scale, the TSC group had better emotional function, less fatigue, less appetite loss, and better function than the CS group, with significant differences in different time points between the groups. QLQ-Oesophagus Module 18 revealed that the TSC group had significantly less appetite loss, dysphagia, dry mouth, pain, and obstruction, and better eating and speech than the CS group. ConclusionsTSC has significant advantages over the CS technique in lowering postoperative symptom burden and improving quality of life for cervical anastomosis on patient-reported outcomes.

Effect of intraoperative anastomotic reinforcement suture on the prevention of anastomotic leakage of double-stapling anastomosis for laparoscopic rectal cancer: a systematic review and meta-analysis.

The use of sutures to strengthen the anastomosis after rectal cancer surgery to reduce the possibility of anastomotic leakage has been debated. The aim of this systematic review and meta-analysis was to investigate the influence of intraoperative anastomotic reinforcing sutures on anastomotic leakage of double-stapling anastomosis for laparoscopic rectal cancer surgery. A systematic search of PubMed, Embase, Web of Science, and Cochrane databases was performed to identify literature examining anastomotic leak as the primary outcome to compare studies of laparoscopic surgery for rectal cancer using the double-stapling anastomosis technique with or without intraoperative anastomotic reinforcement with sutures. A total of 1122 rectal cancer patients from 5 nonrandomized studies were included in the research. In the combined trial, intraoperative anastomotic reinforcement sutures significantly reduced the incidence of anastomotic leakage in patients who underwent laparoscopic rectal cancer surgery (OR, 0.32; 95% CI, 0.19-0.55; p < 0.0001). With or without intraoperative anastomotic reinforcing sutures, the incidence of postoperative reoperation for anastomotic leak did not differ substantially (OR, 0.32; 95% CI, 0.08-1.21, p = 0.09). Moreover, the surgery was prolonged due to anastomotic reinforcement with sutures (OR, 6.64; 95% CI, - 6.18 to 19.47, p = 0.31). Intraoperative anastomotic reinforcement with sutures may be associated with a lower incidence of anastomotic leakage. The amount of research evidence is limited because most of the studies analyzed did not include patients with factors such as neoadjuvant therapy or prophylactic stomas. Therefore, additional multicenter randomized controlled studies with larger size samples are needed to support the validity of the approach.

Vesicourethral Anastomosis in Transvesical Single-Port Robotic Radical Prostatectomy: A Technical Description and Perioperative Outcomes.

Objective: To describe the technical evolution and perioperative outcomes of vesicourethral anastomosis (VUA) in transvesical (TV) single-port robot-assisted radical prostatectomy (SP-RARP). Materials and Methods: A retrospective review was performed on 189 patients who underwent TV SP-RARP by a single surgeon using the purpose-built SP robotic platform. VUA was completed from within the bladder using two unidirectional V-loc sutures in a continuous, semicircular manner with greater emphasis posteriorly. The most recent 20 cases of TV SP-RARP were selected to evaluate the anastomosis technique and to compare the perioperative outcomes with the first 20 cases of TV SP-RARP performed at our institution. Demographic and clinical data were collected from the prospectively maintained database and statistical analysis was performed. Results: VUA was effectively completed in all cases using the aforementioned technique without any suture breaks, need for conversion, or evidence of intraoperative complication, including urine leak. Marked improvement in the learning curve was observed, which translated to significant reduction in the number of VUA sutures (median: 13 vs 15, p < 0.05) and faster anastomosis time (median: 19.1 vs 33.5 minutes, p < 0.05). The number of anastomotic sutures did not correlate with the prostatectomy specimen weight or volume, especially with both being significantly greater in the latest cases (median weight: 45.1 vs 37.6 g, p < 0.05; median volume: 40.9 vs 36.2 mL, p < 0.05). Postoperative outcomes were favorable with immediate continence achieved in 51.3% of our total cohort and with no patients demonstrating evidence of bladder neck contracture. Conclusion: We provided a detailed technical description of VUA in TV SP-RARP. The improved maneuverability of the SP robotic platform allowed for unique movements to facilitate suture placements from within the confined space of the bladder. The learning curve of a single surgeon was shown in our study, which resulted in notable reduction in the number of sutures, faster anastomosis time, and improved perioperative outcomes.

Postoperative complications analysis of circular stapled versus linear stapled anastomosis for patients undergoing esophagectomy: a systematic review and meta-analysis

BackgroundThe choice of anastomosis technique after esophagectomy is closely associated with the postoperative complications. Whether circular stapled or linear stapled anastomosis is the optimal technique has not been established. Therefore, we conducted this meta-analysis to show the latest and most comprehensive published assessment of circular stapled anastomosis in comparison with linear stapled anastomosis in postoperative complications.MethodsDatabases (PubMed, Embase, Web of science, Cochrane Library) were searched for all randomized controlled trials and comparative studies comparing circular stapled anastomosis with linear stapled anastomosis after esophagectomy. The odd ratio and mean difference with 95% confidence interval were calculated. We used the Higgins I² statistics to assess the statistical heterogeneity between studies. Review manager (version 5.4) software was used in this analysis.ResultsSixteen studies with 2322 patients were included in our study. The study demonstrated that the use of linear stapled technique after esophagectomy could reduce the risk of both anastomotic leakage (P = 0.0003) and stricture (P < 0.00001) compared with circular stapled technique. Stratification by anastomotic site showed that no matter what kind of anastomotic site (cervical or thoracic anastomosis) was used, linear stapled anastomosis could effectively reduce the anastomotic stricture in comparison with circular stapled anastomosis. Moreover, linear stapled anastomosis could decrease the risk of thoracic anastomotic leakage. There were no significant differences between circle stapled anastomosis and linear stapled anastomosis in reflux esophagitis (P = 0.17), pneumonia (P = 0.91), operation time (P = 0.41) and hospital stay (P = 0.38).ConclusionsThe study suggested that linear stapled anastomosis could be considered to be an optimal treatment associated with a reduced risk of anastomotic leakage and stricture in comparison with circular stapled anastomosis.