Systematic Review and Meta-Analysis on Colorectal Anastomotic Techniques

Side-to-side magnetic duodeno-ileostomy in adults with severe obesity with or without type 2 diabetes: early outcomes with prior or concurrent sleeve gastrectomy

BACKGROUND

Conventional metabolic/bariatric surgical anastomoses with sutures/staples may cause severe adverse events (AEs).

OBJECTIVES

The study aim was to evaluate the feasibility, safety, and effectiveness of primary and revisional side-to-side duodeno-ileostomy (DI) bipartition using a novel magnetic compression anastomosis device (Magnet Anastomosis System [MS]).

SETTING

Multicenter: private practices and university hospitals.

METHODS

In patients with body mass index ([BMI, kg/m2] ≥35.0 to ≤50.0 with/without type 2 diabetes [T2D] glycosylated hemoglobin [HbA1C > 6.5 %]), two linear MS magnets were delivered endoscopically to the duodenum and ileum with laparoscopic assistance and aligned, initiating magnet fusion and gradual DI (MagDI). The MagDI-after-SG group had undergone prior sleeve gastrectomy (SG); the MagDI + SG group underwent concurrent SG. AEs were graded by Clavien-Dindo Classification (CDC).

RESULTS

Between November 22, 2021 and May 30, 2023, 43 patients (88.0% female, mean age 43.7 ± 1.3 years) underwent the study procedures. The MS met feasibility criteria of magnet device placement, creation of patent anastomoses confirmed radiologically, and magnet passage in 100.0% of patients. There were 64 AEs, most were CDC grade I and II, significantly fewer in the MagDI-after-SG group (P < .001). No device-related AEs including anastomotic leakage, bleeding, obstruction, infection, or death. The MagDI-after-SG group experienced 6-month mean weight loss of 8.0 ± 2.5 kg (P < .01), 17.4 ± 5.0% excess weight loss (EWL). The MagDI + SG group had significantly greater weight loss (34.2 ± 1.6 kg, P < .001), 66.2 ± 3.4% EWL. All patients with T2D improved.

CONCLUSIONS

In early results of a multicenter study, the incisionless, sutureless Magnet System formed patent, complication-free anastomoses in side-to-side DI with prior or concurrent SG.

A novel discrete linkage-type electrode for radiofrequency-induced intestinal anastomosis

INTRODUCTION

For decades, radiofrequency (RF)-induced tissue fusion has garnered great attention due to its potential to replace sutures and staples for anastomosis of tissue reconstruction. However, the complexities of achieving high bonding strength and reducing excessive thermal damage present substantial limitations of existing fusion devices.

MATERIALS AND METHODS

This study proposed a discrete linkage-type electrode to carry out ex vivo RF-induced intestinal anastomosis experiments. The anastomotic strength was examined by burst pressure and shear strength test. The degree of thermal damage was monitored through an infrared thermal imager. And the anastomotic stoma fused by the electrode was further investigated through histopathological and ultrastructural observation.

RESULTS

The burst pressure and shear strength of anastomotic tissue can reach 62.2 ± 3.08 mmHg and 8.73 ± 1.11N, respectively, when the pressure, power and duration are 995 kPa, 160 W and 13 s, and the thermal damage can be controlled within limits. Histopathological and ultrastructural observation indicate that an intact and fully fused stomas with collagenic crosslink can be formed.

CONCLUSION

The discrete linkage-type electrode presents favorable efficiency and security in RF-induced tissue fusion, and these results are informative to the design of electrosurgical medical devices with controllable pressure and energy delivery.

Optimising surgical anastomosis in ileocolic resection for Crohn's disease with respect to recurrence and functionality: two international parallel randomized controlled trials comparing handsewn (END-to-end or Kono-S) to stapled anastomosis (HAND2END and the End2End STUDIES)

BACKGROUND

The most common intestinal operation in Crohn's disease (CD) is an ileocolic resection. Despite optimal surgical and medical management, recurrent disease after surgery is common. Different types of anastomoses with respect to configuration and construction can be made after resection for example, handsewn (end-to-end and Kono-S) and stapled (side-to-side). The various types of anastomoses might affect endoscopic recurrence and its assessment, the functional outcome, and costs. The objective of the present study is to compare the three types of anastomoses with respect to endoscopic recurrence at 6 months, gastrointestinal function, and health care consumption.

METHODS

This is a randomized controlled multicentre superiority trial, allocating patients either to side-to-side stapled anastomosis as advised in current guidelines or a handsewn anastomoses (an end-to-end or Kono-S). It is hypothesized that handsewn anastomoses do better than stapled, and end-to-end perform better than the saccular Kono-S. Two international studies with a similar setup will be conducted mainly in the Netherlands (End2End) and Italy (HAND2END). Patients diagnosed with CD, aged over 16 years in the Netherlands and 18 years in Italy requiring (re)resection of the (neo)terminal ileum are eligible. The first part of the study compares the two handsewn anastomoses with the stapled anastomosis. To detect a clinically relevant difference of 25% in endoscopic recurrence, a total of 165 patients will be needed in the Netherlands and 189 patients in Italy. Primary outcome is postoperative endoscopic recurrence (defined as Rutgeerts score ≥ i2b) at 6 months. Secondary outcomes are postoperative morbidity, gastrointestinal function, quality of life (QoL) and costs.

DISCUSSION

The research question addresses a knowledge gap within the general practice elucidating which type of anastomosis is superior in terms of endoscopic and clinical recurrence, functionality, QoL and health care consumption. The results of the proposed study might change current practice in contrast to what is advised by the guidelines.

TRIAL REGISTRATION

NCT05246917 for HAND2END and NCT05578235 for End2End ( http://www.

CLINICALTRIALS

gov/ ).

Endoscopic management of postoperative bleeding

Postoperative gastrointestinal bleeding is a rare but serious complication that can lead to prolonged hospitalization and significant morbidity and mortality. It can be managed by reoperation, endoscopy, or radiological intervention. Although reoperation carries risks, particularly in critically ill postoperative patients, minimally invasive interventions, such as endoscopy or radiological intervention, confer advantages. Endoscopy allows localization of the bleeding focus and hemostatic management at the same time. Although there have been concerns regarding the potential risk of creating an anastomotic disruption or perforation during early postoperative endoscopy, endoscopic management has become more popular over time. However, there is currently no consensus on the best endoscopic management for postoperative gastrointestinal bleeding because most practices are based on retrospective case series. Furthermore, there is a wide range of individual complexities in anatomical and clinical settings after surgery. This review focused on the safety and effectiveness of endoscopic management in various surgical settings.

The comparison of anastomosis strength and leakage between double-layer full-thickness and single-layer extramucosal intestine anastomosis

Various intestine anastomosis techniques have been studied and used, but which is best is still debated. In our center, double-layer full-thickness intestine anastomosis was still considered as standard. However, a single-layer extramucosal intestine anastomosis has shown favorable results. This study created an anastomotic model to compare the anastomosis strength and leakage between double-layer full-thickness and single-layer extramucosal intestine anastomosis.

METHODS

This experimental study was performed in 20 randomized healthy male pigs, to be included either in Group A (Single-layer extramucosal intestine anastomosis) or Group B (Double-layer full-thickness intestine anastomosis). Enterotomy followed by an end-to-end anastomosis suture was performed in the jejunum. Fourteen days after the operation, any anastomosis leakage and its location was documented. The anastomosis strength was evaluated using manometry. Data were compared between groups using the Mann-Whitney U and Fischer Exact test, considering a significance level of P<0.05.

RESULTS

The overall mean intraluminal anastomotic bursting pressure was 4,257±1,185. Group A had a higher intraluminal anastomotic bursting pressure but was not statistically significant compared to group B (4.726±0.952 vs. 3.787±1.252 kilopascals, P=0.063). One leakage (5%, antimesenteric area) occurred in Group A and three leakages (15%, antimesenteric and mesenteric area) occurred in Group B. However, statistical analysis with Fischer exact showed no significant difference of leakage rate between those groups (P=0.291).

CONCLUSIONS

The anastomosis strength and leakage did not differ significantly between the single-layer extramucosal intestine anastomosis group and the double-layer full-thickness anastomosis group. However, the location of leakage was most common in the antimesenteric area in the double-layer full-thickness anastomosis group.

Biologically inspired gastrointestinal stapler design: "Getting to Zero" complications

As next generation stapling devices enter the marketplace with robotic adaptations, tri-staple technology, preloaded reinforcement materials, etc., in this perspective piece we assert that a "refresh" in our understanding of the mechanisms of action of these devices is needed. While much attention has been paid to explain the mechanical features of one device versus another, it seems that little to no attention is being paid to understand how an intestinal anastomosis responds biologically to the variations in their use and design. Here we will review various aspects of gastrointestinal stapling in the context of emerging technology in the field and expose the gaps in knowledge that exist regarding the effect of gastrointestinal stapling on the biology of healing.

Isoperistaltic vs antiperistaltic anastomosis after right hemicolectomy: A comprehensive review

To optimize the efficiency of ileocolic anastomosis following right hemicolectomy, several variations of the surgical technique have been tested. These include performing the anastomosis intra- or extracorporeally or performing a stapled or hand-sewn anastomosis. Among the least studied is the configuration of the two stumps (i.e., isoperistaltic or antiperistaltic) in the case of a side-to-side anastomosis. The purpose of the present study is to compare the isoperistaltic and antiperistaltic side-to-side anastomotic configuration after right hemicolectomy by reviewing the relevant literature. High-quality literature is scarce, with only three studies directly comparing the two alternatives, and no study has revealed any significant differences in the incidence of anastomosis-related complications such as leakage, stenosis, or bleeding. However, there may be a trend towards an earlier recovery of intestinal function following antiperistaltic anastomosis. Finally, existing data do not identify a certain anastomotic configuration (i.e., isoperistaltic or antiperistaltic) as superior over the other. Thus, the most appropriate approach is to master both anastomotic techniques and select between the two configurations based on each individual case scenario.