New double-stapled anastomotic technique to avoid crossing staple lines

Association Between Cross-Stapling Technique in Mechanical Colorectal Anastomosis and Short-term Outcomes

BACKGROUND

The double-stapled technique is the most common method of colorectal anastomosis in minimally invasive surgery. Several modifications to the conventional technique have been described to reduce the intersection between the stapled lines, as the resulting lateral dog-ears are considered possible risk factors for anastomotic leakage.

OBJECTIVE

This study aimed to analyze the outcomes of patients receiving conventional versus modified stapled colorectal anastomosis after minimally invasive surgery.

DATA SOURCES

A systematic review of the published literature was undertaken. PubMed/MEDLINE, Web of Science, and Embase databases were screened up to July 2023.

STUDY SELECTION

Relevant articles were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles reporting on the outcomes of patients with modified stapled colorectal reconstruction compared with the conventional method of double-stapled anastomosis were included.

INTERVENTIONS

Conventional double-stapling colorectal anastomosis and modified techniques with reduced intersection between the stapled lines were compared.

MAIN OUTCOME MEASURES

The rate of anastomotic leak was the primary end point of interest. Perioperative details including postoperative morbidity were also appraised.

RESULTS

There were 2537 patients from 12 studies included for data extraction, with no significant differences in age, BMI, or proportion of high ASA score between patients who had conventional versus modified techniques of reconstructions. The risk of anastomotic leak was 62% lower for the modified procedure than for the conventional procedure (OR = 0.38 [95% CI, 0.26-0.56]). The incidences of overall postoperative morbidity (OR = 0.57 [95% CI, 0.45-0.73]) and major morbidity (OR = 0.48 [95% CI, 0.32-0.72]) following modified stapled anastomosis were significantly lower than following conventional double-stapled anastomosis.

LIMITATIONS

The retrospective nature of most included studies is a main limitation, essentially because of the lack of randomization and the risk of selection and detection bias.

CONCLUSIONS

The available evidence supports the modification of the conventional double-stapled technique with the elimination of 1 of both dog-ears as it is associated with a lower incidence of anastomotic-related morbidity.

Magnetic resonance imaging-based deep learning model to predict multiple firings in double-stapled colorectal anastomosis

BACKGROUND

Multiple linear stapler firings during double stapling technique (DST) after laparoscopic low anterior resection (LAR) are associated with an increased risk of anastomotic leakage (AL). However, it is difficult to predict preoperatively the need for multiple linear stapler cartridges during DST anastomosis.

AIM

To develop a deep learning model to predict multiple firings during DST anastomosis based on pelvic magnetic resonance imaging (MRI).

METHODS

We collected 9476 MR images from 328 mid-low rectal cancer patients undergoing LAR with DST anastomosis, which were randomly divided into a training set (n = 260) and testing set (n = 68). Binary logistic regression was adopted to create a clinical model using six factors. The sequence of fast spin-echo T2-weighted MRI of the entire pelvis was segmented and analyzed. Pure-image and clinical-image integrated deep learning models were constructed using the mask region-based convolutional neural network segmentation tool and three-dimensional convolutional networks. Sensitivity, specificity, accuracy, positive predictive value (PPV), and area under the receiver operating characteristic curve (AUC) was calculated for each model.

RESULTS

The prevalence of ≥ 3 linear stapler cartridges was 17.7% (58/328). The prevalence of AL was statistically significantly higher in patients with ≥ 3 cartridges compared to those with ≤ 2 cartridges (25.0% vs 11.8%, P = 0.018). Preoperative carcinoembryonic antigen level > 5 ng/mL (OR = 2.11, 95%CI 1.08-4.12, P = 0.028) and tumor size ≥ 5 cm (OR = 3.57, 95%CI 1.61-7.89, P = 0.002) were recognized as independent risk factors for use of ≥ 3 linear stapler cartridges. Diagnostic performance was better with the integrated model (accuracy = 94.1%, PPV = 87.5%, and AUC = 0.88) compared with the clinical model (accuracy = 86.7%, PPV = 38.9%, and AUC = 0.72) and the image model (accuracy = 91.2%, PPV = 83.3%, and AUC = 0.81).

CONCLUSION

MRI-based deep learning model can predict the use of ≥ 3 linear stapler cartridges during DST anastomosis in laparoscopic LAR surgery. This model might help determine the best anastomosis strategy by avoiding DST when there is a high probability of the need for ≥ 3 linear stapler cartridges.

Double-stapled anastomosis without "dog-ears" reduces the anastomotic leakage in laparoscopic anterior resection of rectal cancer: A prospective, randomized, controlled study

Background

Anastomotic leakage (AL) is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate whether the resection of "dog-ears" in laparoscopic anterior resection of rectal cancer (called modified double-stapling technique, MDST) could reduce the rate of AL in patients with middle and high rectal cancer, as compared with the conventional double-stapling technique (DST).

Methods

The clinical data of 232 patients with middle and high rectal cancer were prospectively collected from September 2015 to October 2018. They were randomly divided into the MDST group (n = 116) and the DST group (n = 116) and the data were prospectively analyzed. Morbidity and AL rate were compared between the two groups.

Results

Patient demographics, tumor size, and time of first flatus were similar between the two groups. No difference was observed in the operation time between the two groups. The AL rate was significantly lower in the MDST group than in the DST group (3.4 vs. 11.2%, p = 0.032). The age and anastomotic technique were the factors associated with AL according to the multivariate analysis. The location of the AL in the DST group was further investigated, revealing that AL was in the same place as the "dog-ears" (11/13, 84.6%).

Conclusions

Our prospective comparative study demonstrated that MDST have a better short-term outcome in reducing AL compared with DST. Therefore, this technique could be an alternative approach to maximize the benefit of laparoscopic anterior resection on patients with middle and high rectal cancer. The "dog-ears" create stapled corners potentially ischemic, since they represent the area with high incidence of AL.(NCT:02770911).

Minimally invasive colorectal surgery learning curve

The learning curve in minimally invasive colorectal surgery is a constant subject of discussion in the literature. Discordant data likely reflects the varying degrees of each surgeon’s experience in colorectal, laparoscopic or robotic surgery. Several factors are necessary for a successful minimally invasive colorectal surgery training program, including: Compliance with oncological outcomes; dissection along the embryological planes; constant presence of an expert tutor; periodic discussion of the morbidity and mortality rate; and creation of a dedicated, expert team.

An innovative and convenient technique to reduce anastomotic leakage after double stapling anastomosis: laparoscopic demucositized suture the overlapping point of the "dog ear" area

Anastomotic leakage (AL) is a major cause of postoperative morbidity and mortality in the treatment of colorectal cancer. The aim of this study was to investigate an innovative and convenient technique of laparoscopic demucositized suture the overlapping point of the "dog ear" area after the double stapling anastomosis (lds-DSA), as an improved alternative for conventional DSA, and whether it could reduce the AL rate in laparoscopic anterior resection (Lapa-AR). Between January 2018 and December 2020, a total of 245 patients who underwent Lapa-AR for the treatment of adenocarcinoma of the sigmoid colon or rectal cancer were divided into the lsd-DSA group (n = 99) and the DSA group (n = 146). Data were analyzed retrospectively. Morbidity, AL rate and other perioperative outcomes were compared between the two groups. Patient demographics, preoperative comorbidity, preoperative chemoradiotherapy, tumor size, stage, and other operative details were comparable between the two groups. There was no difference in surgical time between the two groups (196.41 ± 76.71 vs. 182.39 ± 49.10 min, p = 0.088). The overall complication rate was also without a difference (11/99, 11.11% vs. 21/146, 14.38%, p = 0.456), but AL rate significantly lower in the lsd-DSA group than in the DSA group (2/99, 2.02% vs. 12/146, 8.22%, p = 0.040). For other perioperative outcomes, the lsd-DSA group shortened the total and postoperative hospital stay, and the time to pull out drainage tube than in the DSA group. Our comparative study demonstrates lds-DSA to have a better short-term outcome in reducing AL compared with DSA. This technique could be an alternative approach to maximize the patients' benefit in Lapa-AR.

Laparoscopic Low Anterior Resection and Eversion Technique Combined With a Nondog Ear Anastomosis for Mid- and Distal Rectal Neoplasms: A Preliminary and Feasibility Study

The transanal eversion and prolapsing technique is a well-established procedure, and can ensure an adequate distal margin for patients with low rectal neoplasms. Potential leakage risks, however, are associated with bilateral dog ear formation, which results from traditional double-stapling anastomosis. The authors determined the feasibility of combining these techniques with a commercial stapling set to achieve a nondog ear (end-to-end) anastomosis for patients with mid- and distal rectal neoplasms. Patients with early-stage (c/ycT1-2N0), mid- to distal rectal neoplasms and good anal sphincter function were included in this study. Laparoscopic low anterior resection was performed with a standard total mesorectal excision technique downward to the pelvic floor as low as possible. The bowel was resected proximal to the lesion with an endoscopic linear stapler. An anvil was inserted extracorporeally into the proximal colon via an extended working pore. The distal rectum coupled with the lesion was prolapsed and everted out of the anus. The neoplasm was resected with a sufficient margin above the dentate line under direct sight. A transrectal anastomosis without dog ears was performed intracorporeally to reconstitute the continuity of the bowel. Eleven cases, 6 male and 5 female patients, were included in this study. The mean operative time was 191 (129-292) minutes. The mean blood loss was 110 (30-300) mL. The median distal margin distance from the lower edge of the lesion to the dentate line was 1.5 (0.5-2.5) cm. All the resection margins were negative. Most patients experienced uneventful postoperative recoveries. No patient had anastomotic leak. Most patients had an acceptable stool frequency after loop ileostomy closure. Our preliminary data demonstrated the safety and feasibility of achieving a sound anastomosis without risking potential anastomotic leakage because of dog ear formation.