Obtaining secure stapling of a double stapling anastomosis. J Surg Res. 2015;193:652-657. [PMID: 25277356 DOI: 10.1016/j.jss.2014.08.044]

Compression pre-stapler firing and post-ignition wait during sleeve gastrectomy: a prospective randomized trial

BACKGROUND

Insufficient research exists on the stapling technique in and duration of laparoscopic sleeve gastrectomy (LSG).

OBJECTIVES

This study aimed to assess the clinical outcomes using a 30-second precompression and post-firing waiting time without extra support for the stapling line.

DESIGN AND SETTINGS

Randomized controlled prospective study at a university hospital.

METHODS

This study included 120 patients treated between January 2022 and February 2023. The patients were divided into the non-waiting group (T0) and waiting group (T1), each with 60 patients. Perioperative complications were analyzed using statistical tests.

RESULTS

The waiting group (T1) showed a significant reduction in the number of intraoperative bleeding points requiring intervention compared with the non-waiting group (T0) (81 versus 134, P < 0.05). In T0, postoperative C-reactive protein (CRP) levels increased (P < 0.05) and hemoglobin levels decreased significantly (P <0.05). The study recorded 22 postoperative complications, accounting for 18.3% of all cases during the 30-day postoperative period.

CONCLUSIONS

The study concluded that the 30 sec + 30 sec stapling technique reduces perioperative bleeding, length of stay, and serious complication rates and is practical and effective for LSG.

CLINICAL TRIAL REGISTRATION

ClinicalTrials.gov with registration code NCT05703035; link: https://clinicaltrials.gov/ct2/show/NCT05703035.

Long-Term Outcomes of Laparoscopic Greater Curvature Plication and Laparoscopic Sleeve Gastrectomy: Critical Appraisal of the Role of Gastric Plication in Bariatric Surgery

Background and Objectives: This single-center study aimed to assess the role of laparoscopic greater curvature plication (LGCP) in bariatric surgery. Materials and Methods: Using data from our institution’s prospectively maintained database, we identified adult patients with obesity who underwent either laparoscopic sleeve gastrectomy (LSG) or LGCP between January 2012 and July 2017. In total, 280 patients were enrolled in this study. Results: The body mass index was higher in the LSG group than in the LGCP group (39.3 vs. 33.3, p < 0.001). Both groups achieved significant weight loss during the 3-year follow-up (p < 0.001). The weight-reduction rate was higher in the LSG group than in the LGCP group 6, 12, and 24 months postoperatively (p = 0.001, 0.001, and 0.012, respectively). The reoperation rate of the LGCP group was higher than that of the LSG group (p = 0.001). No deaths were recorded in either group. Conclusions: Although both the LGCP and LSG groups achieved significant weight loss over three years, the LGCP group demonstrated a lower weight-reduction rate and a higher reoperation rate than the LSG group. Thus, it is necessary to reassess the role of LGCP in bariatric surgery, particularly when LSG is a feasible alternative.

Short-Term Outcomes of Tri-Staple Versus Universal Staple in Laparoscopic Anterior Resection of Rectal and Distal Sigmoid Colonic Cancer: A Matched-Pair Analysis

BACKGROUND

Anastomotic leakage is a serious complication in laparoscopic colorectal surgeries. To resolve this problem, a new stapling technology (Tri-staple) is developed. In this study, we aim to compare the short-term outcomes of Tri-staple versus Universal staple in laparoscopic anterior resection of rectal and distal sigmoid colonic cancer.

METHODS

A total of 446 patients were admitted to our hospital and received laparoscopic anterior resection for rectal and distal sigmoid colonic cancer between January 2016 and December 2020. Among them, Tri-staples were used in 202 patients, and the Universal staples were used in 244 patients. Propensity score matching was performed, followed by a comparison between the two groups (Tri-staple vs. Universal staple) in the incidences of anastomotic leakage, bleeding, and reoperation.

RESULTS

In total, 270 patients were included in this retrospective cohort study by the propensity score matching, with each group having 135 patients. Tri-staple group had a significant lower incidence of anastomotic leakage compared with the Universal staple group (4.44% vs. 11.11%, P < 0.05). The reoperation rate was also lower in Tri-staple group than the Universal staple group (3.70% vs. 8.15%, P < 0.05). The anastomotic bleeding rates, average postoperative hospital stay, average drain indwelling period, and average fasting period had no statistical differences between the two groups.

CONCLUSION

The usage of Tri-staple in laparoscopic anterior resection of rectal and distal sigmoid colonic cancer is associated with lower postoperative complications compared with Universal staple. Future high-quality randomized controlled trials are needed to confirm our findings.

Strategy to Avoid Anastomotic Leakage in Laparoscopic Colorectal Resection Using the Indocyanine Green Fluorescence System

Purpose

Anastomotic leakage (AL) in colorectal resections is often caused by insufficient blood flow to the stump. Injecting indocyanine green can help detect blood flow intraoperatively. In this study, we evaluated our original strategy using an indocyanine green fluorescence system to avoid AL.

Methods

We retrospectively evaluated 79 patients who underwent laparoscopic colorectal resection for colon cancer using a double-stapling technique. Blood flow in oral stumps was evaluated by measuring indocyanine green fluorescence time (FT). We investigated AL cases in detail and analyzed correlations between FT and risk factors for AL.

Results

Of the 79 patients, 7 (8.9%) developed AL. We divided patients by FTs: &gt;60 seconds, 50 to 60 seconds, and &lt;50 seconds. The AL rates were FT &gt;60 seconds, 60%; FT 50 to 60 seconds, 10.3%; and FT &lt;50 seconds, 2.2%. The AL rate of high-risk cases (with more than 2 risk factors) were calculated and we made our original strategy to avoid AL as the following. Further resection or diverting stomas were needed by the FT &gt;60 seconds group, and by members of the FT 50 to 60 seconds group with ≥3 risk factors. The FT &lt;60 seconds group needed no additional management.

Conclusions

Patients with delayed FT (&gt;60 seconds, or 50–60 seconds with ≥3 risk factors) may need revision of the anastomosis (diverting stoma or additional resection) to avoid AL. Our original strategy may contribute to reduce AL in colorectal operations.

Compression injury of the circular stapler for gastrointestinal end-to-end anastomosis: preliminary in-vitro study

Purpose

This preliminary in-vitro study was designed to evaluate the risk factors of compression injury from use of a circular stapler for end-to-end anastomosis.

Methods

Transparent collagen plates were prepared in dry and wet conditions. Physical properties of collagen plates and porcine colon tissue were examined using a rheometer. Adjustable and fixed-type circular staplers were applied on the collagen plates and the gap distance and compressive pressure were measured during anvil approximation. Tissue injury was evaluated using a compression injury scale. Compression properties were accessed to optimal or overcompression based on gap distance.

Results

Unacceptable injuries were rarely observed on the dry collagens, regardless of compression device. In the adjustable compression, the compressibility ratio was similar between dry and wet collagen. Overcompression and unacceptable injury increased on the wet collagens. In the fixed compression, the compressibility ratio increased significantly and unacceptable injuries were observed in more than 50% of wet collagens. Peak pressure was significantly higher in the fixed-compression types than those of adjustable type. On bivariate correlation analysis, fixed-compression type and wet collagens were respectively associated with overcompression. On multivariate analysis, edematous collagen condition was the most important risk factor and proximal anvil side, fixed compression type, and overcompression were also independent risk factors for unacceptable compression injury.

Conclusion

In the edematous tissue condition, unintentional overcompression could be increased and result in tissue injury on the compression line of the circular stapler.

Clinical Outcomes of Laparoscopic Greater Curvature Plication and Laparoscopic Sleeve Gastrectomy: a Case-Matched Control Study

BACKGROUND

Laparoscopic greater curvature plication (LGCP) is a new bariatric procedure that is similar to laparoscopic sleeve gastrectomy (LSG) in that it uses a restrictive mechanism. Comparative studies between LGCP and LSG were still limited. The aim of this study was to compare the clinical outcomes of the two procedures based on the same clinical conditions.

METHODS

From January 2012 to December 2015, 260 patients with morbid obesity underwent LGCP and LSG in a single center. Data on patient demography, operation time, complications, hospital stay, body mass index loss, percentage of excess weight loss (%EWL), and improvement in comorbidities were collected. A propensity-matched analysis, incorporating pre-operative variables, was used to compare the short-term outcomes between LGCP and LSG.

RESULTS

Propensity matching produced 48 patients in each group. Patients who underwent LGCP were predominately female (75.5%, 41.1% of the LSG patients were female, p = 0.028). Baseline BMI and excess weight were significantly lower in the LGCP group (p < 0.001). The LSG group showed a greater decrease in excess body weight than the LGCP group (LSG, 47.36 ± 12.95% in 3 months, 57.97 ± 19.28% in 6 months, 66.28 ± 25.42% in 12 months; LGCP, 39.67 ± 12.58% in 3 months, 47.40 ± 19.30% in 6 months, 48.02 ± 20.17% in 12 months, p = 0.008, 0.032, 0.010). Perioperative complications and resolution of obesity-related comorbidities were not significantly different between the two groups.

CONCLUSION

LGCP and LSG are both feasible and safe procedures for surgical weight reduction. In short-term follow-ups, LSG demonstrates a better excess body weight reduction while having perioperative complications similar to LGCP.

Anatomical basis for the choice of laparoscopic surgery for low rectal cancer through the pelvic imaging data-a cohort study

Background

Low rectal cancer surgery without anus conservation needs permanent ileostomy or colostomy which seriously affects the quality of life of patients. Therefore, low rectal cancer surgery not only pays attention to the safety of surgical treatment but also to the anus conservation.

Methods

Sixty-seven patients suffering from low rectal cancer had undergone laparoscopic surgery which was analyzed through retrospective study. They were divided into the anus-conserving and non-anus-conserving groups. Thirty-five set of pelvic data was obtained from the preoperative CT and MRI images. After that, the discriminant function was obtained to predict the surgery methods for patients with low rectal carcinoma.

Results

Anal-conserving group discriminant function (F1) = − 33.698 + 6.045 × anal margin distance (cm) + 1.105 × T4; non-anus-conserving group discriminant function (F2) = − 14.125 + 3.138 × anal margin distance (cm) + 0.804 × T4. If F1 is greater than F2, then the case can be treated as the anus reservation while if F2 is greater than F1 the case cannot be treated anus reservation. The accuracy of the discriminant function was evaluated which was found to be 97%.

Conclusion

The discriminant function of pelvic data provides anatomical basis for the choice of surgical methods for low rectal cancer.

Overlap Anastomosis for Digestive Reconstruction during Laparoscopic Distal Gastrectomy with Intensive Regional Lymph Node Dissection: Physiological Impact of Preserving the Mesenteric Autonomic Nerves in the Lifted Jejunal Limb

Laparoscopic gastrectomy is a treatment for gastric cancer, and isoperistaltic side-to-side reconstruction is called "overlap anastomosis." The physiological advantages of preserving the autonomic nerves in the jejunal limb for digestive reconstruction are well known. Here, we focused on overlap anastomosis with autonomic nerve-preserved mesojejunum of the lifted jejunal limb for laparoscopic distal gastrectomy with intentional lymph node dissection. Our surgical techniques and technical pitfalls were described in detail. The jejunum was partially sacrificed to preserve the autonomic nerves in the lifted jejunal limb. The length of the staple line was 35 - 40 mm. The endostapler entry was carefully closed to avoid even subtle stenosis. Twelve patients were retrospectively evaluated with a follow-up of 5.0 ± 0.6 years. Histological findings according to the Japanese classification were stage IA or IB. Dietary intake and postoperative ambulation occurred at 3.3 ± 1.0 and 1.3 ± 0.5 days after surgery, respectively. Postoperative complications according to Clavien-Dindo classification were one each of grade I and grade II. Postoperative hospital stay was 6.7 ± 1.6 days. Five patients were medication-free at final follow-up, with no recurrence in any patient. Overlap anastomosis with autonomic nerve-preserved jejunal limb was safe and feasible for laparoscopic distal gastrectomy with lymph node dissection.

Effects of precompression time and strength on the physical characteristics of quasi-stapled porcine small intestinal tissue

Precompression is vital when performing gastrointestinal anastomosis with staplers. However, research on the internal changes in intestinal tissue under stapling is lacking, and the effects of precompression have not been clarified. In this study, a stapler was modified, and the multifrequency bioimpedance of porcine small intestinal tissue was measured from before clamping the tissue with the stapler until the release of the tissue after precompression without firing. The Cole _Y model was fitted to the bioimpedance, and the changes in the tissue were analyzed using the model parameters: G₀, extracellular fluid conductance, and Δ G, intracellular fluid conductance. The results show that the changes of G₀ and Δ G could be divided into four stages: rapid decrease, slow decrease, intense resilience, and slow recovery. During slow decrease stage, there was a greater decrease of G₀ and Δ G (1.02E-05 ± 1.12E-05 S and 1.73E-05 ± 2.12E-05 S in precompression time's increase, 1.68E-05 ± 8.74E-06 S and 1.20E-05 ± 1.09E-05 S in precompression strength's increase). On the contrary, during intense resilience stage, there was a less increase of G₀ and Δ G (0.88E-05 ± 4.86E-05 S and 9.15E-05 ± 9.37E-05 S in precompression time's increase, 2.72E-05 ± 3.53E-05 S and 1.02E-04 ± 8.54E-05 S in precompression strength's increase). In conclusion, the effects of precompression factors on tissue have been preliminary revealed: the tissue under precompression becomes thinner and less resilient. To improve the precompression effects and reduce any excessive pressure exerted on the staples by tissue resilience, the precompression time and strength should be increased appropriately.

Secure overlap stapling using a linear stapler with bioabsorbable polyglycolic acid felt

INTRODUCTION

Despite the availability of various anastomosis techniques, postoperative anastomotic complications such as anastomosis failure and bleeding develop in some patients. Automatic suturing devices have been widely used for gastrointestinal anastomosis. However, overly thick or thin tissue, displacement of tissue, and the creation of a staple-on-staple site may lead to incomplete staple formation. These factors are considered to be related to postoperative complications such as anastomosis failure.

METHODS

The iDrive™ Ultra Powered Stapling System was used to fire the automatic suturing device. Two types of automatic suturing devices were employed: (i) the Endo GIA™ Reinforced Reload with Tri-Staple™ Technology with a cartridge with the reinforcement material Neoveil™; and (ii) the Endo GIA™ with Tri-Staple™ Technology with no reinforcement material. Stapling was performed using a two-stage crossing approach to make a staple-on-staple site.

RESULTS

The rates of complete formation with the Endo GIA™ with Tri-Staple™ Technology were 95.6 ± 0.6% for stomach tissue and 95.6 ± 2.3% for colon tissue, which is thinner than stomach tissue. In contrast, the rates of complete formation with the Endo GIA™ Reinforced Reload with Tri-Staple™ Technology were 99.3 ± 1.27% for stomach tissue and 100.0 ± 0.0% for colon tissue.

CONCLUSION

Our results showed that the Endo GIA™ Reinforced Reload with Tri-Staple™ Technology had higher rates of complete staple formation than the Endo GIA™ with Tri-Staple™ Technology, irrespective of tissue thickness and the presence of a staple-on-staple site.

ICG fluorescence imaging for quantitative evaluation of colonic perfusion in laparoscopic colorectal surgery

BACKGROUND

Fluorescence technology with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. However, a subjective evaluation of fluorescence intensity based on the surgeon's visual judgement is a major limitation. This study evaluated the quantitative assessment of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery.

METHODS

This is a retrospective analysis of a prospectively maintained database of 112 patients who underwent laparoscopic surgery for left-sided colorectal cancers. After distal transection of the bowel, the specimen was extracted extracorporeally and then the proximal colon was divided within the well-perfused area based on the ICG fluorescence imaging. We evaluated whether quantitative assessment of intestinal perfusion by measuring ICG intensity could predict postoperative outcomes: F _max, T _max, T _1/2, and Slope were calculated.

RESULTS

Anastomotic leakage (AL) occurred in 5 cases (4.5%). Based on the fluorescence imaging, the surgical team opted for further proximal change of the transection line up to an "adequate" fluorescent portion in 18 cases (16.1%). Among the 18 patients, AL occurred in 4 patients (4/18: 22.2%), whereas it occurred in only 1 case (1/94: 1.0%) in the good perfusion patients who did not need proximal change of the transection line. The F _max of the AL group was less than 52.0 in all 5 cases (5/5), whereas that of the non-AL group was in only 8 cases (8/107): with an F _max cutoff value of 52.0, the sensitivity and specificity for the prediction of AL were 100 and 92.5%, respectively. Regarding postoperative bowel movement recovery, the T _max of the early flatus group or early defecation group was significantly lower than that of the late flatus group or late defecation group, respectively.

CONCLUSIONS

ICG fluorescence imaging is useful for assessing anastomotic perfusion in colorectal surgery, which can result in more precise operative decisions tailored for an individual patient.

Changes in Small Intestine Tissue Compressed by a Linear Stapler Based on Cole Y Model

Clarifying changes in gastrointestinal tissue compressed by surgical stapler is a crucial prerequisite for stapler design optimization. For this study, a stapler was modified, and multifrequency bioimpedance of a porcine small intestine tissue compressed by the stapler was measured. The Cole _Y model was fitted to the bioimpedance, and changes in tissue were analyzed using model parameters: G ₀, extracellular fluid conductance; ΔG, intracellular fluid conductance; C _cpeF, equivalent capacitance of cell membrane. The changes could be divided into two stages: first, all parameters decreased sharply with slopes more than 15.70 ± 2.67, 4.25 ± 1.23 μS/s and 72.68 ± 6.99 pF/s respectively; and subsequently, with an increase in compression strength, G ₀ decreased with slopes less than 2.54 ± 0.40 μS/s, ΔG decreased slightly with slope of 0.26 ± 0.04 μS/s after fluctuating mildly, and C _cpeF remained nearly invariant after initially increasing with slope of -2.94 ± 0.64 pF/s. In conclusion, when the stapler is closed, a portion of tissue is squeezed out of the measurement space, causing all parameters' sharp decrease. Subsequently, the stapler continues compressing the tissue, leading to extracellular fluid expulsion. The changes in intracellular fluid are related to the compression strength and may be explained by cell restoration. This study could provide a basis for stapler design optimization.

Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis

Anastomotic leakage (AL) is one of the most devastating complications after rectal cancer surgery. The double stapling technique has greatly facilitated intestinal reconstruction especially for anastomosis after low anterior resection (LAR). Risk factor analyses for AL after open LAR have been widely reported. However, a few studies have analyzed the risk factors for AL after laparoscopic LAR. Laparoscopic rectal surgery provides an excellent operative field in a narrow pelvic space, and enables total mesorectal excision surgery and preservation of the autonomic nervous system with greater precision. However, rectal transection using a laparoscopic linear stapler is relatively difficult compared with open surgery because of the width and limited performance of the linear stapler. Moreover, laparoscopic LAR exhibits a different postoperative course compared with open LAR, which suggests that the risk factors for AL after laparoscopic LAR may also differ from those after open LAR. In this review, we will discuss the risk factors for AL after laparoscopic LAR.

Evaluation of intestinal perfusion by ICG fluorescence imaging in laparoscopic colorectal surgery with DST anastomosis

BACKGROUND

Decreased blood perfusion is an important risk factor for postoperative anastomotic leakage (AL). Fluorescence imaging with indocyanine green (ICG) provides a real-time assessment of intestinal perfusion. This study evaluated the utility of ICG fluorescence imaging in determining the transection line of the proximal colon during laparoscopic colorectal surgery with double stapling technique (DST) anastomosis.

METHODS

This was a prospective single-institution study of 68 patients with left-sided colorectal cancers who underwent laparoscopic colorectal surgery between August 2013 and December 2014. After distal transection of the bowel, the specimen was extracted extracorporeally and then the mesentery was divided along the planned transection line determined by the surgeons' judgement under normal q. After ICG was injected intravenously, intestinal perfusion of the proximal colon was assessed in the fluorescent imaging mode. Intestinal perfusion was examined in relation to the patient-, tumor- and surgery-related variables using univariate and multivariate analyses.

RESULTS

ICG fluorescence imaging showed that intestinal perfusion was present at 3 mm (median) distal to the initially planned transection line. ICG fluorescence imaging resulted in a proximal change of the transection line by more than 5 mm in 18 patients (26.5 %) and, particularly, by more than 50 mm in 3 patients (4.4 %), compared with the initially planned transection line. Univariate analysis revealed that diabetes mellitus, anticoagulation therapy, preoperative chemotherapy and operative time were significantly associated with poor intestinal perfusion. Multivariate analysis identified anticoagulation therapy (P = 0.021) and preoperative chemotherapy (P = 0.019) as independent risk factors for poor intestinal perfusion. Three patients (4.5 %) with a change of transection line developed AL.

CONCLUSIONS

ICG fluorescence imaging is useful for determining the transection line in laparoscopic colorectal surgery with DST anastomosis. Anticoagulation therapy and preoperative chemotherapy are important risk factors for poor intestinal perfusion.