The use of the LigaSure device and the Stapler in closure of the small bowel: a comparative ex vivo study

Assessing the influence of parameters on tissue welding in small bowel end-to-end anastomosis in vitro and in vivo

BACKGROUND

The use of high-frequency electric welding technology for intestinal end-to-end anastomosis holds significant promise. Past studies have focused on in vitro, and the safety and efficacy of this technology is uncertain, severely limiting the clinical application of this technology. This study investigates the impact of compression pressure, energy dosage, and duration on anastomotic quality using a homemade anastomosis device in both in vitro and in vivo settings.

METHODS

Two hundred eighty intestines and 5 experimental pigs were used for in vitro and in vivo experiments, respectively. The in vitro experiments were conducted to study the effects of initial pressure (50-400 kpa), voltage (40-60 V), and time (10-20 s) on burst pressure, breaking strength, thermal damage, and histopathological microstructure of the anastomosis. Optimal parameters were then inlaid into a homemade anastomosis and used for in vivo experiments to study the postoperative porcine survival rate and the pathological structure of the tissues at the anastomosis and the characteristics of the collagen fibers.

RESULTS

The anastomotic strength was highest when the compression pressure was 250 kPa, the voltage was 60 V, and the time was 15 s. The degree of thermal damage to the surrounding tissues was the lowest. The experimental pigs had no adverse reactions after the operation, and the survival rate was 100%. 30 days after the operation, the surgical site healed well, and the tissues at the anastomosis changed from immediate adhesions to permanent connections.

CONCLUSION

High-frequency electric welding technology has a certain degree of safety and effectiveness. It has the potential to replace the stapler anastomosis in future and become the next generation of new anastomosis device.

A novel electrode for reducing tissue thermal damage in radiofrequency-induced intestinal anastomosis

PURPOSE

This study aimed to design a novel electrode for reducing tissue thermal damage in radiofrequency-induced intestinal anastomosis.

MATERIAL AND METHODS

We developed and compared two electrodes (Ring electrode, and Plum electrode with reduced section of the middle fusion area by nearly 80% arising from novel structural design) by performing ex-vivo experiments and finite element analysis.

RESULTS

In contrast to the Ring electrode group, slightly higher mean strength is acquired with the tensile force and burst pressure results increasing from 9.7 ± 1.47 N, 84.0 ± 5.99 mmHg to 11.1 ± 1.71 N, 89.4 ± 6.60 mmHg, respectively, as well as a significant reduction in tissue thermal damage for the Plum electrode group, with compression pressure of 20 kPa, RF energy of 120 W and welding duration of 8 s applied to the target regions to achieve anastomosis. Besides, the novel structural design of the Plum electrode can counteract the tension generated by intestinal peristalsis and enhance the biomechanical strength of the anastomotic area. The histological observation showed that the fusion area of the two-layer intestinal tissue is tightly connected with decreased thickness.

CONCLUSION

The novel electrode (Plum electrode) could reduce tissue thermal damage in radiofrequency-induced intestinal anastomosis.

An ex vivo preliminary investigation into the impact of parameters on tissue welding strength in small intestine mucosa-mucosa end-to-end anastomosis

Background: Tissue welding is an electrosurgical technique that can fuse tissue for small intestine anastomosis. However, limited knowledge exists on its application in mucosa-mucosa end-to-end anastomosis. This study investigates the effects of initial compression pressure, out-put power, and duration time on anastomosis strength ex vivo in mucosa-mucosa end-to-end anastomosis. Methods: Ex vivo porcine bowel segments were used to create 140 mucosa-mucosa end-to-end fusions. Different experimental parameters were employed for fusion, including initial com-pression pressure (50kPa-400 kPa), output power (90W, 110W, and 140W), and fusion time (5, 10, 15, 20 s). The fusion quality was measured by burst pressure and optical microscopes. Results: The best fusion quality was achieved with an initial compressive pressure between 200 and 250 kPa, an output power of 140W, and a fusion time of 15 s. However, an increase in output power and duration time resulted in a wider range of thermal damage. There was no significant difference between the burst pressure at 15 and 20 s (p > 0.05). However, a substantial increase in thermal damage was observed with longer fusion times of 15 and 20 s (p < 0.05). Conclusion: The best fusion quality for mucosa-mucosa end-to-end anastomosis ex vivo is achieved when the initial compressive pressure is between 200 and 250 kPa, the output power is approximately 140W, and the fusion time is approximately 15 s. These findings can serve as a valuable theoretical foundation and technical guidance for conducting animal experiments in vivo and subsequent tissue regeneration.

Ex vivo evaluation of a technique for equine jejunocecal anastomosis using radiofrequency thermofusion and a Cushing oversew

OBJECTIVE

To describe a technique for a side-to-side jejunocecal anastomosis in horses using radiofrequency thermofusion (TF) of the intestines supported by a Cushing oversew and to compare this anastomosis to handsewn and stapled techniques.

STUDY DESIGN

Ex vivo study.

SAMPLE POPULATION

Intestinal tracts from 24 slaughtered horses.

METHODS

A radiofrequency device was used to perform a jejunocecal anastomosis (Group RFA). The construction time and bursting pressure of this construct were compared with those of a hand-sewn double layer (Group HS) and stapled anastomoses (Group ST) without oversew of the staple line. Histology was also performed for the TF anastomoses to evaluate the extent of the thermal damage.

RESULTS

The median (range) construction time (min) for the TF (15.8 [14.4-16.8]) was not significantly different from that for the HS (25.5 [24.2-26.3]) and ST (10.8 [9.7-12.5]) groups (p = .07). The construction time for ST was shorter than that for HS group (p < .001). The average (standard deviation) bursting pressure (mmHg) for HS (153.1 +/- 17.5) was higher than that for RFA (76 +/- 15) and ST groups (48 +/- 13; p < .001). The bursting pressure of the RFA was higher than that of the ST anastomoses (p = .001). The thermal damage caused by the device was within the suture oversew in the deeper layers, whereas it extended a few mm beyond the suture line in the serosa.

CONCLUSION

Radiofrequency assisted anastomoses provide similar construction times to current techniques and have a higher bursting pressure than ST anastomoses.

CLINICAL SIGNIFICANCE

Radiofrequency-assisted anastomoses with a suture oversew demonstrated comparable bursting pressures to ST anastomoses. The use of the radiofrequency device on the intestine is extra label and causes serosal tissue damage, which may increase the risk of adhesions.

Minimizing thermal damage using self-cooling jaws for radiofrequency intestinal tissue fusion

INTRODUCTION

Radiofrequency (RF)-induced tissue fusion shows great potential in sealing intestinal tissue without foreign materials. To improve the performance of RF-induced tissue fusion, a novel self-cooling jaw has been designed to minimize thermal damage during the fusion.

MATERIAL AND METHODS

The prototype of self-cooling jaws was developed and manufactured. A total number of 60 mucosa-to-mucosa fusions were conducted using ex-vivo porcine intestinal segments with the proposed design and conventional bipolar jaws. The effects of intestinal fusion were evaluated based on temperature curves, burst pressure, thermal damage, and histological appearances.

RESULTS

The self-cooling jaws showed significant decrease in temperature during the fusion process. An optimal burst pressure (5.7 ± 0.5 kPa) and thermal damage range (0.9 ± 0.1 mm) were observed when the applied RF power was 100 W. The thermal damage range of the prototype has almost decreased 36% in comparison with the conventional bipolar jaws (1.4 ± 0.1 mm). The histological observation revealed that a decrease of thermal damage was achieved through the application of self-cooling jaws.

CONCLUSIONS

The self-cooling jaws were proved to be effective for reducing the thermal damage during RF-induced tissue fusion, which could potentially promote the clinical application of tissue fusion techniques in the future.

Characteristics of Collagen Changes in Small Intestine Anastomoses Induced by High-Frequency Electric Field Welding

High-frequency electric field welding-induced tissue fusion has been explored as an advanced surgical method for intestinal anastomoses; however, intrinsic mechanisms remain unclear. The aim of this study was to investigate microcosmic changes of collagen within the fusion area, with various parameters. Ex vivo small intestine was fused with mucosa-mucosa. Four levels of compressive pressure (100 kPa, 150 kPa, 200 kPa, 250 kPa) were applied for 10 s in order to fuse the colons under a power level of 140 W. Then, collagen fibers of the fusion area were examined by fibrillar collagen alignment and TEM. Three levels of power (90 W, 110 W, 140 W) and three levels of time (5 s, 10 s, 20 s) were applied in order to fuse colons at 250 kPa, and then collagen within the fusion area was examined by Raman spectroscopy. Fibrillar collagen alignment analysis showed that with the increase in compression pressure, alignment of the collagen in the fusion area gradually increased, and the arrangement of collagen fibers tended to be consistent, which was conducive to the adhesion of collagen fibers. TEM showed that pressure changed the distribution and morphology of collagen fibers. Raman spectroscopy showed that increased power and time within a certain range contributed to collagen cross linking. Peak positions of amide I band and amide III band changed. These results suggested that higher power and a longer amount of time resulted in a decrease in non-reducible cross links and an increase in reducible cross links. Compression pressure, power, and time can affect the state of collagen, but the mechanisms are different. Compressive pressure affected the state of collagen by changing its orientation; power and time denatured collagen by increasing temperature and improved the reducible cross linking of collagen to promote tissue fusion.

Comparison of Two Radiofrequency Vessel-Sealing Device for Laparoscopic Ovariectomy in African Lionesses (Panthera Leo)

Simple Summary

This study evaluated two vessel-sealing devices for dissecting ovaries in adult obese African lionesses undergoing laparoscopic ovariectomy. We evaluated the surgery time the intra- and postoperative complications. The results of our study confirmed the significant advantages of employing the Caiman 12 vessel-sealing device in comparison with the LigaSure Atlas in terms of the time needed to complete ovariectomy, although both instruments could be considered safe. The use of the Caiman 12 is recommended when performing laparoscopic ovariectomies in adults with obesity.

Abstract

To evaluate two vessel-sealing devices with different jaw lengths for dissecting ovaries in adult obese African lionesses undergoing laparoscopic ovariectomy. Twelve lionesses (n = 12) were recruited. The surgical procedures were performed through three portals, with a retractor platform positioned at the umbilical port and cannulas placed 3–4 cm cranial and caudal to the device at the level of the midline. Ovariectomy was performed using a vessel-sealing device according to a randomization list. We evaluated the surgery time the intra- and postoperative complications. The total surgery time was 49.3 min (range 40–61 min) in the Atlas group and significantly lower in the Caiman group (mean 31.8 min, range 26–51 min). The installation phase was similar between the groups. The ovariectomy time was significantly lower in the Caiman group (mean 7.8 min, range 4–11 min) than in the Atlas group (mean 20 min, range 16–30 min). Controlled bleeding was observed at the tip of the uterine horn in two cases in the Atlas group. No other complications were noted. The results of our study confirmed the significant advantages of employing the Caiman 12 vessel-sealing device in comparison with the LigaSure Atlas in terms of the time needed to complete ovariectomy, although both instruments could be considered safe. The use of the Caiman 12 is recommended when performing laparoscopic ovariectomies in adults with obesity.

Ultrasound location of ground-glass opacity during thoracoscopic surgery

OBJECTIVES

Application of video-assisted thoracoscopy brought lung surgery into the minimally invasive era; the lack of tactile feedback using VATS, remains a disadvantage because surgeons are unable to locate lesions with a finger or device. This study aimed to investigate the effectiveness, the applicability and the utility of intraoperative ultrasound (IU), for the localization of small ground-glass opacity (GGO) lesions in the parenchyma, as a guide in finding their margins in a deflated lung.

MATERIALS AND METHODS

We included 15 consecutive patients undergoing diagnostic resection of GGOs via VATS in the Thoracic Surgery Unit of the University of 'Luigi Vanvitelli' of Naples from November 2019 to December 2021. They were under general anaesthesia, when the lung had been collapsed, the probe was placed in the region where the target lesion was thought to reside on the basis of low-dose computed tomography scanning. GGO could be identified their sizes, echo levels and posterior echo was recorded by IU when the lung was completely deflated.

RESULTS

We conducted a retrospective single-centre study. All GGOs were identified by IU. The mean size and depth were 14.1 ± 0.5 and 4.8 ± 0.3 mm, respectively. Six (40%) lesions had hyperechoic patterns, 9 (60%) had mixed echogenicity where the hyperechoic patterns were irregularly mixed with hypoechoic patterns. The final diagnoses included 2 (15%) atypical adenomatous hyperplasia; 2 (15%) adenocarcinomas in situ; 3 (23%) minimally invasive adenocarcinomas and 6 (46%) invasive adenocarcinomas.

CONCLUSIONS

The results of our study showed that IU could safely and effectively detect GGOs.

Ex-Vivo Evaluation of "First Tip Closing" Radiofrequency Vessel Sealing Devices for Swine Small Intestinal Transection

This study compared burst pressure (BP), number of activations, and histological assessment of ex vivo swine small intestine loops transected by stapler, a single fulcrum radiofrequency vessel sealing (RFVS) device, and the newly-developed jaws RFVS. Fifty (n = 50) 20 cm long jejunal loops were randomly assigned to be transected with RFVS devices and linear stapler (Caiman5, Caiman Maryland, Caiman12, Ligasure Atlas, and Stapler group as control respectively). Caiman5, Caiman12 and stapler required only one activation to complete the sealing. The mean BP in Caiman5 and Caiman Maryland groups were significantly lower (p < 0.05) than the S group as control and the other RFVS devices studied. RFVS Caiman12 and Ligasure Atlas produced mean BP values that were close to the Control and did not differ between them. The lumen was totally closed in the Caiman12 and Ligasure Atlas groups. The findings of this investigation were promising; we discovered that Caiman12 and Ligasure Atlas produce comparable mechanical capabilities as well as stapled intestinal closure, however Caiman12 need a single activation to complete the transection.

The Beneficial Effects of Physical Activity in Lung Cancer Prevention and/or Treatment

Lung cancer is the most lethal cancer: it has a significant incidence and low survival rates. Lifestyle has an important influence on cancer onset and its progression, indeed environmental factors and smoke are involved in cancer establishment, and in lung cancer. Physical activity is a determinant in inhibiting or slowing lung cancer. Certainly, the inflammation is a major factor responsible for lung cancer establishment. In this scenario, regular physical activity can induce anti-inflammatory effects, reducing ROS production and stimulating immune cell system activity. On lung function, physical activity improves lung muscle strength, FEV1 and forced vital capacity. In lung cancer patients, it reduces dyspnea, fatigue and pain. Data in the literature has shown the effects of physical activity both in in vivo and in vitro studies, reporting that its anti-inflammatory action is determinant in the onset of human diseases such as lung cancer. It has a beneficial effect not only in the prevention of lung cancer, but also on treatment and prognosis. For these reasons, it is retained as an adjuvant in lung cancer treatment both for the administration and prognosis of this type of cancer. The purpose of this review is to analyze the role of physical activity in lung cancer and to recommend regular physical activity and lifestyle changes to prevent or treat this pathology.

The Potential Role of Nutrition in Lung Cancer Establishment and Progression

Lung cancer is a devastating disease with a high incidence and low survival rates, so recent studies have focused on analyzing the risk factors that might prevent this disease from developing or have protective/therapeutic effects. Nutrition is an important key factor in the prevention and treatment of lung cancer. Various factors appear to be involved in the development of the latter, such as cigarette smoking or certain external environmental factors. The increase in oxidative stress is therefore an integral part of the carcinogenesis process. The biological role of bioactive factors derived from adipose tissue, mainly adipokines, is implicated in various cancers, and an increasing body of evidence has shown that certain adipocytokines contribute to the development, progression and prognosis of lung cancer. Not all adipokines stimulate tumor growth; in fact, adiponectin inhibits carcinogenesis by regulating both cell growth and the levels of inflammatory cytokines. Adiponectin expression is deregulated in several cancer types. Many nutritional factors have been shown to increase adiponectin levels and therefore could be used as a new therapeutic strategy for combating lung cancer. In addition, foods with antioxidant and anti-inflammatory properties play a key role in the prevention of many human diseases, including lung cancer. The purpose of this review is to analyze the role of diet in lung cancer in order to recommend dietary habit and lifestyle changes to prevent or treat this pathology.

LigaSure Vessel Sealing System for Small Bowel Transection During Roux Limb Construction

Roux limb construction is an essential part of several major reconstructive hepatobiliary and upper gastrointestinal surgeries. This can be achieved with a stapling device or suturing. For over two decades, the LigaSure vessel sealing systems (Medtronic, MN, USA) have been in use for omental division, mesenteric transection, and sealing of vessels. We used the LigaSure vessel sealing system with a ForceTriad energy platform (Medtronic) for transection of the bowel during the formation of the Roux limb for a Roux-en-Y reconstruction. Between July 2019 and December 2020, patients who had Roux limb construction as part of a pancreato-enteric anastomosis in surgery for chronic pancreatitis were analysed. The data was reviewed from a prospectively maintained database. Fifteen patients had undergone surgery for chronic pancreatitis. The mentioned technique takes approximately eight minutes to construct a Roux limb. There was no bleeding from the gut ends that had been transected. There was no breach in the bowel’s seal. The field was free of enteric contamination. In the post-operative course of these individuals, there was no Roux limb-related morbidity. This procedure is useful because it is cost-effective, time-saving, dependable, and prevents contamination and blood loss. It is also simple to learn and apply.

Swine Small Intestine Sealing Performed by Different Vessel Sealing Devices: Ex-Vivo Test

This study aimed to evaluate the sealing quality of swine small intestine using different laparoscopic radiofrequency vessel sealing devices (two 5 mm: RFVS-1 and -2; one 10 mm: RFVS-3) and a harmonic scalpel (HS) compared to golden standard closure technique. The study was divided into two arms. In study arm 1: n = 50 swine intestinal loops (10 per group) were transected with each instrument and the loops in which the devices provided complete sealing, at the gross inspection, were tested for maximum burst pressure (BP) and histological evaluation and compared to an automatic linear stapler. After the BP tests, the devices that achieved significantly lower BP values were excluded from the second arm. The RFVS-1 and -3 provided statistically significant results and were used in study arm 2, to obtain full-thickness biopsies along the antimesenteric border of the loop and were compared with hand-sewn intestinal closure (n = 30; 10 per group). The biopsies were histologically evaluated for thermal injury and diagnostic features, and intestinal loops tested for BP. RFVS-3 achieved comparable results (69.78 ± 4.23 mmHg, interquartile range (IQR) 5.8) to stapler closing technique (71.09 ± 4.22 mmHg, IQR 4.38; p > 0.05), while the RFVS-1 resulted in significantly (p < 0.05) lower BP (45.28 ± 15.23 mmHg, IQR 24.95) but over the physiological range, conversely to RFVS-2 (20.16 ± 7.19 mmHg, IQR 12.02) and HS (not measurable). RFVS-3 resulted not significantly different (p > 0.05) (45.09 ± 8.75 mmHg, IQR 10.48) than Suture (35.71 ± 17.51 mmHg, IQR 23.77); RFVS-1 resulted significantly lower values (23.96 ± 10.63 mmHg, IQR 9.62; p < 0.05). All biopsies were judged diagnostic. Data confirmed that RFVS-1 and -3 devices provided suitable intestinal sealing, with BP pressures over the physiological range. Conversely, the HS and RFVS-2 should not be considered for intestinal sealing. RFVS devices could be employed to obtain small intestine stump closure or full-thickness biopsies. However, further studies should be performed in live animals to assess the role of the healing process.

Tissue fusion technology versus suture and staple in porcine bowel anastomosis: an in vivo study

The aim of this study was to make a comparison between the tissue fusion technique and conventional methods for sealing bowel anastomosis. Eighteen female domestic pigs (Suidae, Sus) were used in our study. Tissue-fused anastomoses (LigaSure groups) were made in 13 animals (5 anastomoses per animal), which were subdivided into 4 groups according to different manufacturing settings: “LigaSure-L-1” and “LigaSure-L-2”, with low energy output level with 1 or 2 device-activated tissue sealing times, and “LigaSure-M” and “LigaSure-H”, with medium or high energy output level. As controls, automatically stapled (GIA group) and hand-sewn (suture group) anastomoses were utilized in 3 and 2 animals, respectively. There was no statistical difference in the overall leakage rate between the GIA group (6.7%) and the LigaSure groups (15%) (P=1.000). There was less proliferating epithelium covering the anastomosis gap in the LigaSure groups compared with the other two groups. The gap between the two extremities of muscular layers of the anastomosis in the LigaSure groups was filled with collagen fibers. More proliferating cell nuclear antigen (PCNA)-positive cells were found in the anastomoses of the LigaSure groups compared with the other two groups (P=0.010). Our results showed that the tissue fusion technology was a feasible and safe method for anastomoses.

Ex vivo comparison of leakage pressures and leakage location with a novel technique for creation of functional side-to-side canine small intestinal anastomoses

OBJECTIVE

To determine the ability of functional side-to-side small intestinal anastomoses (FSS-SIA) created with an electrothermal bipolar vessel sealing (EBVS) device to resist leakage.

STUDY DESIGN

Experimental, ex vivo.

SAMPLE POPULATION

Jejunal segments (n = 130) from 10 healthy canine cadavers.

METHODS

Four types of anastomoses were created (two segments/construct and 15 constructs/group): EBVS (group A), EBVS + transverse stapling (group B), stapled (group C), and EBVS + suture augmentation (group D). Initial leakage pressure (ILP), initial leakage location (ILL), and maximal intraluminal pressure were compared between groups, and five group A constructs were analyzed histologically.

RESULTS

Initial leakage pressure was greater in group D than in groups A, B, and C (P < .011). There was a difference in ILL among groups (P = .003). Leakage occurred at the side-to-side intestinal anastomosis fusion line in 13 of 15 (87%) constructs for groups A and B and in nine of 15 (60%) constructs for group D. Maximal intraluminal pressure was greater in group C than in groups A, B, and D (P < .004). Histological examination was consistent with collagenous fusion without cavitation defects.

CONCLUSION

Functional side-to-side small intestinal anastomosis was consistently achieved with an EBVS device. Augmentation of EBVS anastomoses with simple interrupted sutures along the anastomotic fusion line increased ILP compared with stapled anastomoses.

CLINICAL SIGNIFICANCE

Despite the success and feasibility of creating an FSS-SIA with an EBVS device, additional in vivo studies are required to determine the effectiveness of intestinal fusion prior to clinical implementation.

Mesenchymal Stem Cells Combined with Tissue Fusion Technology Promoted Wound Healing in Porcine Bowel Anastomosis

Objective

To evaluate the possible biological effect of allogenic mesenchymal stem cells (MSCs) combined with tissue fusion technology on the anastomosis.

Methods

Sixteen pigs were divided into a 7 d group and 14 d group, each of which was further subdivided into an MSC-treated group and a control group. Five anastomoses per animal were established using LigaSure ForceTriad (Covidien, MA, USA), a tissue sealing system. Cell migration and tissue-specific differentiation potency, in addition to potential cytokine and genetic changes, were investigated.

Results

There were no significant between-group differences in postoperative complications and anastomosis burst pressure. The number of proliferating cell nuclear antigen- (PCNA-) positive cells was significantly higher in the MSC-treated group as compared with that in the control group (P = 0.021). Labeled MSCs were found in the mucosal layer, villus, and lamina propria, as well as in the lamina muscularis mucosae, where they exhibited characteristics of smooth muscle cells.

Conclusions

Grafted MSCs significantly promoted epithelial and connective cell proliferation and maintained their cell migration capacity and differentiation potential in the fused anastomotic tissues, without causing severe postoperative complications.

Surgical approach in thymectomy: Our experience and review of the literature

Aim

Thymectomy is the main treatment for thymoma and patients with myasthenia gravis (MG). The traditional approach is through a median sternotomy, but, recently, thymectomy through minimally invasive approaches is increasingly performed. Our purpose is an analysis and discussion of the clinical presentation, the diagnostic procedures and the surgical technique. We also consider post-operative complications and results, over a period of 5 years (May 2011–June 2016), in thymic masses admitted in our Thoracic Surgery Unit.

Methods

We analyzed 8 patients who underwent surgical treatment for thymic masses over a period of 5 years. 6 patients (75%) had thymoma, 2 patients (25%) had thymic carcinomas. 2 patients with thymoma (33%) had myasthenia gravis. We performed a complete surgical resection with median sternotomy as standard approach.

Results

One patient (12%) died in the postoperative period. The histological study revealed 6 (75%) thymoma and 2 (25%) thymic carcinomas. Post-operative morbidity occurred in 2 patients (25%) and were: pneumonia in 1 case (12%), atrial fibrillation and pleural effusion in 2 patients (25%). One patient with thymoma type A recurred at skeletal muscle 2-years after surgery.

Conclusions

Thymic malignancies are rare tumors. Surgical resection is the main treatment, but a multimodal approach is useful for many patients. Radical thymectomy is completed removing all the soft tissue in the anterior mediastinum between the two phrenic nerves and this is the most important factor in controlling myasthenia and influencing survival in patients with thymoma. Open (median sternotomy) approach has been the standard approach for thymectomy for the better visualization of the anatomical structures. Actually, video-assisted thoracoscopic surgery (VATS) thymectomy and robotic video-assisted thoracoscopic (R-VATS) approach versus open surgery has an equal if not superior oncological efficacy, better perioperative complications and survival outcomes.

Idiopathic pleural panniculitis with recurrent pleural effusion not associated with Weber-Christian disease

A 82-year-old patient with dyspnea and a recurrent history of pleural effusion was admitted into our unit. He performed a Chest computed tomography showing right pleural effusion. Video-assisted thoracoscopy (VATS) exploratory showed parietal pleural thickening of adipose tissue. The surgical procedure consisted, therefore, in the execution of multiple biopsies of the parietal pleura which appeared covered, on the whole surface, by islands of adipose tissue, without macroscopic pathological aspects. After the procedure was performed pleurodesis with talc. The definitive histological examination consisted of normal mesothelial cells surrounded by fatty tissue infiltrated by small lymphocytes in a patient without skin lesions or visceral or systemic signs of inflammatory involvement of the adipose tissue. We reported a rare case of idiopathic pleural panniculitis with recurrent pleural effusion not associated with Weber-Christian disease.

Role of Laparoscopic Splenectomy in Elderly Immune Thrombocytopenia

The management of older patients with chronic primary immune thrombocytopenia (ITP) is still very challenging because of the fragility of older patients who frequently have severe comorbidities and/or disabilities. Corticosteroid-based first-line therapies fail in most of the cases and patients require a second-line treatment, choosing between rituximab, thrombopoietin-receptor agonists and splenectomy. The choice of the best treatment in elderly patients is a compromise between effectiveness and safety and laparoscopic splenectomy may be a good option with a complete remission rate of 67% at 60 months. But relapse and complication rates remain higher than in younger splenectomized ITP patients because elderly patients undergo splenectomy with unfavorable conditions (age >60 year-old, presence of comorbidities, or multiple previous treatments) which negatively influence the outcome, regardless the hematological response. For these reasons, a good management of concomitant diseases and the option to not use the splenectomy as the last possible treatment could improve the outcome of old splenectomized patients.

Fine-needle cytology in the follow-up of breast carcinoma

The postoperative follow-up strategies for breast carcinoma (BC) utilize different procedures; the aim of this study was to investigate the role of fine-needle cytology (FNC) in the follow-up of BC patients. Two hundred sixty-six FNC samples from 190 BC patients have been reviewed. The target anatomical sites were 190 breast including 155 ipsilateral and 145 contralateral breast lesions and 76 extra-mammary nodules. Extra-mammary lesions included lymph nodes, thyroidal nodules, soft tissue lesions, (subcutaneous and sub-scars), salivary glands and deep located masses. Diagnostic distribution of the breast lesions was as follows: 51 positive, 15 indeterminate/suspicious, 119 negative and 5 inadequate. Positive cases included 43 ipsilateral and 8 contralateral BC, 9 BC in different quadrants from those of onset of the first BC. Sensitivity, specificity and accuracy have been 90, 91 and 90&, respectively. FNC, in a correct setting, is a reliable and effective method for the follow-up management of BC patients.

Diagnostic yield and safety of C-TBNA in elderly patients with lung cancer

Conventional transbronchial needle aspiration (C-TBNA) is a minimally invasive technique used primarily in the diagnosis and staging of lung cancer. Currently lung cancer is mostly considered a disease of the elderly and the management of this disease in older patients is a growing concern. In this study we aimed to assess the diagnostic yield and safety of C-TBNA in elderly patients. A retrospective review of 88 consecutive C-TBNA procedures for nodal staging in suspected or confirmed primary lung cancer or pathological confirmation in suspected advanced lung cancer was performed. Patients were divided into less than 70 (<70yrs) or 70 and older (≥70yrs) age groups for analysis. There were no significant differences either in the diagnostic yield (69% in patients aged < 70 yrs and 74% patients aged ≥ 70 yrs (p=0.5) nor in the complication rate (respectively 8.8% in patients aged < 70 yrs and 6.9% in patients aged ≥ 70 yrs (p=0.7) between the two age groups. Reported complications were minor bleeding and poor tolerance; no major complications were observed. Based on our experience, C-TBNA represents a useful and safe alternative procedure for the diagnosis and staging of lung cancer in elderly patients.

Evaluation of the LigaSure(™) Vessel Sealing System for bowel transection and intestinal anastomosis-an experimental study in a porcine model

BACKGROUND

The purpose of the present study is to assess the value of the LigaSure™ Vessel Sealing System (LVSS) as a means for bowel transection and intestinal anastomosis.

METHODS

We compared the LVSS for (1) transecting bowel and (2) creation of an intestinal anastomosis with standard methods such as stapler (S) and hand-sewn (HS) in a porcine model. For each study arm, i.e., bowel transection and anastomosis creation, both the small bowel and colon were examined. In total, ten transections and ten anastomoses were performed for each. Burst and anastomotic leak pressures were compared.

RESULTS

In the study arm 1, LVSS achieved lowest burst pressures in both small bowel (LVSS 39.8 ± 3.6 mmHg, S 81.9 ± 3.9, HS 111.9 ± 14.7 mmHg, p < 0.0001) and colon transections (LVSS 21.5 ± 2.6 mmHg, S 79.5 ± 4.9, HS 91.0 ± 5.2 mmHg, p < 0.0001). There was no difference in burst pressures between S and HS in both small bowel and colon transections. In the study arm 2, LVSS showed the lowest anastomotic leak pressures for small bowel (LVSS 26.4 ± 2.6 mmHg, S 52.1 ± 6.2, HS 87.4 ± 7.0 mmHg, p < 0.0001) and colonic anastomoses (LVSS 16.9 ± 1.3 mmHg, S 55.9 ± 4.3, HS 74.4 ± 4.4 mmHg, p < 0.0001). Furthermore, small bowel and colonic anastomoses using S demonstrated significantly lower leak pressures than HS anastomosis p < 0.001 and p = 0.004, respectively.

CONCLUSIONS

The LVSS achieves significantly lower burst pressures and anastomotic leak pressures for bowel transection and intestinal anastomosis than S and HS techniques. However, due to the achieved pressure levels of 39.8 ± 3.6 mmHg, LVSS appears to be a sufficient stand-alone method for bowel transection. Whether it can be used to perform intestinal anastomosis warrants further research in a survival model.

Comparison of a New High-Frequency Electric Welding System for Intestinal Closure with Hand-Sewn In Vivo Pig Model

BACKGROUND

Various surgical small intestinal anastomosis methods are in current use, but improvements are always desired. Thus, we compared the feasibility, effectiveness, and safety of a new high-frequency electric welding (HFEW) system for sealing the small bowel versus a hand-sewn in vivo pig model.

MATERIALS AND METHODS

The 96 bowel segments of three pigs were randomized to be sutured either by the HFEW-300 PATONMED device (E.O. Paton Electric Welding Institute of the National Academy of Sciences of Ukraine, Kiev, Ukraine) or hand-sewn, and mucosa-to-mucosa fusions were subjected in vivo testing in the pigs. Bursting pressures, suture time, thermal damage, and the temperature of sealed ends were measured.

RESULTS

Segments that had been treated with a hand-sutured ligature or double-sealed with HFEW were compared. Burst pressure was significantly higher in the hand-sutured group than in the HFEW group (136.2 mm Hg versus 75.8 mm Hg, P<.01). All 48 pig small bowels closed by the HFEW-300 generator showed a success rate of 100.0%. The closing time in the HFEW group was significantly shorter (P<.01). The pathological changes of the closed ends were mainly presented as acute thermal- and pressure-induced injuries.

CONCLUSIONS

Outcomes of the current in vivo study suggest that HFEW is an effective and safe method for ligation of the small bowel in pigs.

Histological characteristics of collagen denaturation and injuries in bipolar radiofrequency-induced colonic anastomoses

Bipolar radiofrequency-induced thermo-fusion has been explored as an advanced surgical method for intestinal anastomoses; however, the histological characteristics of collagen denaturation and injuries arising from this process remain unclear. The aim of this study was to investigate the microcosmic changes and tissue damage of fusion regions with various parameters of injury. Ex vivo colons of pigs were fused serosa-serosa on two carrier rings, which were installed on a homemade anastomotic device. Five levels of compressive pressure from 171 to 313 kPa were applied for 5s to fuse the colons under radiofrequency power of 160 W, and then the collagen denaturation of the fused region was examined by transmission electron microscopy. Light microscopy was utilized to observe histological slices that were stained with picrosirius red in order to visualize the tissue injuries under two levels of radiofrequency power (120 vs. 140 W) and operation time (5 vs. 10s). Transmission electron micrographs showed that increased compressive pressure led to thicker denatured collagen fibrils and wider gaps between each collagen fibril. Serosa adhesion regions appeared abundant in collagen. No histological differences were observed when 120 W of power was applied for 5 and 10s. Significant muscle cracking occurred when colons were fused using 140 W for 5s. When the operation time was extended to 10s, 140 W led to tight fusion and less splitting on muscles. These results suggest that higher compressive pressure results in more severe collagen unfolding and also reduces collagen crosslinking in fused colons. Improved radiofrequency power along with operation time could avoid tissue injury upon radiofrequency-induced colonic anastomoses.

The Feasibility of LigaSure to Create Intestinal Anastomosis

Objective. To evaluate the feasibility and the effectiveness of LigaSure Forced Triad to create intestinal anastomosis in an ex vivo porcino model. Methods. Colon samples (n = 100) were prospectively randomized into 2 groups: LigaSure group (n = 90) and Stapler group (n = 10). The LigaSure group was divided into 9 subgroups, each of 10 samples, according to the different power levels of the LigaSure system (Bar 1, Bars 2, and Bars 3) and radiofrequency application (1 application, 2 applications, and 3 applications) used. All anastomoses were tested for early burst pressure. The LigaSure subgroup having the highest burst pressure was compared with the Stapler group. Finally, the specimen was reviewed by the same pathologist. Results. The burst pressures of the 9 subgroups of LigaSure segments were the following: 29.7 ± 4.5 (Subgroup a); 27.4 ± 3.1 (Subgroup b); 25.3 ± 4 (Subgroup c); 32.9 ± 2.3 (Subgroup d); 30.7 ± 3.8 (Subgroup e); 25.7 ± 4.8 (Subgroup f); 42 ± 4.7 (Subgroup g); 31.8 ± 3.8 (Subgroup h); and 28.5 ± 3 (Subgroup j). Subgroup g (3 bars-power levels/1 frequency application) had the highest burst pressure ( P < .001; ANOVA test). No significant difference was found between burst pressure of Subgroup g and Stapler group (42 ± 4.7 vs 42 ± 4.3, respectively, P = .9). On histological view, the LigaSure anastomosis was formed by collagen sealed without cavitation defects. Conclusions. Our study seems to confirm the feasibility of creating intestinal anastomosis using LigaSure. However, further researches in in vivo models are mandatory before recommending its clinical usage in such settings.