Clinical diagnostic advances in intestinal anastomotic techniques: Hand suturing, stapling, and compression devices

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.

Evaluating Performance of Circular Staplers Using Comparative Test Methods for Evidence-Based Surgery

BACKGROUND

Circular stapler anastomosis is a common surgical procedure. Despite technological advancements, anastomotic leak remains a postoperative concern. Assessment of new technologies is impeded by variations in test methods and analysis, precluding outcome reproducibility and direct comparisons of results across studies. The development of robust and reproducible preclinical test methods is critical to accelerating stapling technology advancements.

METHODOLOGY

Leak pressure, staple line perfusion and security, and device removal force were quantified for triple-row (Tri-staple EEA, TriEEA) and double-row staplers (Echelon Circular Powered, ECP). Leak and perfusion testing were performed in vivo. Device removal force and staple line security testing were performed with synthetic medium using an Instron. Data were analyzed using unpaired student's t-test or Kruskal-Wallis test, with statistical significance defined as P < .05.

RESULTS

Leak pressure was 73% higher in TriEEA vs ECP (P = .016). TriEEA staple line failure force was lower than ECP at 40 and 50 mmHg (P = .001 and P = .023, respectively). Perfusion to the staple line was higher (148%) for TriEEA than for ECP (P = .003) and the force required to remove the device from its stapled anastomosis was 78% lower for TriEEA than for ECP (P < .001).

DISCUSSION/CONCLUSIONS

This report addresses a primary limitation in stapling research by presenting novel methodologies which enhance clinical relevance and provide sufficient detail for reproduction by independent investigators. These methods are applied to a comparison between triple-row and double-row staplers to demonstrate utility of new test methods in assessing key technology design features.

The Colorectal Anastomosis: A Timeless Challenge

Colorectal anastomosis is a sophisticated problem that demands an elaborate discussion and an elegant solution. "Those who forget the past are condemned to repeat it." George Santayana, Life of Reason , 1905.

A self-locking loop as an alternative to purse-string suture in colon anastomosis: a feasibility study

Background

Colorectal cancer is common in humans where treatment involves surgical removal of the cancerous part of the intestines. In the anastomosis procedure a purse-string suture may be time consuming to perform. The aim was to replace the purse-string suture, to develop and test a self-locking loop for temporary sealing of the lumen in colon anastomosis.

Methods

A new device, a flexible band with a locking mechanism was constructed, the I-Tie^®. Small protrusions, designed for increased friction between device and tissue, were added to one side of the flexible band in order to enhance the grip at closure of the loop around tissue. The device was initially tested in vitro on pig intestines. In an in vivo study, the short-term implant was tested in a new suture-free method, CREX, and with traditional circular staplers for colonic anastomosis. Ten female pigs of approximately 50 kg were used in the in vivo test. The self-locking device was used for closure of the lumen around anvils in CREX (n = 5), and around anvil in traditional circular stapler anastomosis (n = 5). Two self-locking devices were used in each animal.

Results

The self-locking device could close the lumen of colon around the anvil and trocar. Subjectively, the device achieved a tight closure of the colon and did not interfere with the anastomosis techniques.

Conclusions

The technology was perceived as potentially timesaving and easy to use. We conclude the device may be an alternative to the traditional purse-string suture for temporary closure of the colon lumen in colon anastomosis.

Can a nickel-titanium memory-shape device serve as a substitute for the stapler in gastrointestinal anastomosis? A systematic review and meta-analysis

BACKGROUND

Recently, a nickel-titanium (NiTi) memory-shape device has been successfully used in gastrointestinal anastomosis. The aim of this study was to investigate the feasibility and safety of the device.

METHODS

Four databases, reference lists, and the World Health Organization International Clinical Trials Registry Platform were systematically searched for randomized controlled trials assessing the clinical efficacy of a NiTi memory-shape device compared with that of a stapler in gastrointestinal or colorectal anastomosis.

RESULTS

Seven randomized controlled trials regarding the use of compression anastomosis clips (CACs) were enrolled for meta-analysis. The use of CACs was associated with a significant reduction in hospital duration (mean = -0.88 d; 95% confidence interval [CI], -1.38 to -0.38), the time to flatus (mean = -0.36 d; 95% CI, -0.08 to -0.04), and the start of oral intake (mean = -0.45 d; 95% CI, -0.83 to -0.06), as well as a nonsignificant change in postoperative complications and mortality. These clinical outcomes did not significantly change with the use of compression anastomosis rings.

CONCLUSIONS

Colonic anastomosis with a CAC is likely to reduce hospital duration, time to flatus, and the start of oral intake without influencing mortality or postoperative complications and may be a safe and preferable choice in colonic anastomosis. Further well-designed trials should be performed to determine the safety and efficacy of the newly developed compression anastomosis ring in both ileocolic and colorectal anastomosis.

COMPRES: a prospective postmarketing evaluation of the compression anastomosis ring CAR 27(™) /ColonRing(™)

AIM

Preclinical studies have suggested that nitinol-based compression anastomosis might be a viable solution to anastomotic leak following low anterior resection. A prospective multicentre open label study was therefore designed to evaluate the performance of the ColonRing(™) in (low) colorectal anastomosis.

METHOD

The primary outcome measure was anastomotic leakage. Patients were recruited at 13 different colorectal surgical units in Europe, the United States and Israel. Institutional review board approval was obtained.

RESULTS

Between 21 March 2010 and 3 August 2011, 266 patients completed the study protocol. The overall anastomotic leakage rate was 5.3% for all anastomoses, including a rate of 3.1% for low anastomoses. Septic anastomotic complications occurred in 8.3% of all anastomoses and 8.2% of low anastomoses.

CONCLUSION

Nitinol compression anastomosis is safe, effective and easy to use and may offer an advantage for low colorectal anastomosis. A prospective randomized trial comparing ColonRing(™) with conventional stapling is needed.

The weaned pig as a model for Doxorubicin-induced mucositis

BACKGROUND

Chemotherapy-induced mucositis (CIM) complicates cancer therapy and limits maximum tolerated doses and efficacy. Rodent models do not reproducibly mimic clinical CIM, so alternative models are needed.

METHODS

CIM severity was assessed after weaned pigs were treated with doxorubicin (5 and 3.75 mg/kg) using clinical observations, laboratory parameters and gastrointestinal structure and functions. Bovine colostrum was provided as an experimental intervention to the pigs treated receiving the 3.75 mg/kg dose.

RESULTS

Doxorubin at 3.75 mg/kg decreased food intake and weight gain (p < 0.05) and caused diarrhea and vomiting that coincided with damage to the small intestine mucosa based on histological scoring (p < 0.05). It resulted in higher serum TNF-α concentrations, increased chloride secretion and reduced brush border membrane disaccharidase activities and carrier-mediated glucose uptake (all p < 0.05). The gastrointestinal damage and dysfunction resemble the clinical and laboratory features of CIM in humans; these can be partially prevented by providing cow colostrum.

CONCLUSION

The weaned pig is a relevant large animal for studying CIM and evaluating existing and experimental interventions for mucositis.

Niti CAR 27 Versus a Conventional End-to-End Anastomosis Stapler in a Laparoscopic Anterior Resection for Sigmoid Colon Cancer

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.

Histopathologic advantages of compression ring anastomosis healing as compared with stapled anastomosis in a porcine model: a blinded comparative study

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.

Healing of ileocolic nitinol compression anastomosis: a novel porcine model of subtotal colectomy

BACKGROUND

There are limited large animal models for the research of novel anastomotic technologies. Subtotal colectomy requires the anastomosis of relatively remote segments of the alimentary tract that are different anatomically, histologically, and pose significant physiological challenge. The quest for a foreign material-free anastomotic line reintroduced nitinol compression anastomosis into clinical use in the last decade.

OBJECTIVE

To evaluate the safety, histological, and physiological parameters of side-to-side ileocolic nitinol compression anastomosis in a newly developed large animal model, mimicking the human subtotal colectomy.

INTERVENTION

Resection of the entire spiral colon with an ileocolic side-to-side compression anastomosis in 12 animals, compared to resection of a short ileal segment in 6 animals. All anastomoses were constructed by using a novel nitinol-based compression device. The animals were followed up to 30 days postoperatively and were reoperated and sacrificed.

RESULTS

All 12 animals underwent successful subtotal colectomy with side-to-side nitinol compression anastomosis. No signs of abdominal infection were found. The increase in the colectomized animals' bodyweight over the postoperative course was significantly lower and the animals presented with longer periods of diarrhea. The histopathology revealed minimal inflammation and foreign body reaction with good alignment of the bowel wall layers in both groups. The anastomotic line width was shown to be reduced during the healing course of the compression anastomoses.

CONCLUSIONS

Side-to-side nitinol compression anastomosis is safe and demonstrates favorable functional and histopathological features. The porcine model of subtotal colectomy can be used for further research of novel anastomotic technologies.