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Lee AY, Cho JY. Clinical diagnostic advances in intestinal anastomotic techniques: Hand suturing, stapling, and compression devices. World J Gastrointest Surg 2024; 16:1231-1234. [PMID: 38817301 PMCID: PMC11135308 DOI: 10.4240/wjgs.v16.i5.1231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Revised: 02/05/2024] [Accepted: 04/28/2024] [Indexed: 05/23/2024] Open
Abstract
The development of intestinal anastomosis techniques, including hand suturing, stapling, and compression anastomoses, has been a significant advancement in surgical practice. These methods aim to prevent leakage and minimize tissue fibrosis, which can lead to stricture formation. The healing process involves various phases: hemostasis and inflammation, proliferation, and remodeling. Mechanical staplers and sutures can cause inflammation and fibrosis due to the release of profibrotic chemokines. Compression anastomosis devices, including those made of nickel-titanium alloy, offer a minimally invasive option for various surgical challenges and have shown safety and efficacy. However, despite advancements, anastomotic techniques are evaluated based on leakage risk, with complications being a primary concern. Newer devices like Magnamosis use magnetic rings for compression anastomosis, demonstrating greater strength and patency compared to stapling. Magnetic technology is also being explored for other medical treatments. While there are promising results, particularly in animal models, the real-world application in humans is limited, and further research is needed to assess their safety and practicality.
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Affiliation(s)
- Ah Young Lee
- Division of Gastroenterology, Department of Internal Medicine, Cha Gangnam Medical Center, Cha University College of Medicine, Seoul 06135, South Korea
| | - Joo Young Cho
- Division of Gastroenterology, Department of Internal Medicine, Cha Gangnam Medical Center, Cha University College of Medicine, Seoul 06135, South Korea
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Vilhjalmsson D, Lepsenyi M, Syk I, Grönberg A, Thorlacius H. Transanal formation of anastomosis using C-REX device is feasible and effective in high anterior resection. Int J Colorectal Dis 2023; 38:127. [PMID: 37173554 PMCID: PMC10182144 DOI: 10.1007/s00384-023-04420-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 04/25/2023] [Indexed: 05/15/2023]
Abstract
PURPOSE C-REX is a novel instrument for creating stapleless colorectal anastomosis by compression. The aim of this study was to evaluate the feasibility and effectiveness of C-REX in open and laparoscopic high anterior resections. METHODS A prospective clinical safety study on 21 patients reconstructed with C-REX colorectal anastomosis following high anterior resection of the sigmoid colon using two different devices for intraabdominal (n = 6) or transanal (n = 15) placement of the anastomotic rings. Any signs of complications were prospectively monitored by a predefined protocol. Anastomotic contact pressure (ACP) was measured via a catheter-based system, and time for evacuation of the anastomotic rings by the natural route was noted. Blood samples were collected daily, and flexible endoscopy was performed postoperatively to examine macroscopic appearance of the anastomoses. RESULTS One of six patients operated with the intraabdominal anastomosis technique with an ACP of 50 mBar had to be reoperated because of anastomotic leakage. None of the 15 patients operated with the transanal technique (5 open and 10 laparoscopic procedures) had anastomotic complications, and their ACP ranged between 145 and 300 mBar. C-REX rings were uneventfully expelled by the natural route in all patients after a median of 10 days. Flexible endoscopy showed well-healed anastomoses without stenosis in 17 patients and a moderate subclinical stricture in one patient. CONCLUSION These results indicate that the novel transanal C-REX device is a feasible and effective method for colorectal anastomosis following high anterior resections, irrespective of open or laparoscopic approach. Moreover, C-REX allows measurement of intraoperative ACP and thereby a quantitative evaluation of the anastomotic integrity.
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Affiliation(s)
- Dadi Vilhjalmsson
- Department of Clinical Sciences, Section of Surgery, Malmö, Lund University, Malmö, 205 02, Sweden
| | - Mattias Lepsenyi
- Department of Clinical Sciences, Section of Surgery, Malmö, Lund University, Malmö, 205 02, Sweden
| | - Ingvar Syk
- Department of Clinical Sciences, Section of Surgery, Malmö, Lund University, Malmö, 205 02, Sweden
| | - Anders Grönberg
- Section of Development, CarpoNovum, Halmstad, 302 41, Sweden
| | - Henrik Thorlacius
- Department of Clinical Sciences, Section of Surgery, Malmö, Lund University, Malmö, 205 02, Sweden.
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Oliveira A, Faria S, Gonçalves N, Martins A, Leão P. Surgical approaches to colonic and rectal anastomosis: systematic review and meta-analysis. Int J Colorectal Dis 2023; 38:52. [PMID: 36814011 PMCID: PMC9947093 DOI: 10.1007/s00384-023-04328-6] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/28/2023] [Indexed: 02/24/2023]
Abstract
PURPOSE Postoperative complications after a colonic and rectal surgery are of significant concern to the surgical community. Although there are different techniques to perform anastomosis (i.e., handsewn, stapled, or compression), there is still no consensus on which technique provides the least number of postoperative problems. The objective of this study is to compare the different anastomotic techniques regarding the occurrence or duration of postoperative outcomes such as anastomotic dehiscence, mortality, reoperation, bleeding and stricture (as primary outcomes), and wound infection, intra-abdominal abscess, duration of surgery, and hospital stay (as secondary outcomes). METHODS Clinical trials published between January 1, 2010, and December 31, 2021, reporting anastomotic complications with any of the anastomotic technique were identified using the MEDLINE database. Only articles that clearly defined the anastomotic technique used, and report at least two of the outcomes defined were included. RESULTS This meta-analysis included 16 studies whose differences were related to the need of reoperation (p < 0.01) and the duration of surgery (p = 0.02), while for the anastomotic dehiscence, mortality, bleeding, stricture, wound infection, intra-abdominal abscess, and hospital stay, no significant differences were found. Compression anastomosis reported the lowest reoperation rate (3.64%) and the handsewn anastomosis the highest (9.49%). Despite this, more time to perform the surgery was required in compression anastomosis (183.47 min), with the handsewn being the fastest technique (139.92 min). CONCLUSIONS The evidence found was not sufficient to demonstrate which technique is most suitable to perform colonic and rectal anastomosis, since the postoperative complications were similar between the handsewn, stapled, or compression techniques.
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Affiliation(s)
- Ana Oliveira
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, 4710-057, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
- 3B's Research Group, I3Bs - Research Institute on Biomaterials, Biodegradables & Biomimetics; Headquarters of the European Institute of Excellence on Tissue Engineering & Regenerative Medicine, University of Minho, AvePark-Parque de Ciência e Tecnologia, Zona Industrial da Gandra, Barco, Guimarães, 4805-017, Portugal
| | - Susana Faria
- Centre of Mathematics (CMAT), Department of Mathematics, University of Minho, Guimarães, 4800-058, Portugal
| | - Nuno Gonçalves
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, 4710-057, Portugal
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
| | - Albino Martins
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal
- 3B's Research Group, I3Bs - Research Institute on Biomaterials, Biodegradables & Biomimetics; Headquarters of the European Institute of Excellence on Tissue Engineering & Regenerative Medicine, University of Minho, AvePark-Parque de Ciência e Tecnologia, Zona Industrial da Gandra, Barco, Guimarães, 4805-017, Portugal
| | - Pedro Leão
- Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, 4710-057, Portugal.
- ICVS/3B's-PT Government Associate Laboratory, Braga/Guimarães, Portugal.
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Steger J, Jell A, Ficht S, Ostler D, Eblenkamp M, Mela P, Wilhelm D. Systematic Review and Meta-Analysis on Colorectal Anastomotic Techniques. Ther Clin Risk Manag 2022; 18:523-539. [PMID: 35548666 PMCID: PMC9081039 DOI: 10.2147/tcrm.s335102] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2021] [Accepted: 03/18/2022] [Indexed: 11/23/2022] Open
Abstract
Purpose Anastomosis creation after resective gastrointestinal surgery is a crucial task. The present review examines the techniques and implants currently available for anastomosis creation and analyses to which extent they already address our clinical needs, with a special focus on their potential to enable further trauma minimization in visceral surgery. Methods A multi-database research was conducted in MEDLINE, Scopus, and Cochrane Library. Comparative controlled and uncontrolled clinical trials dealing with anastomosis creation techniques in the intestinal tract in both German and English were included and statistically significant differences in postoperative complication incidences were assessed using the RevMan5.4 Review Manager (Cochrane Collaboration, Oxford, UK). Results All methods and implant types were analyzed and compared with respect to four dimensions, assessing the techniques’ current performances and further potentials for surgical trauma reduction. Postoperative outcome measures, such as leakage, stenosis, reoperation and mortality rates, as well as the tendency to cause bleeding, wound infections, abscesses, anastomotic hemorrhages, pulmonary embolisms, and fistulas were assessed, revealing the only statistically significant superiority of hand-suture over stapling anastomoses with respect to the occurrence of obstructions. Conclusion Based on the overall complication rates, it is concluded that none of the anastomosis systems addresses the demands of operative trauma minimization sufficiently yet. Major problems are furthermore either low standardization potentials due to dependence on the surgeons’ levels of experience, high force application requirements for the actual anastomosis creation, or large and rigid device designs interfering with flexibility demands and size restrictions of the body’s natural access routes. There is still a need for innovative technologies, especially with regard to enabling incisionless interventions.
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Affiliation(s)
- Jana Steger
- Technical University of Munich, TUM School of Medicine, Chair of Research Group Minimally Invasive Interdisciplinary Therapeutical Intervention (MITI), Munich, Germany
- Correspondence: Jana Steger, Tel +49 89 4140-5898, Email
| | - Alissa Jell
- Technical University of Munich, TUM School of Medicine, Chair of Research Group Minimally Invasive Interdisciplinary Therapeutical Intervention (MITI), Munich, Germany
- Technical University of Munich, TUM School of Medicine, Clinic and Polyclinic for Surgery, Munich, Germany
| | - Stefanie Ficht
- Technical University of Munich, TUM School of Engineering and Design, Department of Mechanical Engineering and Munich Institute of Biomedical Engineering, Chair of Medical Materials and Implants, Garching, Germany
| | - Daniel Ostler
- Technical University of Munich, TUM School of Medicine, Chair of Research Group Minimally Invasive Interdisciplinary Therapeutical Intervention (MITI), Munich, Germany
| | - Markus Eblenkamp
- Technical University of Munich, TUM School of Engineering and Design, Department of Mechanical Engineering and Munich Institute of Biomedical Engineering, Chair of Medical Materials and Implants, Garching, Germany
| | - Petra Mela
- Technical University of Munich, TUM School of Engineering and Design, Department of Mechanical Engineering and Munich Institute of Biomedical Engineering, Chair of Medical Materials and Implants, Garching, Germany
| | - Dirk Wilhelm
- Technical University of Munich, TUM School of Medicine, Chair of Research Group Minimally Invasive Interdisciplinary Therapeutical Intervention (MITI), Munich, Germany
- Technical University of Munich, TUM School of Medicine, Clinic and Polyclinic for Surgery, Munich, Germany
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Reischl S, Wilhelm D, Friess H, Neumann PA. Innovative approaches for induction of gastrointestinal anastomotic healing: an update on experimental and clinical aspects. Langenbecks Arch Surg 2020; 406:971-980. [PMID: 32803330 PMCID: PMC8208906 DOI: 10.1007/s00423-020-01957-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2020] [Accepted: 08/04/2020] [Indexed: 12/17/2022]
Abstract
PURPOSE In most cases, traditional techniques to perform an anastomosis following gastrointestinal resections lead to successful healing. However, despite focused research in the field, in certain high-risk situations leakage rates remain almost unchanged. Here, additional techniques may help the surgeon to protect the anastomosis and prevent leakage. We give an overview of some of the latest developments on experimental and clinical techniques for induction of anastomotic healing. METHODS We performed a review of the current literature on approaches to improve anastomotic healing. RESULTS Many promising approaches with a high clinical potential are in the developmental pipeline. Highly experimental approaches like inhibition of matrix metalloproteinases, stem cell therapy, hyperbaric oxygen therapy, induction of the hypoxic adaptive response, and the administration of growth factors are still in the preclinical phase. Other more clinical developments aim to strengthen the anastomotic suture line mechanically while shielding it from the influence of the microbiome. Among them are gluing, seaming the staple line, attachment of laminar biomaterials, and temporary intraluminal tubes. In addition, individualized bowel preparation, selectively reducing certain detrimental microbial populations could become the next stage of bowel preparation. Compression anastomoses are evolving as an equivalent technique additional to established hand-sewn and stapled anastomoses. Fluorescence angiography and flexible endoscopy could complement intraoperative quality control additionally to the air leak tests. Virtual ileostomy is a concept to prepare the bowel for the easy formation of a stoma in case of leakage. CONCLUSION A variety of promising diagnostic and prophylactic measures that may support the surgeon in identifying high-risk anastomoses and support them according to their potential deficits is currently in development.
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Affiliation(s)
- Stefan Reischl
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Dirk Wilhelm
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Helmut Friess
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany
| | - Philipp-Alexander Neumann
- Department of Surgery, School of Medicine, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany.
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Hybrid fluorescent magnetic gastrojejunostomy: an experimental feasibility study in the porcine model and human cadaver. Surg Endosc 2019; 34:1393-1400. [DOI: 10.1007/s00464-019-06963-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2019] [Accepted: 07/01/2019] [Indexed: 02/08/2023]
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Chen M, Cao J, Huang D, Zhang B, Pan L, Zhang Z, Wang Z, Ye Y, Xiu D, Li D, Cai X. End-to-end intestinal anastomosis using a novel biodegradable stent for laparoscopic colonic surgery: a multicenter study. Surg Today 2019; 49:1003-1012. [PMID: 31256255 DOI: 10.1007/s00595-019-01841-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2019] [Accepted: 06/02/2019] [Indexed: 02/06/2023]
Abstract
PURPOSE Our animal studies have demonstrated the safety and feasibility of end-to-end intestinal anastomosis using a stent for laparoscopic colonic surgery. Therefore, we designed a non-inferiority trial to investigate the outcomes of stent anastomosis (SA) vs. those of conventional hand-sewn anastomosis (CA). METHODS A multicenter randomized controlled trial was conducted between December, 2016 and April, 2018. The primary outcome was the healing condition of the anastomoses, evaluated by endoscopy 6 months postoperatively. The secondary outcomes were the anastomotic completion time, anastomotic leak, intestinal obstruction, peritoneal effusion, and bleeding. Quality of life (QOL) was evaluated by questionnaires. RESULTS The subjects of this study were 60 patients, randomly divided into a SA group (n = 30) and a CA group (n = 30). There were no differences in anastomotic healing conditions (P = 1.00). The stent procedure was associated with a significantly shorter anastomosis time than the hand-sewn anastomosis (13.517 ± 4.281 vs. 20.333 ± 2.998 min, respectively; P < 0.001). There were no significant differences in anastomotic leakage, intestinal obstruction, peritoneal effusion, or bleeding between the groups. Questionnaires revealed almost no discrepancy between baseline QOL scores and those assessed 2, 4, 8, 12, and 24 weeks postoperatively in either group. CONCLUSIONS Intestinal anastomosis with a stent is a non-inferior strategy for laparoscopic colonic surgery, which requires less time for the anastomosis.
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Affiliation(s)
- Mingyu Chen
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
- Key Laboratory of Endoscopic Technique Research of Zhejiang Province, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China
| | - Jiasheng Cao
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
| | - Diyu Huang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
| | - Bin Zhang
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
| | - Long Pan
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China
| | - Zhongtao Zhang
- Department of General Surgery, Beijing Friendship Hospital, Capital Medical University, Beijing, 100032, China
| | - Zhenjun Wang
- Department of Anorectal Surgery, Beijing Chao-yang Hospital, Capital Medical University, Beijing, 100020, China
| | - Yingjiang Ye
- Department of Gastrointestinal Surgery, Peking University People's Hospital, Beijing, 100032, China
| | - Dianrong Xiu
- Department of General Surgery, Peking University Third Hospital, Beijing, 100089, China
| | - Dechuan Li
- Department of Colorectal Surgery, Zhejiang Cancer Hospital, Hangzhou, 310011, China
| | - Xiujun Cai
- Department of General Surgery, Sir Run-Run Shaw Hospital, Zhejiang University, No.3 East Qingchun Road, Hangzhou, 310016, China.
- Key Laboratory of Endoscopic Technique Research of Zhejiang Province, Sir Run-Run Shaw Hospital, Zhejiang University, Hangzhou, 310016, China.
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Tabola R, Cirocchi R, Fingerhut A, Arezzo A, Randolph J, Grassi V, Binda GA, D'Andrea V, Abraha I, Popivanov G, Di Saverio S, Zbar A. A systematic analysis of controlled clinical trials using the NiTi CAR™ compression ring in colorectal anastomoses. Tech Coloproctol 2017; 21:177-184. [PMID: 28132113 DOI: 10.1007/s10151-017-1583-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2016] [Accepted: 01/09/2017] [Indexed: 02/08/2023]
Abstract
Anastomotic leak following colorectal surgery can be a devastating adverse event. The ideal stapling device should be capable of rapid creation of an anastomosis with serosal apposition without the persistence of a foreign body or a foreign body reaction which potentially contribute to early anastomotic dehiscence or late anastomotic stricture. A systematic review was performed examining available data on controlled randomized and non-randomized trials assessing the NiTi compression anastomosis ring-(NiTi CAR™) (NiTi Solutions, Netanyah Israel) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards. A protocol for this meta-analysis has been registered on PROSPERO (CRD42016050934). The initial search yielded 45 potentially relevant articles. After screening titles and abstracts for relevance and assessment for eligibility, 39 of these articles were eventually excluded leaving 6 studies for analysis in the review. Regarding the primary outcome measure, the overall anastomotic leak rate was 2.2% (5/230) in the compression anastomosis group compared with 3% (10/335) in the conventional anastomosis group; this difference was not statistically significant (RR 0.75, 95% CI 0.25-2.24; participants = 565; studies = 6; I 2 = 0%). There were no statistically significant differences between compression and conventional anastomoses in any of the secondary outcomes. This review was unable to demonstrate any statistically significant differences in favor of the compression anastomosis technique over conventional manual or stapled mechanical anastomoses.
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Affiliation(s)
- R Tabola
- Department of General and Gastrointestinal Surgery, Medical University of Wrocław, Wrocław, Poland
| | - R Cirocchi
- Department of General and Oncologic Surgery, University of Perugia, Perugia, Italy.
| | - A Fingerhut
- Section for Surgical Research, Department of Surgery, Medical University of Graz, Graz, Austria
| | - A Arezzo
- Department of Surgical Sciences, University of Turin, Turin, Italy
| | - J Randolph
- Tift College of Education, Mercer University, Atlanta, GA, USA
| | - V Grassi
- Department of General and Oncologic Surgery, University of Perugia, Perugia, Italy
| | - G A Binda
- Colorectal Surgery Unit, Galliera Hospital, Genoa, Italy
| | - V D'Andrea
- Department of Surgical Sciences, "Sapienza" University of Rome, Rome, Italy
| | - I Abraha
- Department of Geriatrics and Geriatric Emergency Care, Italian National Research Center on Aging (IRCCS-INRCA), Ancona, Italy
| | - G Popivanov
- Department of Abdominal Surgery, Military Medical Academy, Sofia, Bulgaria
| | - S Di Saverio
- General (Colorectal), Emergency and Trauma Surgery Service, Maggiore Hospital Regional Emergency Surgery and Trauma Center, Bologna Local Health Services, Bologna, Italy
| | - A Zbar
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Ramat Gan, Israel.,Department of Anatomy, University of Otago, Dunedin, New Zealand
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Bobkiewicz A, Studniarek A, Krokowicz L, Szmyt K, Borejsza-Wysocki M, Szmeja J, Marciniak R, Drews M, Banasiewicz T. Gastrointestinal tract anastomoses with the biofragmentable anastomosis ring: is it still a valid technique for bowel anastomosis? Analysis of 203 cases and review of the literature. Int J Colorectal Dis 2017; 32:107-111. [PMID: 27695974 PMCID: PMC5219882 DOI: 10.1007/s00384-016-2661-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/19/2016] [Indexed: 02/04/2023]
Abstract
PURPOSE Biofragmentable anastomosis ring (BAR) is an alternative to manual and stapled anastomoses performed within the upper and lower gastrointestinal (GI) tract. The aim of this study was to evaluate the effectiveness of BAR utility for bowel anastomoses based on our own material. METHODS A retrospective analysis was performed to a total of 203 patients who underwent bowel surgery with the use of BAR anastomosis within upper and lower gastrointestinal tract between 2004 and 2014. Data for the analysis was collected based on medical records, treatment protocols, and the results of histological examinations. RESULTS The study group consisted of 86 women and 117 men. The most common underlying pathology was a malignant disease (n = 165). Biofragmentable anastomosis ring (BAR) size 31 was the most commonly used (n = 87). A total of 169 colocolic or colorectal anastomoses and 28 ileocolic and 8 enteroenteric anastomoses were performed. The mortality rate was 0.5 % (n = 1) whereas re-surgery rate within 30 days was 8.4 % (n = 17). Twenty-eight patients developed perioperative complications with surgical site infection as the most common one (n = 11). Eight patients developed specific complications associated with BAR including an anastomotic leak (n = 6) and intestinal obstruction (n = 2). The mean time of hospital stay after surgery was 12.7 days. CONCLUSIONS The use of BAR for the GI tract anastomoses is simple and rapid method and it is characterized with an acceptable number of perioperative mortality and complication rates. Based on our experience, we recommend the use of BAR anastomosis in different types of intestinal anastomosis in varying clinical scenarios.
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Affiliation(s)
- Adam Bobkiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland.
| | - Adam Studniarek
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Lukasz Krokowicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Krzysztof Szmyt
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Maciej Borejsza-Wysocki
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Jacek Szmeja
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Ryszard Marciniak
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Michal Drews
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
| | - Tomasz Banasiewicz
- Department of General, Endocrinological Surgery and Gastroenterological Oncology, Poznan University of Medical Sciences, Przybyszewskiego 49, 60-355, Poznan, Poland
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10
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Compression versus hand-sewn and stapled anastomosis in colorectal surgery: a systematic review and meta-analysis of randomized controlled trials. Tech Coloproctol 2016; 20:667-76. [PMID: 27554096 DOI: 10.1007/s10151-016-1521-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/01/2016] [Accepted: 07/04/2016] [Indexed: 12/17/2022]
Abstract
Anastomotic leaks are a feared complication of colorectal resections and novel techniques that have the potential to decrease them are still sought. This study aimed to compare the anastomotic leak rates in patients undergoing compression anastomoses versus hand-sewn or stapled anastomoses. Randomized controlled trials (RCTs) comparing outcomes of compression versus conventional (hand-sewn and stapled) colorectal anastomosis were collected from MEDLINE, Embase and the Cochrane Library. The quality of the RCTs and the potential risk of bias were assessed. Pooled odds ratios (OR) were calculated for categorical outcomes and weighted mean differences for continuous data. Ten RCTs were included, comprising 1969 patients (752 sutured, 225 stapled, and 992 compression anastomoses). Most used the biofragmentable anastomotic ring. There was no significant difference between the two groups in terms of anastomotic leak rates (OR 0.80, 95 % confidence interval (CI) 0.47, 1.37; p = 0.42), stricture (OR 0.54: 95 % CI 0.18, 1.64; p = 0.28) or mortality (OR 0.70; 95 % CI 0.39, 1.26; p = 0.24). Compression anastomosis was associated with an earlier return of bowel function: 1.02 (95 % CI 1.37, 0.66) days earlier (p < 0.001) and a shorter postoperative stay; 1.13 (95 % CI 1.52, 0.74) days shorter (p < 0.001), but significant heterogeneity among studies was observed. There was an increased risk of postoperative bowel obstruction in the compression group (OR 1.87; 95 % CI 1.07, 3.26; p = 0.03). There was no significant difference in wound-related and general complications, or length of surgery. Compression devices do not appear to provide an advantage over conventional techniques in fashioning colorectal anastomoses and are associated with an increased risk of bowel obstruction.
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Compression anastomotic ring-locking procedure (CARP) is a safe and effective method for intestinal anastomoses following left-sided colonic resection. Int J Colorectal Dis 2015; 30:969-75. [PMID: 25989929 DOI: 10.1007/s00384-015-2257-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 05/12/2015] [Indexed: 02/04/2023]
Abstract
BACKGROUND Compression anastomotic ring-locking procedure (CARP) is a novel procedure for creating colonic anastomoses. The surgical procedure allows perioperative quantification of the compression pressure between the intestinal ends within the anastomosis and postoperative monitoring of the anastomotic integrity. We have recently shown that CARP is a safe and effective method for colonic anastomoses in pigs, and the purpose of the present study was to evaluate CARP for colonic anastomoses in humans. MATERIALS AND METHODS This is a prospective study on 25 patients undergoing elective left-sided colonic resection. Time for evacuation of the anastomotic rings, perioperative compression pressure, and adverse effects were recorded. Postoperative blood samples were collected daily, and flexible sigmoidoscopy was performed 8-12 weeks after surgery to examine the anastomoses. RESULTS Fourteen out of 25 patients underwent CARP. CARP was not used in 11 patients due to advanced tumor disease (two cases) and size restrictions (nine cases). No case of anastomotic leakage, bowel obstruction, or stenosis formation was observed. No device-related perioperative adverse events were noted. The surgical device evacuated spontaneously in all patients by the natural route after a median of 10 days. Perioperative compression pressure ranged between 85 and 280 mBar (median 130 mBar). Flexible sigmoidoscopy revealed smooth anastomoses without signs of pathological inflammation or stenosis in all cases. CONCLUSION Our results indicate that the novel suture-less CARP is a safe and effective method for creating colonic anastomoses. Further studies are warranted in larger patient populations to compare CARP head-on-head with stapled and/or hand-sewn colonic anastomoses.
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Jang SI, Choi J, Lee DK. Magnetic compression anastomosis for treatment of benign biliary stricture. Dig Endosc 2015; 27:239-49. [PMID: 24905938 DOI: 10.1111/den.12319] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 05/30/2014] [Indexed: 12/13/2022]
Abstract
Endoscopic and percutaneous procedures have shown high success rates when used to treat benign biliary stricture. However, cases in which a guidewire cannot be passed through a refractory stricture or a complete obstruction are difficult to treat using conventional methods. Magnetic compression anastomosis (MCA) has emerged as a non-surgical alternative avoiding operational mortality and morbidity. The feasibility and safety of MCA have been experimentally and clinically verified in cases of biliobiliary and bilioenteric anastomosis. However, no pre-MCA assessment modality capable of predicting outcomes is as yet available, and no universally effective magnet delivery method has as yet been established, rendering it difficult to identify patients for whom MCA is appropriate. Various experimental studies seeking to overcome these limitations are underway. Such work will improve our in-depth understanding of MCA, which has been trialed in various fields. Upon further development, MCA may become a ground-breaking option for treatment of benign strictures that are difficult to resolve using conventional methods, and MCA may be expected to be minimally traumatic and highly effective. The aim of the present study was to discuss the current status of MCA and the direction of MCA development by reviewing clinical and experimental MCA data.
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Affiliation(s)
- Sung Ill Jang
- Department of Internal Medicine, Kangnam Sacred Heart Hospital, Hallym University College of Medicine, Seoul, Korea
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Vilhjalmsson D, Olofsson P, Syk I, Thorlacius H, Grönberg A. The compression anastomotic ring-locking procedure: a novel technique for creating a sutureless colonic anastomosis. Eur Surg Res 2014; 54:139-47. [PMID: 25531546 DOI: 10.1159/000368354] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Accepted: 09/15/2014] [Indexed: 11/19/2022]
Abstract
BACKGROUND/AIM Compression anastomoses might represent an improvement over traditional hand-sewn or stapled techniques. Herein, we describe a novel concept of sutureless colonic anastomosis named compression anastomotic ring-locking procedure (CARP). MATERIALS AND METHODS The surgical device consists of two anastomotic rings and their associated helping tools, facilitating the placement of the rings into the intestinal ends. Furthermore, four catheters are connected to the surgical device, allowing the evaluation of the anastomosis during and after surgery. A total of 31 pigs underwent a low colocolic anastomosis using the anastomotic rings. The compression pressure was measured perioperatively and up to 96 h after surgery. Anastomotic integrity and morphology were analyzed by use of radiology and histology, respectively. A long-term follow-up was conducted in a subgroup of pigs up to 108 days after surgery when the bursting pressure and stricture formation were examined. RESULTS All animals recovered uneventfully, and macroscopic examination revealed intact anastomoses without signs of pathological inflammation or adhesions. The perioperative compression pressure was inversely proportional to the gap size between the anastomotic rings. For example, an anastomotic gap of 1.5 mm created a colonic anastomosis with a perioperative compression pressure of 91 mbar, which remained constant for up to 48 h and resulted in a markedly increased compression pressure. Contrast infusion via the catheters effectively visualized the anastomoses, and no leakage was detected within the study. The surgical device was spontaneously evacuated from the intestines within 6 days after surgery. Histology showed collagen bridging of the anastomoses already 72 h after surgery. Long-term follow-up (54-108 days) revealed no stricture formation in the anastomoses, and the bursting pressure ranged from 120 to 235 mbar. The majority of bursts (10/12) occurred distant from the anastomoses. CONCLUSION We conclude that the surgical device associated to CARP is safe and efficient for creating colonic anastomoses. Further studies in patients undergoing colorectal surgery are warranted.
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Affiliation(s)
- Dadi Vilhjalmsson
- Section of Surgery, Department of Clinical Sciences, Lund University, Malmö, Sweden
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Zaritzky M, Ben R, Johnston K. Magnetic gastrointestinal anastomosis in pediatric patients. J Pediatr Surg 2014; 49:1131-7. [PMID: 24952802 DOI: 10.1016/j.jpedsurg.2013.11.002] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2013] [Revised: 10/29/2013] [Accepted: 11/02/2013] [Indexed: 12/11/2022]
Abstract
BACKGROUND/PURPOSE To describe 17 patients who underwent magnetic, non-surgical gastrointestinal (GI) anastomoses. METHODS Patients with GI obstruction, stenosis, or atresia were treated with image-guided and/or endoscopically placed discoid magnet pairs or catheter-based bullet-shaped magnet pairs. RESULTS Anastomosis was achieved in 7 days in an 11-year-old with gastric outlet obstruction due to metastatic colon cancer. Anastomosis was achieved in 8 and 10 days in 2 patients (age 2.0 years and 3.4 years) who had rectocolonic stenosis. Re-anastomosis was achieved in an average of 6 days (range 3 to 7 days) in 5 patients (age 6 months to 5.9 years) with severe recurrent postsurgical esophageal stenosis refractory to dilatation. Primary esophageal anastomosis was achieved in an average of 4.2 days (range 3 to 6 days) in 9 patients with esophageal atresia (Type A or Type C surgically converted to Type A) with a gap length of 4 cm or less. The average age of these esophageal atresia patients was 3 months (range 23 days to 5 months). CONCLUSION Minimally invasive magnet placement was feasible and achieved anastomosis in all patients.
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Affiliation(s)
- Mario Zaritzky
- Department of Radiology, The University of Chicago Medicine, Comer Children's Hospital, 5721S. Maryland Avenue, Chicago, IL 60637, USA.
| | - Ricardo Ben
- Department of Gastroenterology, Hospital de Niños de La Plata, Calle 14 Nro 1631, La Plata, Buenos Aires, Argentina
| | - Krystal Johnston
- MED Institute, Inc., 1 Geddes Way, West Lafayette, IN 47906, USA
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Kwag SJ, Kim JG, Kang WK, Lee JK, Oh ST. Niti CAR 27 Versus a Conventional End-to-End Anastomosis Stapler in a Laparoscopic Anterior Resection for Sigmoid Colon Cancer. Ann Coloproctol 2014; 30:77-82. [PMID: 24851217 PMCID: PMC4022756 DOI: 10.3393/ac.2014.30.2.77] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Accepted: 07/24/2013] [Indexed: 01/04/2023] Open
Abstract
PURPOSE The Niti CAR 27 (ColonRing) uses compression to create an anastomosis. This study aimed to investigate the safety and the effectiveness of the anastomosis created with the Niti CAR 27 in a laparoscopic anterior resection for sigmoid colon cancer. METHODS In a single-center study, 157 consecutive patients who received an operation between March 2010 and December 2011 were retrospectively assessed. The Niti CAR 27 (CAR group, 63 patients) colorectal anastomoses were compared with the conventional double-stapled (CDS group, 94 patients) colorectal anastomoses. Intraoperative, immediate postoperative and 6-month follow-up data were recorded. RESULTS There were no statistically significant differences between the two groups in terms of age, gender, tumor location and other clinical characteristics. One patient (1.6%) in the CAR group and 2 patients (2.1%) in the CDS group experienced complications of anastomotic leakage (P = 0.647). These three patients underwent a diverting loop ileostomy. There were 2 cases (2.1%) of bleeding at the anastomosis site in the CDS group. All patients underwent a follow-up colonoscopy (median, 6 months). One patient in the CAR group experienced anastomotic stricture (1.6% vs. 0%; P = 0.401). This complication was solved by using balloon dilatation. CONCLUSION Anastomosis using the Niti CAR 27 device in a laparoscopic anterior resection for sigmoid colon cancer is safe and feasible. Its use is equivalent to that of the conventional double-stapler.
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Affiliation(s)
- Seung-Jin Kwag
- Department of Surgery, Gyeongsang National University, Postgraduate School of Medicine, Jinju, Korea
| | - Jun-Gi Kim
- Department of Surgery, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Won-Kyung Kang
- Department of Surgery, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Jin-Kwon Lee
- Department of Surgery, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
| | - Seong-Taek Oh
- Department of Surgery, The Catholic University of Korea, Seoul St. Mary's Hospital, Seoul, Korea
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Histopathologic advantages of compression ring anastomosis healing as compared with stapled anastomosis in a porcine model: a blinded comparative study. Dis Colon Rectum 2014; 57:506-13. [PMID: 24608308 DOI: 10.1097/dcr.0000000000000009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The performances of compression and stapled devices were compared previously in porcine colorectal anastomosis. The compression anastomosis was associated with elevated bursting strength and anastomotic patency in this model as compared with the stapled anastomosis. OBJECTIVE The purpose of this work was to compare the histopathologic features between compression and stapled methods in the healing of colorectal anastomoses using a porcine model. DESIGN This was a blinded comparison study. SETTINGS The study was conducted at a single university surgery department. PATIENTS Fifty crossbred pigs were used in this study. MAIN OUTCOME MEASURES Fifty crossbred pigs underwent rectal transection 20 cm from the anal verge and end-to-end compression or stapled anastomosis. The anastomotic tissues were harvested 3, 7, 30, and 90 days postoperatively (n = 5-6). Tissue repair parameters associated with the wound healing were analyzed using image analysis morphometry and histological architecture assessments. RESULTS A different microscopic pattern of the anastomotic area was shown between groups. Foreign body response was rated (p < 0.001) as minimal in the compression and moderate in the stapled group. The scarring area in the compression anastomosis group, on postoperative day 90 (4 ± 3 × 10(5) μm) was lower (p = 0.016) than in the stapled group (2 ± 1 × 10(6) μm). In addition, the anastomotic line was narrower (p = 0.003) 90 days after surgery in the compression samples (0.77 ± 0.20 mm) compared with that in the stapled group (1.86 ± 0.19 mm). Lastly, in terms of inflammatory cells, the compression biopsies showed lower (p < 0.001) numbers of mononuclear cells, polymorphonuclear cells, and lymphocytes in the anastomotic tissues 30 and 90 days from surgery. LIMITATIONS The long-term effect of the compression technique on the anastomotic patency in colorectal anastomoses should be further investigated in human studies. CONCLUSIONS Compression anastomotic healing was associated with less foreign body reactions, scarring, and inflammation as compared with stapled anastomoses in a large animal model.
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An GS, Huai ZQ, Sheng Z, Min ZS, Wen YJ, Ming HD, Xing ZZ. Innovative magnetic rings for circumferential mucosectomy: preliminary research. Surg Today 2014; 45:78-82. [DOI: 10.1007/s00595-014-0878-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2013] [Accepted: 02/13/2014] [Indexed: 11/30/2022]
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Kusnierz K, Lekston Z, Zhavoronkov D, Mrowiec S, Lampe P. A nickel–titanium memory-shape device for gastrojejunostomy: comparison of the compression anastomosis clip and a hand-sewn anastomosis. J Surg Res 2014; 187:94-100. [DOI: 10.1016/j.jss.2013.10.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2013] [Revised: 10/01/2013] [Accepted: 10/03/2013] [Indexed: 01/13/2023]
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Kopelman D. Compression anastomosis, the optimal hollow viscus anastomosis: are we there yet? Expert Rev Med Devices 2014; 4:423-5. [PMID: 17605675 DOI: 10.1586/17434440.4.4.423] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Kopelman D, Hatoum OA, Kimmel B, Monassevitch L, Nir Y, Lelcuk S, Rabau M, Szold A. Compression gastrointestinal anastomosis. Expert Rev Med Devices 2014; 4:821-8. [DOI: 10.1586/17434440.4.6.821] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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21
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A modular magnetic anastomotic device for minimally invasive digestive anastomosis: proof of concept and preliminary data in the pig model. Surg Endosc 2014; 28:1613-23. [DOI: 10.1007/s00464-013-3360-2] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2013] [Accepted: 11/28/2013] [Indexed: 12/24/2022]
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Yan X, Fan C, Ma J, Li J, Dong D, Wang H, Ma F, Zheng X, Lv Y. Portacaval shunt established in six dogs using magnetic compression technique. PLoS One 2013. [PMID: 24098809 DOI: 10.1371/journal.pone.0076873pone-d-13-21426] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND AND AIMS Installing the transjugular intrahepatic portosystemic shunt for portal hypertension is relatively safe, but complications are still high. To explore a new method of portacaval shunt, the magnetic compression technique was introduced into the shunting procedure. METHODS A portal-inferior vena cava shunt was performed on 6 male mongrel dogs by two hemocompatible Nd-Fe-B permanent magnets, parent and daughter. The parent magnet was applied to the inferior vena cava guided by a catheter through the femoral vein. The daughter magnet was moved to the anastomosis position on the portal vein with a balloon catheter through the splenic vein. After the daughter magnet reached the target position, the two magnets acted to compress the vessel wall and hold it in place. Five to 7 days later, under X-ray guidance, the magnets were detached from the vessel wall with a rosch-uchida transjugular liver access set. One month later, histological analysis and portal venography were performed. RESULTS 5-7 days after the first surgery, a mild intimal hyperplasia in the portal vein and the inferior vena cava, and continuity of the vascular adventitia from the portal vein to the inferior vena cava as observed. During the second surgery, the contrast media could be observed flowing from the portal vein into the inferior vena cava. Portal venography revealed that the portosystemic shunt was still present one month after the second surgery. CONCLUSIONS Magnamosis via a device of novel design was successfully used to establish a portacaval shunt in dogs.
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Affiliation(s)
- Xiaopeng Yan
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi'an Jiaotong University, Xi'an Shaanxi Province, China ; XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi'an Jiaotong University, Xi'an Shaanxi Province, China
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Yan X, Fan C, Ma J, Li J, Dong D, Wang H, Ma F, Zheng X, Lv Y. Portacaval shunt established in six dogs using magnetic compression technique. PLoS One 2013; 8:e76873. [PMID: 24098809 PMCID: PMC3786958 DOI: 10.1371/journal.pone.0076873] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2013] [Accepted: 08/28/2013] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND AND AIMS Installing the transjugular intrahepatic portosystemic shunt for portal hypertension is relatively safe, but complications are still high. To explore a new method of portacaval shunt, the magnetic compression technique was introduced into the shunting procedure. METHODS A portal-inferior vena cava shunt was performed on 6 male mongrel dogs by two hemocompatible Nd-Fe-B permanent magnets, parent and daughter. The parent magnet was applied to the inferior vena cava guided by a catheter through the femoral vein. The daughter magnet was moved to the anastomosis position on the portal vein with a balloon catheter through the splenic vein. After the daughter magnet reached the target position, the two magnets acted to compress the vessel wall and hold it in place. Five to 7 days later, under X-ray guidance, the magnets were detached from the vessel wall with a rosch-uchida transjugular liver access set. One month later, histological analysis and portal venography were performed. RESULTS 5-7 days after the first surgery, a mild intimal hyperplasia in the portal vein and the inferior vena cava, and continuity of the vascular adventitia from the portal vein to the inferior vena cava as observed. During the second surgery, the contrast media could be observed flowing from the portal vein into the inferior vena cava. Portal venography revealed that the portosystemic shunt was still present one month after the second surgery. CONCLUSIONS Magnamosis via a device of novel design was successfully used to establish a portacaval shunt in dogs.
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Affiliation(s)
- Xiaopeng Yan
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Chao Fan
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- Department of General Surgery, Tangdu Hospital, Fourth Military Medical University, Xi’an Shaanxi Province, China
| | - Jia Ma
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Jianhui Li
- Department of Surgical Oncology, Third Affiliated Hospital, College of Medicine, Xi’an Jiaotong University (Shaanxi Provincial People’s Hospital), Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Dinghui Dong
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Haohua Wang
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Feng Ma
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Xinglong Zheng
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
| | - Yi Lv
- Department of Hepatobiliary Surgery, First Affiliated Hospital, College of Medicine, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- XJTU Research Institute of Advanced Surgical Technology and Engineering, Xi’an Jiaotong University, Xi’an Shaanxi Province, China
- * E-mail:
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Lambe T, Ríordáin MGÓ, Cahill RA, Cantillon-Murphy P. Magnetic compression in gastrointestinal and bilioenteric anastomosis: how much force? Surg Innov 2013; 21:65-73. [PMID: 23592733 DOI: 10.1177/1553350613484824] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
AIM The concept of compression alimentary anastomosis is well established. Recently, magnetic axial alignment pressures have been encompassed within such device constructs. We quantify the magnetic compression force and pressure required to successfully achieve gastrointestinal and bilioenteric anastomosis by in-depth interrogation of the reported literature. METHODS Reports of successful deployment and proof of anastomotic patency on survival were scrutinized to quantify the necessary dimensions and strengths of magnetic devices in (a) gastroenteral anastomosis in live porcine models and (b) bilioenteric anastomosis in the clinical setting. Using a calculatory tool developed for this work (magnetic force determination algorithm, MAGDA), ideal magnetic force and compression pressure were quantified from successful reports with regard to their variance by intermagnet separation. RESULTS Optimized ranges for both compression force and pressure were determined for successful porcine gastroenteral and clinical bilioenteric anastomoses. For gastroenteral anastomoses (porcine investigations), an optimized compression force between 2.55 and 3.57 kg at 2-mm intermagnet separation is recommended. The associated compression pressure should not exceed 60 N/cm(2). Successful bilioenteric anastomoses is best clinically achieved with intermagnet compression of 18 to 31 g and associated pressures between 1 and 3.5 N/mm(2) (at 2-mm intermagnet separation). CONCLUSION The creation of magnetic compression anastomoses using permanent magnets demonstrates a remarkable resilience to variations in magnetic force and pressure exertion. However, inappropriate selection of compression characteristics and magnet dimensions may incur difficulties. Recommendations of this work and the availability of the free online tool (http://magda.ucc.ie/) may facilitate a factor of robustness in the design and refinement of future devices.
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Kusnierz K, Morawiec H, Lekston Z, Zhavoronkov D, Lucyga M, Lampe P. NiTi Shape Memory Compression Anastomosis Clip in Small- and Large-Bowel Anastomoses. Surg Innov 2013; 20:580-5. [DOI: 10.1177/1553350612474494] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The aim of the study was to present a clinical use of compression anastomosis clip (CAC) implants made of shape memory materials—nickel titanium alloys (NiTi). The concept involved in the use of CAC was to compress 2 bowel walls together, cause necrosis, and detach the CAC from the tissue to be expelled with the stool. The CAC is a double-ring elliptical device with a diameter of 30 mm. The device has the ability to recover its original closed shape when it senses a change in ambient temperature. In all, 20 anastomoses using CACs were performed: 6 of the small with the large bowel and 14 between the small bowel and small bowel. Two patients experienced complications. Although the anastomosis is not difficult to perform, the rules on how to apply the CAC must be well known. Because only a small number of anastomoses have been performed by us to date, this procedure requires further study.
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Compression anastomosis ring device in colorectal anastomosis: a review of 1,180 patients. Am J Surg 2013; 205:447-51. [PMID: 23290352 DOI: 10.1016/j.amjsurg.2012.03.013] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2011] [Revised: 02/19/2012] [Accepted: 03/04/2012] [Indexed: 12/22/2022]
Abstract
BACKGROUND The nickel-titanium compression anastomosis ring device (ColonRing, NiTi Surgical Solutions, Netanya, Israel) has been cleared by the Food and Drug Administration in 2006 to construct gastrointestinal anastomoses. We evaluated the anastomotic leak rate after end-to-end anastomosis using the ColonRing device. METHODS Using a multinational (16 countries), multicenter (178 centers) data registry provided by NiTi Surgical Solutions, Netanya, Israel, we retrospectively examined clinical data of patients who underwent elective laparoscopic or open left-sided colectomy and anterior resection from January 2008 to June 2010. RESULTS A total of 1,180 patients underwent end-to-end anastomosis using the ColonRing device during the study period. The overall anastomotic leak rate was 3.22% (38 patients). The median length of hospital stay was 6 days (range 2 to 21 days). The median ring expulsion time was 8 days. The earliest ring expulsion time was 6 days; however, in 1 patient, the ring did not expel. In 4 patients, the anastomosis had to be immediately recreated because of 1 misfiring and 3 incomplete anastomoses. CONCLUSIONS The use of the ColonRing device is feasible and safe and could be considered an alternative technology for end-to-end colorectal anastomosis.
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Marano L, Braccio B, Schettino M, Izzo G, Cosenza A, Grassia M, Porfidia R, Reda G, Petrillo M, Esposito G, Di Martino N. Sutureless jejuno-jejunal anastomosis in gastric cancer patients: a comparison with handsewn procedure in a single institute. BMC Surg 2012; 12 Suppl 1:S27. [PMID: 23173807 PMCID: PMC3499244 DOI: 10.1186/1471-2482-12-s1-s27] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND The biofragmentable anastomotic ring has been used to this day for various types of anastomosis in the gastrointestinal tract, but it has not yet achieved widespread acceptance among surgeons. The purpose of this retrospective study is to compare surgical outcomes of sutureless with suture method of Roux-and-Y jejunojejunostomy in patients with gastric cancer. METHODS Two groups of patients were obtained based on anastomosis technique (sutureless group versus hand sewn group): perioperative outcomes were recorded for every patient. RESULTS The mean time spent to complete a sutureless anastomosis was 11 ± 4 min, whereas the time spent to perform hand sewn anastomosis was 23 ± 7 min. Estimated intraoperative blood loss was 178 ± 32 ml in the sutureless group and 182 ± 23 ml in the suture-method group with no significant differences. No complications were registered related to enteroanastomosis. Intraoperative mortality was none for both groups. CONCLUSIONS The Biofragmentable Anastomotic Ring offers a safe and time-saving method for the jejuno-jejunal anastomosis in gastric cancer surgery, and for this purpose the ring has been approved as a standard method in our clinic. Nevertheless currently there are few studies on upper gastrointestinal sutureless anastomoses and this could be the reason for the low uptake of this device.
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Affiliation(s)
- Luigi Marano
- Institution VIII General and Gastrointestinal Surgery, Chief Prof N Di Martino, School of Medicine, Second University of Naples, Piazza Miraglia 2, 80138 Naples, Italy.
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Gonzales KD, Douglas G, Pichakron KO, Kwiat DA, Gallardo SG, Encinas JL, Hirose S, Harrison MR. Magnamosis III: delivery of a magnetic compression anastomosis device using minimally invasive endoscopic techniques. J Pediatr Surg 2012; 47:1291-5. [PMID: 22703808 DOI: 10.1016/j.jpedsurg.2012.03.042] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 03/06/2012] [Indexed: 12/11/2022]
Abstract
PURPOSE Magnamosis creates a secure sutureless anastomosis through magnetic compression. In this study, we further develop and test delivery devices capable of creating a secure duodeno-colonic anastomosis using available minimally invasive endoscopic techniques. METHODS Eight pigs underwent general anesthesia. Colonoscopy was used to deliver 1 magnetic ring to the hepatic flexure. Simultaneously, upper endoscopy delivered the other magnetic ring into the duodenum using a variety of techniques. The 2 magnetic rings were brought into magnetic proximity under laparoscopic guidance. The pigs were recovered and examined daily followed by sacrificing at 1, 2, 4, and 6 weeks. RESULTS The device designed to deliver and release each magnetic ring evolved from using a guide wire and balloon devices to redesigning the magnetic ring casing with a groove to accommodate an endoscopic snare. Laparoscopic visualization assured safe magnet mating of intestinal segments. The duodeno-colonic anastomoses created with the snare yielded widely patent anastomoses. In vitro testing revealed excellent burst pressure. Histology revealed complete healing as early as 1 week. CONCLUSION We redesigned the magnamosis device to facilitate delivery by endoscopic techniques. The snare technique allows endoscopic positioning and controlled release of the magnetic rings for a secure side-to-side duodeno-colonic anastomosis.
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Affiliation(s)
- Kelly D Gonzales
- Department of Surgery, University of California, San Francisco, San Francisco, CA 94143-0570, USA
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Zbar AP, Nir Y, Weizman A, Rabau M, Senagore A. Compression anastomoses in colorectal surgery: a review. Tech Coloproctol 2012; 16:187-99. [PMID: 22534832 DOI: 10.1007/s10151-012-0825-6] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2011] [Accepted: 02/28/2012] [Indexed: 12/15/2022]
Abstract
The main serious risks of anastomotic construction in the colon and rectum include dehiscence and stricture formation. There is a resurgence of interest in sutureless anastomoses formed by compression elements since the introduction of shape memory alloy (SMA) systems, which evoke minimal early inflammatory response whilst maintaining anastomotic integrity. Currently, the most commonly used SMA is the nickel-titanium (NiTi) alloy that is highly biocompatible, returning to its pre-deformed stable (austenite) shape under different mechanical and thermal loads for use in humans. Pre-clinical data for shape memory alloy systems in colorectal anastomoses are limited, but it appears to be safe in porcine and canine models with limited leakage and reduced stricture formation. There does not appear to be any difference in tissue biochemistry of inflammatory markers when compared with conventional stapled techniques, although the few studies available show a markedly reduced early inflammatory response at the anastomotic site with the NiTi device. The majority of the clinical data concerning compression anastomoses are derived from the biofragmentable anastomotic ring device. This device has fallen out of use because of reported leaks, instrumental failure and problems with device expulsion. A novel SMA device, the NiTi anastomotic ring, permits construction of a low rectal anastomosis construction during open or laparoscopic procedures. The preliminary data demonstrate a safety comparable to conventional staple technology. This device also provides the potential of benefit of reduced anastomotic inflammation, because the compression ring results in direct serosa-to-serosa (or alternatively serosa-to-muscularis propria) apposition without the persistence of residual foreign material. This type of construction could lead to a reduced incidence of early anastomotic leakage and/or the development of anastomotic stenosis. Randomized clinical trials employing a NiTi arm for elective, emergency and high-risk colorectal anastomoses are required to determine its indications and clinical profile as well as to assess whether such technology may selectively obviate the need for proximal diversion in low colorectal anastomoses.
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Affiliation(s)
- A P Zbar
- Department of Surgery and Transplantation, Chaim Sheba Medical Center, Sackler Medical School, Tel Aviv University, Tel Aviv, Israel.
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Leroy J, Perretta S, Diana M, Wall J, Lindner V, Harrison M, Marescaux J. An original endoluminal magnetic anastomotic device allowing pure NOTES transgastric and transrectal sigmoidectomy in a porcine model: proof of concept. Surg Innov 2011; 19:109-16. [PMID: 22143749 DOI: 10.1177/1553350611429029] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION While experimental natural orifice transluminal endoscopic surgery (NOTES) sigmoid colectomies have been reported, pure NOTES anastomoses are restricted by the limited reach of commercially available circular staplers. MAGNAMOSIS is a set of self-orienting magnetic rings that can be delivered endoluminally throughout the colon to generate a compression anastomosis. Aim. To assess the feasibility of a pure NOTES transrectal (TR) and transgastric (TG) approach to perform any segmental colectomy. MATERIALS AND METHODS One pig (50 kg) underwent the experimental procedure as follows: (a) creation of the TG access to the peritoneal cavity, (b) precise transluminal placement of the proximal MAGNAMOSIS ring, (c) creation of the TR access with the TEO and transrectal dissection of the sigmoid mesentery, (d) resection of the surgical specimen, (e) transrectal extraction of the specimen, (f) delivery and mating of the distal MAGNAMOSIS ring, and (g) closure of the TG and TR viscerotomies. The animal survived for 14 days at which time burst pressure and histology were performed. RESULTS A pure NOTES TR and TG segmental colectomy was performed in 139 minutes. The postoperative course was uneventful. The animal had a formed bowel movement including the magnetic rings on postoperative day 5. Endoscopic examination at postoperative day 14 revealed a patent anastomosis. Necropsy revealed no abscess or signs of peritonitis. Burst pressure was >198 mm Hg. The histology showed a sealed anastomosis with mild inflammation. CONCLUSIONS MAGNAMOSIS enabled a totally NOTES partial colectomy with combined TG and TR access. The flexible delivery options and low cost of manufacturing could make MAGNAMOSIS an attractive alternative to circular staplers.
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Affiliation(s)
- Joël Leroy
- IRCAD/EITS Institute, University Hospital of Strasbourg, Strasbourg, France.
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Compression anastomoses in colon and rectal surgery with the NiTi ColonRing™. Tech Coloproctol 2011; 16:29-35. [PMID: 22139026 DOI: 10.1007/s10151-011-0794-1] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/12/2011] [Accepted: 11/18/2011] [Indexed: 12/23/2022]
Abstract
BACKGROUND The aim of this prospective study was to evaluate safety and efficacy of the NiTi ColonRing™ for anastomoses on the colon or rectum. METHODS During the period September 2008-June 2011, anastomosis using the NiTi ColonRing™ was scheduled to be performed on 60 patients (36 females, 24 males/mean aged 67 years), 53 of whom underwent colectomy for cancer and 7 reconstruction after Hartmann's procedure. Application of the device failed in one case due to anatomical reasons. Colorectal resections performed were as follows: Right hemicolectomy (5 patients), left colectomy (2), sigmoidectomy (15) and low anterior resection (31). A follow-up clinic visit after 1 month was planned for all patients. Ten patients among the first 14 had rectosigmoidoscopy at 2-3 months. All cancer patients were scheduled for colonoscopy at 12 months. RESULTS No intraoperative or postoperative bleeding related to the anastomotic technique was recorded. Median hospital stay after surgery was 10.2 days (9-22 days). One patient died on day 13 due to myocardial infarction. Clinically apparent leak was detected in one patient who had undergone reconstruction after Hartmann; the only treatment required was total parenteral nutrition for 12 days. Anastomotic stenosis occurred in another one patient who had undergone reconstruction after Hartmann; it was easily resolved by balloon dilatation. Mild complications were encountered in 23 other patients (39%). Oral feeding started after day 4. Anastomotic rings were expelled naturally within 7-17 days (mean, 9.2 days). A satisfactory anastomosis was revealed in patients examined colonoscopically at 2-3 and 12 months. Mean follow-up was 15.2 months (2-33 months). CONCLUSIONS NiTi ColonRing™ is reliable, safe and efficacious for large bowel anastomoses.
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Smart Self-Assembling MagnetS for ENdoscopy (SAMSEN) for transoral endoscopic creation of immediate gastrojejunostomy (with video). Gastrointest Endosc 2011; 73:353-9. [PMID: 21183179 DOI: 10.1016/j.gie.2010.10.024] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2010] [Accepted: 10/13/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND Gastrojejunostomy is important for palliation of malignant gastric outlet obstruction and surgical obesity procedures. A less-invasive endoscopic technique for gastrojejunostomy creation is conceptually attractive. Our group has developed a compression anastomosis technology based on endoscopically delivered self-assembling magnets for endoscopy (SAMSEN) to create an instant, large-caliber gastrojejunostomy. OBJECTIVE To develop and evaluate an endoscopic means of gastrojejunostomy creation by using SAMSEN. SETTING Developmental laboratory and animal facility. DESIGN Animal study and human cadaveric study. SUBJECTS Yorkshire pigs (7 cadaver, 5 acute); human (1 cadaver). INTERVENTIONS A transoral procedure for SAMSEN delivery was developed in porcine and human cadaver models. Subsequently, gastrojejunostomy creation by using SAMSEN was performed in 5 acute pigs. The endoscope was advanced into the peritoneal cavity through the gastrotomy, and a segment of the small bowel was grasped and pulled closer to the stomach. An enterotomy was created, and a custom overtube was advanced into the small bowel for deployment of the first magnetic assembly. Next, a reciprocal magnetic assembly was deployed in the stomach. The 2 magnetic systems were mated under fluoroscopic and endoscopic guidance. Contrast studies assessed for gastrojejunostomy leak. Immediate necropsies were performed. MAIN OUTCOME MEASUREMENTS Technical feasibility and complications. RESULTS Gastrojejunostomy creation by using SAMSEN was successful in all 5 animals. Deep enteroscopy was performed through the stoma without difficulty. No leaks were identified on contrast evaluation. At necropsy, the magnets were properly deployed and robustly coupled together, resistant to vigorous tissue manipulation. LIMITATIONS Acute animal study. CONCLUSIONS Endoscopic creation of immediate gastrojejunostomy by using SAMSEN is technically feasible.
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Pichakron KO, Jelin EB, Hirose S, Curran PF, Jamshidi R, Stephenson JT, Fechter R, Strange M, Harrison MR. Magnamosis II: Magnetic compression anastomosis for minimally invasive gastrojejunostomy and jejunojejunostomy. J Am Coll Surg 2011; 212:42-9. [PMID: 21184956 DOI: 10.1016/j.jamcollsurg.2010.09.031] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2010] [Revised: 09/16/2010] [Accepted: 09/22/2010] [Indexed: 12/22/2022]
Abstract
BACKGROUND Previously we demonstrated the safety and patency of a magnetic compression anastomosis (magnamosis). We present the further development of this technique, with specific focus on optimizing device design for minimally invasive magnamosis. STUDY DESIGN The magnamosis device was designed to incorporate 3 features: 2 convex-concave radially symmetric halves that magnetically self-align, a central channel for immediate patency, and specially engineered radial topography of the mating surfaces to promote gradual remodeling. Each symmetrical half consists of a ring-shaped neodymium-iron-boron magnet encased in polycarbonate casing. Twenty-one young adult pigs underwent either magnetic gastrojejunostomy (n = 13) or jejunojejunostomy (n = 8). Animals were euthanized at 1, 2, 4, and 6 weeks after operation. Anastomoses were studied with contrast radiography, burst pressure, and histology. RESULTS Gastrojejunostomy: In all animals with successful placement of magnets, anastomoses were patent by contrast fluoroscopy, well healed by histologic examination, and showed excellent burst strength. Jejunojejunostomy: All animals had uneventful clinical courses, indicating that the magnamosis with immediate patency functioned properly without device dislodgement. At sacrifice, all magnamoses were patent, well healed by histology, and had burst strengths that equaled or exceeded that of traditional stapled anastomoses. CONCLUSIONS Minimally invasive placement of a custom magnetic device in the stomach and jejunum allows intraluminal self-alignment and subsequent compression anastomosis over 3 to 10 days. The magnamosis is immediately patent and develops strength equal to or greater than that of hand-sewn or stapled anastomoses. Magnamosis is effective in the pig model, and may be a safe, effective, and minimally invasive alternative to current anastomotic strategies in humans.
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Buchberg BS, Masoomi H, Bergman H, Mills SD, Stamos MJ. The use of a compression device as an alternative to hand-sewn and stapled colorectal anastomoses: is three a crowd? J Gastrointest Surg 2011; 15:304-10. [PMID: 21063913 PMCID: PMC3035790 DOI: 10.1007/s11605-010-1376-7] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/10/2010] [Accepted: 10/19/2010] [Indexed: 01/31/2023]
Abstract
BACKGROUND The NiTi CAR™ 27 is a newer device that uses compression to create an anastomosis. An analysis of this device in the creation of colorectal anastomoses in humans has yet to be reported in the USA. METHODS A non-randomized, prospective pilot study of the NiTi CAR™ 27 device in patients undergoing a left-sided colectomy between March 2008 and August 2009 was performed. RESULTS Twenty-three patients (9 men and 14 women) underwent a left-sided colectomy and compression anastomosis with the CAR™ 27 device. Minor morbidities, 3 of 23 (13%) patients, included one small postoperative abscess requiring antibiotics alone and two postoperative anastomotic strictures requiring balloon dilation. Major morbidities, 1 of 23 (4%) patients, included a partial anastomotic dehiscence/leak requiring surgical dismantling of the anastomosis and diversion. CONCLUSION The CAR™ 27 device shows promise as a safe and effective alternative for the creation of colorectal anastomoses. However, studies in a larger patient population are warranted to demonstrate equivalence of this device.
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Affiliation(s)
- Brian S. Buchberg
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
| | - Hossein Masoomi
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
| | - Herlinda Bergman
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
| | - Steven D. Mills
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
| | - Michael J. Stamos
- Department of Surgery, University of California-Irvine Medical Center, 333 City Blvd. West, Suite 700, Orange, CA 92868 USA
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Tulchinsky H, Kashtan H, Rabau M, Wasserberg N. Evaluation of the NiTi Shape Memory BioDynamix ColonRing™ in colorectal anastomosis: first in human multi-center study. Int J Colorectal Dis 2010; 25:1453-8. [PMID: 20556401 DOI: 10.1007/s00384-010-0985-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/04/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND Shape-memory compression bowel anastomosis using a nickel and titanium alloy may reduce leak rates and eliminate foreign anastomotic material. Its safety and efficacy had been demonstrated by animal studies. We conducted the first prospective multi-center clinical evaluation of the safety and effectiveness of BioDynamix anastomosis with ColonRing™ for large-bowel end-to-end or side-to-end anastomosis. MATERIALS AND METHODS The ColonRing™ was compared to the standard double-stapled colorectal/colocolonic anastomosis. Intraoperative and immediate postoperative and 1- and 3-month postoperative follow-up data were recorded. RESULTS Ten study patients (four males, median age 62 years, range 35-75) were compared to 13 demographically matched controls (six males, median age 62 years, range 47-82). Colorectal neoplasia was the most frequent indication for surgery (21/23 patients, 91%). The median anastomotic distance from the anal verge for both groups was 10 cm (6-20 cm). The first postoperative bowel movement was on day 5 ±2.2 (study group) and on day 4 ±1.8 (controls), and the median hospital stay was 8 days (6-14 days) and 7 days (6-13 days), respectively. There were no anastomotic leaks. There were three minor complications in each group, unrelated to the device in the study group. Two patients required transanal digital extraction of the ring which was detached but not expelled (one had a soft anastomotic stricture). CONCLUSIONS Our preliminary results in this first study on humans indicate that the safety and efficacy of BioDynamix anastomosis with ColonRing™ in colorectal anastomosis in human is comparable to standard staples technology and warrant larger studies for further validation.
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Affiliation(s)
- Hagit Tulchinsky
- Department of Surgery B, Tel Aviv Sourasky Medical Center, 6 Weizman Street, Tel Aviv, Israel, 64239.
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Abstract
Colorectal anastomotic leak remains one of the most feared post-operative complications, particularly after anterior resection of the rectum with, the shift from abdomino-peritoneal resections to total mesorectal excision and primary anastomosis. The literature fails to demonstrate superiority of stapled over hand-sewn techniques in colorectal anastomosis, regardless of the level of anastomosis, although a high stricture rate was noted in the former technique. Thus, improvements in safety aspects of anastomosis and alternatives to hand-sewn and stapled techniques are being sought. Here, we review alternative anastomotic techniques used to fashion bowel anastomosis. Compression anastomosis using compression anastomotic clips, endoluminal compression anastomotic rings, AKA-2, biofragmental anastomotic rings, or Magnamosis all involve the concept of creating a sutureless end-to-end anastomosis by compressing two bowel ends together, leading to a simultaneous necrosis and healing process that joins the two lumens. Staple line reinforcement is a new approach that reduce the drawbacks of staplers used in colorectal practice, i.e. leakage, bleeding, misfiring, and inadequate tissue approximation. Various non-absorbable, semi or fully absorbable materials are now available. Two other techniques can provide alternative anastomotic support to the suture line: a colorectal drain and a polyester stent, which can be utilized in ultra-low rectal excision and can negate the formation of a defunctioning stoma. Doxycycline coated sutures have been used to overcome the post-operative weakness in anastomosis secondary to rapid matrix degradation mediated by matrix metalloproteinase. Another novel technique, the electric welding system, showed promising results in construction of a safe, neat, smooth sutureless bowel anastomosis. Various anastomotic techniques have been shown to be comparable to the standard techniques of suturing and stapling. However, most of these alternatives need to be accepted and optimized for future use.
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Kopelman Y, Siersema PD, Nir Y, Szold A, Bapaye A, Segol O, Willenz EP, Lelcuk S, Geller A, Kopelman D. Endoluminal compression clip: full-thickness resection of the mesenteric bowel wall in a porcine model. Gastrointest Endosc 2009; 70:1146-57. [PMID: 19647245 DOI: 10.1016/j.gie.2009.05.015] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2008] [Accepted: 05/01/2009] [Indexed: 01/12/2023]
Abstract
BACKGROUND Performing a full-thickness intestinal wall resection of a sessile polyp located on the mesenteric side with a compression clip may lead to compression of mesenteric vessels. The application of such a clip may therefore cause a compromised blood supply in the particular bowel segment, leading to perforation. OBJECTIVE To evaluate the performance of a newly developed, nitinol compression clip, called the NiTi clamp, for full-thickness resection of the bowel wall, while the clip is deliberately deployed endoluminally on the mesenteric side. DESIGN Prospective animal study. Multinational, multidisciplinary; gastroenterology and general surgery, research cooperation. SETTING Animal research laboratory. INTERVENTION Six pigs were operated upon and endoscopically evaluated and then killed after 3 weeks. Linear compression closure clips based on nitinol springs were used. Three longitudinal enterotomies were performed: in the cecum, spiral colon, and proximal rectum. Four clips were deployed in each animal. MAIN OUTCOME MEASUREMENTS A total of 23 clips were deployed. The average expulsion day was 9 days. RESULTS All but 3 clips were normally expelled. One pig developed bowel ischemia due to intussusception. In endoscopic procedures, no signs of significant segmental mucosal ischemia were found. The macroscopic appearance of the compression closure lines was thin and delicate, but epithelialization was significantly delayed at 5 sites. LIMITATION Differences between porcine and human colorectal anatomy. CONCLUSION Full-thickness clamping of the bowel with the NiTi clamp, including the local mesenteric vasculature, does not significantly impair local healing of the clamp site and gives hope to further development of novel full-thickness endoscopic resection technologies.
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Affiliation(s)
- Yael Kopelman
- Gastroenterology Institute, Israel Institute of Technology, Haifa, Israel.
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Jamshidi R, Stephenson JT, Clay JG, Pichakron KO, Harrison MR. Magnamosis: magnetic compression anastomosis with comparison to suture and staple techniques. J Pediatr Surg 2009; 44:222-8. [PMID: 19159747 DOI: 10.1016/j.jpedsurg.2008.10.044] [Citation(s) in RCA: 75] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2008] [Accepted: 10/07/2008] [Indexed: 12/11/2022]
Abstract
PURPOSE An ideal anastomosis between hollow viscera should be easily performed, strong, and operator independent. We hypothesized that transluminal attraction between magnets in the intestine could be harnessed to create an intestinal compression anastomosis (magnamosis) with these characteristics. We further hypothesized that variation of attraction force and geometry of compression would affect the quality of the intestinal anastomosis. METHODS We designed a self-orienting device composed of 2 neodymium-iron-boron magnets affixed to polytetrafluoroethylene moldings. Two topologies were evaluated: one designed with 'uniform' compression and the other with 'gradient' compression. Sixteen young adult pigs (Sus scrofa) underwent laparotomy with creation of a magnetic side-to-side anastomosis: 8 with the uniform device and 8 with the gradient device. Each also had a stapled anastomosis, and 5 had an additional hand-sutured anastomosis. Animals were euthanized at 1, 2, and 3 weeks after operation, then anastomoses were compared on the basis of gross appearance, histology, functional radiography, and mechanical integrity. RESULTS All magnetic devices formed patent anastomoses without leak. One stapled anastomosis resulted in a contained leak. Mechanical integrity of magnetic anastomoses was not statistically significantly different from staple or suture counterparts, and there was a trend toward greater strength with magnetic anastomoses. Comparison between device types revealed the gradient device trended toward greater strength and earlier patency (67% vs 33% at 1 week). There was no evidence of stenosis, and histologic examination demonstrated tissue remodeling with mucosal and serosal apposition across the magnamoses. CONCLUSIONS The magnetic compression anastomosis (magnamosis) device is a safe and effective means of sutureless full-thickness intestinal anastomosis with serosal apposition in a pig model. Gradient compression is superior to uniform compression. This technique is compatible with endoscopic and natural orifice approaches.
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Affiliation(s)
- Ramin Jamshidi
- Department of Surgery, University of California San Francisco, CA 94143-0570, USA
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Liu PC, Jiang ZW, Zhu XL, Wang ZM, Diao YQ, Li N, Li JS. Compression anastomosis clip for gastrointestinal anastomosis. World J Gastroenterol 2008; 14:4938-42. [PMID: 18756603 PMCID: PMC2739948 DOI: 10.3748/wjg.14.4938] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the feasibility of compression anastomosis clip (CAC) for gastrointestinal anastomosis proximal to the ileocecal junction.
METHODS: Sixty-six patients undergoing gastrointe-stinal anastomosis proximal to the ileocecal junction were randomized into two groups according to the anastomotic method, CAC or stapler.
RESULTS: The postoperative recovery of patients in CAC and stapled anastomosis groups was similar. No postoperative complication related to the anastomotic method was found in either group. Both upper gastrointestinal contrast radiography at the early postoperative course and endoscopic examination after a 6-mo follow-up showed a better healing at the compression anastomosis.
CONCLUSION: CAC can be used not only in colonic surgery but also in gastrointestinal anastomosis. Our result strongly suggests that CAC anastomosis is safe in various complication circumstances. However, it should be further confirmed with a larger patient sample.
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Kaidar-Person O, Rosenthal RJ, Wexner SD, Szomstein S, Person B. Compression anastomosis: history and clinical considerations. Am J Surg 2008; 195:818-26. [PMID: 18367149 DOI: 10.1016/j.amjsurg.2007.10.006] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2007] [Revised: 09/23/2007] [Accepted: 10/10/2007] [Indexed: 12/26/2022]
Abstract
BACKGROUND Despite the fact that the concept of compression anastomosis has been investigated for nearly 2 centuries, it has not yet achieved widespread acceptance. The aim of the current report is to review the literature regarding compression anastomoses. DATA SOURCES A multi-database search was conducted using PubMed, Ovid, and the Cochrane Databases (all until June 2007), in addition to electronic links to related articles and references of selected articles. The following terms were used for the search in various combinations: anastomosis, anastomoses, sutureless, compression, nickel-titanium; Nitinol; CAC; CAR; AKA-2, Valtrac biofragmentable anastomotic ring, BAR. Language restrictions were not applied. CONCLUSIONS The various methods of compression anastomosis have been shown to be at least comparable to the standard techniques of suturing and stapling. The measurement of outcomes, including cost, safety, and efficacy of treatment, indicated that compression anastomosis can save time, is cost-effective, and offers an acceptable cost/benefit ratio compared to both stapled and sutured anastomoses. However, compression anastomosis did not gain worldwide popularity.
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Affiliation(s)
- Orit Kaidar-Person
- Department of Colorectal Surgery, Cleveland Clinic Florida, Weston, FL, USA
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Franklin ME, Ramila GP, Treviño JM, González JJ, Russek K, Glass JL, Kim G. The use of bioabsorbable staple line reinforcement for circular stapler (BSG "Seamguard") in colorectal surgery: initial experience. Surg Laparosc Endosc Percutan Tech 2007; 16:411-5. [PMID: 17277658 DOI: 10.1097/sle.0b013e31802b68fe] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Of all the complications associated with colorectal surgery, the most devastating and constant, despite all techniques being performed properly is anastomotic leakage, especially in left colon and rectal resections with rates as high as 50% when the rectum is involved. In 2005, our center published the preliminary experience with the use of linear staple line reinforcement for colon surgery. The purpose of this paper is to present a series of cases using a new conformation of bioabsorbable reinforcement for circular staplers in 5 patients, 2 patients with rectal cancer, 2 patients with diverticular disease, and 1 patient with sigmoid cancer. These initial data are very promising and has encouraged us to continue using this device on further patients.
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