Triangulating stapling technique: an alternative approach to colorectal anastomosis

Which Anastomotic Techniques Is the Best Choice for Cervical Esophagogastric Anastomosis in Esophagectomy? A Bayesian Network Meta-Analysis

INTRODUCTION

The optimal choice of anastomotic techniques for cervical esophagogastric anastomosis in esophagectomy remains unclear.

METHODS

An electronic literature search of PubMed, Embase, and Web of Science (data up to April 2022) was conducted and screened to compare hand sewn (HS), circular stapling (CS), side-to-side linear stapling (LS), and triangulating stapling (TS) for cervical esophagogastric anastomosis. Anastomotic leak, pulmonary complications, anastomotic stricture, and reflux esophagitis of the 4 anastomotic techniques were evaluated using a Bayesian network meta-analysis by R.

RESULT

Twenty-nine studies were ultimately included, with a total of 5,020 patients from 9 randomized controlled trials, 7 prospect cohort studies, and 13 retrospective case-control studies in the meta-analysis. The present study demonstrates that the incidence of anastomotic leakage is lower in TS than HS and CS (TS vs. HS: odds ratio (OR) = 0.32, 95% CI: 0.1 to 0.9; TS vs. CS: OR = 0.37, 95% CI: 0.13 to 1.0), and the incidence of anastomotic stricture is lower in TS than in HS and CS (TS vs. HS: OR = 0.32, 95% CI: 0.11 to 0.86; TS vs. CS: OR = 0.23, 95% CI: 0.08 to 0.58). TS ranks best in terms of anastomotic leakage, pulmonary complication, anastomotic stricture, and reflux esophagitis.

CONCLUSION

TS for cervical esophagogastric anastomosis of esophagectomy had a lower incidence of anastomotic leakage and stricture. TS should be preferentially recommended. Large-scale RCTs will be needed to provide more evidence in future studies.

An experience of total laparoscopic partial colectomy with intracorporeal triangulating anastomosis in an obese patient with descending colon cancer

A 68-year-old woman was transferred to the emergency room of Okayama City Hospital because of worsening epigastric pain. After the examination, she was diagnosed with descending colon cancer, and laparoscopic colectomy was planned. However, exteriorization of the bowels to produce anastomosis was difficult because the rich adipose tissue of the mesocolon hardly stretched, and the abdominal wall was thick as the patient was obese. Therefore, an intracorporeal triangulating end-to-end anastomosis was performed. The colon was divided at 10 cm either side from the tumor using an endoscopic linear stapler. After the resection of the stumps with staples, the posterior walls were tied with stay sutures and then stapled with an endoscopic linear stapler. The anterior wall was stapled twice in the same manner, and the intracorporeal anastomosis was completed. The patient's postoperative course was uneventful. This technique provided an alternative intracorporeal anastomotic technique as troubleshooting in laparoscopic colectomy.

Short-term outcomes of extracorporeal colo-colonic triangular anastomosis versus functional end-to-end anastomosis in laparoscopic-assisted surgery for left-sided colon cancer: a propensity score matching analysis

PURPOSE

To the best of our knowledge, no studies have compared the short-term outcomes between colo-colonic extracorporeal triangular anastomosis (TA) and functional end-to-end anastomosis (FEEA), with a focus on laparoscopic-assisted surgery for left-sided colon cancer. Therefore, this study compared the short-term outcomes of these anastomoses using propensity score matching analysis.

METHODS

This retrospective study included 129 patients with stage I-IV left-sided colon cancer who underwent laparoscopic-assisted surgery with colo-colonic extracorporeal TA (n = 75) or FEEA (n = 54) between May 2009 and March 2021. After propensity score matching, 84 patients (TA, n = 42; FEEA, n = 42) were included in the analysis. The primary endpoint was the complication rate for all grades, and the secondary endpoints were the rates of Clavien - Dindo grade ≥ 3 complications and anastomotic leakage.

RESULTS

In the matched cohort, there were no significant differences in the complication rates for all grades (35.7% vs. 26.2%, p = 0.479), Clavien - Dindo grade ≥ 3 complications (11.9% vs. 11.9%, p = 1), and anastomotic leakage (0% vs. 4.8%, p = 0.494) between the TA and FEEA groups. In the univariate logistic regression analysis, TA did not increase the frequency of complications for any grades compared with FEEA (odds ratio: 1.570, 95% confidence interval: 0.616-3.980, p = 0.347).

CONCLUSION

Extracorporeal TA demonstrated equivalent short-term outcomes compared with FEEA in cases of laparoscopic-assisted surgery for left-sided colon cancer. TA can be an alternative anastomosis technique in cases wherein FEEA is difficult to perform.

Short- and long-term outcomes of laparoscopic surgery with extracorporeal anastomosis for transverse colon cancer: comparison of triangulating anastomosis with functional end-to-end anastomosis

BACKGROUND

We compared triangulating anastomosis (TRI) with functional end-to-end anastomosis (FEEA) in terms of patient demographics, clinicopathological features, and short- and long-term outcomes in this study.

METHODS

From November 2005 to May 2016, 315 patients with transverse colon cancer underwent laparoscopic resection. TRI was performed in 62 patients and FEEA in 253 patients. Patients with another concomitant cancer, who received neoadjuvant chemotherapy, and/or who underwent another operation at the same time were excluded.

RESULTS

The patients' backgrounds were comparable in each group. Transverse colectomy was selected more frequently in TRI and right hemicolectomy in FEEA. The operation time was shorter in TRI. The rate of anastomotic leakage was comparable (1.6% in TRI vs. 0.8% in FEEA). Stricture was more common in TRI (8.1% vs. 0%) and bleeding was more common in FEEA (1.6% vs. 10.6%). The rate of long-term complications was comparable in each group. Overall survival of stage 0-III patients was comparable in each group (94.7% in TRI vs. 93.7% in FEEA). 5-year disease-free survival of stage 0-III, stage II, and stage III patients was also comparable in each group (94.8% vs. 93.0%, 100% vs. 92.1%, and 80.3% vs. 79.2% in TRI and FEEA, respectively).

CONCLUSION

The short- and long-term outcome rates were acceptable in both groups. Specific attempts to prevent complications are required for each anastomotic procedure.

Laparoscopic complete mesocolic excision with central vascular ligation for splenic flexure colon cancer: short- and long-term outcomes

Background

Complete mesocolic excision (CME) with central vascular ligation (CVL) for colon cancer is an essential procedure for improved oncologic outcomes after surgery. Laparoscopic surgery for splenic flexure colon cancer was recently adopted due to a greater understanding of surgical anatomy and improvements in surgical techniques and innovative surgical devices.

Methods

We retrospectively analyzed the data of patients with splenic flexure colon cancer who underwent laparoscopic CME with CVL at our institution between January 2005 and December 2017.

Results

Forty-five patients (4.8%) were enrolled in this study. Laparoscopic CME with CVL was successfully performed in all patients. The median operative time was 178 min, and the median estimated blood loss was 20 g. Perioperative complications developed in 6 patients (13.3%). The median postoperative hospital stay was 9 days. According to the pathological report, the median number of harvested lymph nodes was 15, and lymph node metastasis developed in 14 patients (31.1%). No metastasis was observed at the root of the middle colic artery or the inferior mesenteric artery. The median follow-up period was 49 months. The cumulative 5-year overall survival and disease-free survival rates were 85.9% and 84.7%, respectively. The cancer-specific survival rate in stage I-III patients was 92.7%. Recurrence was observed in 5 patients (11.1%), including three patients with peritoneal dissemination and two patients with distant metastasis.

Conclusions

Laparoscopic CME with CVL for splenic flexure colon cancer appears to be oncologically safe and feasible based on the short- and long-term outcomes in our study. However, it is careful to introduce this procedure to necessitate the anatomical understandings and surgeon’s skill. The appropriate indications must be established with more case registries because our experience is limited.

iTriangular Stapling Technique: A Novel Reconstruction Method and Clinical Outcomes of Cervical Esophagogastric Anastomosis after Esophagectomy

BACKGROUND

We herein report the feasibility and safety of cervical end-to-end anastomosis by the iTriangular stapling technique (iTST), which was developed as an extension of the triangular stapling technique (TST) after minimally invasive esophagectomy (MIE).

METHODS

A total of 45 patients with thoracic esophageal cancer who underwent reconstruction with cervical esophagogastric anastomosis by iTST using a linear stapler after MIE between January 2016 and January 2019 were retrospectively reviewed. We modified and improved upon the TST by adding a 1- to 2-cm vertical incision on the anterior wall of the remnant esophageal stump to enlarge the anastomotic lumen and thereby reduce the risk of anastomotic stenosis. The short-term patient outcomes were determined to assess the safety and feasibility of our procedures.

RESULTS

The median operating time was 686 (range, 319-1110) minutes, and the median blood loss was 170 (range, 5-1180) ml. There were no cases of anastomotic stenosis in this study, although 2 patients (4.4%) developed minor anastomotic leakage. A case (2.2%) of tracheal fistula due to the apex of the triangular anastomosis was resolved simply by delaying the patient's oral intake. The mean length of the hospitalization was 21 days.

CONCLUSIONS

The iTST provides a larger lumen unlimited by the size of the esophagus in cervical esophagogastric anastomosis. This technique is feasible, and sufficient short-term results have been achieved. Further studies with the accumulation of more cases will be required to prove the benefits of iTST for reconstruction after MIE.

Impact of a Long Linear Staplers on the Incidence of Stricture after Triangulating Esophagogastric Anastomosis

BACKGROUND

Various techniques have been reported for esophagogastric anastomosis to prevent anastomotic leakage. Recently, not only postoperative anastomotic leakage but also anastomotic stricture is considered important because stricture contributes to the patient's postoperative quality of life. However, the best procedure for anastomosis has not been established.

MATERIALS AND METHODS

The authors divided 101 patients with thoracic or abdominal esophageal cancer who underwent cervical triangulating esophagogastric anastomosis using a linear stapler between May 2017 and May 2020 into 2 groups: surgery with a short (45 mm) linear stapler (SS group, n=59) or a long (60 mm) stapler (LS group, n=42). The frequencies of anastomotic leakage and stricture were compared between the 2 groups.

RESULTS

The incidence of anastomotic leakage and stricture without leakage were significantly lower in the LS versus SS group (respectively: leakage: 15% vs. 0%, P=0.01; stricture: 36% vs. 7%, P=0.01). A short linear stapler and anastomotic leakage were independent risk factors for anastomotic stricture in the multivariate analysis (short stapler: odds ratio, 3.27; 95% confidence interval, 1.08-9.9; P=0.03; anastomotic leakage: odds ratio, 2.78; 95% confidence interval, 1.02-8.5; P=0.04).

CONCLUSION

A long linear stapler is preferable for cervical triangulating esophagogastric anastomosis.

Meta-Analysis of Two Different Methods for Cervical Esophagogastric Anastomosis: Triangulating Versus Circular Stapling

Background: The standard treatment for esophageal carcinoma is extensive resection of the tumor and esophagogastric anastomosis despite the high incidence of related anastomotic complications, such as stricture and leakage. Thus, the choice of the cervical esophagogastric anastomotic method-triangulating stapling (TS) versus circular stapling (CS)-is a critical decision for the surgeon. Aim: To compare the incidence of major adverse outcomes between TS and CS in patients with resectable thoracic esophageal cancer. Methods: For this meta-analysis, PubMed, Embase, Wiley Online Library, Google Scholar, Wanfang, and China National Knowledge Infrastructure databases were searched for subject-relevant studies by using a rigorous study protocol established according to the recommendations of the Cochrane Handbook. Anastomotic leakage, anastomotic stricture, and postoperative pulmonary complications were the primary endpoints used for comparison. Relative risk (RR) with 95% confidence intervals (CI) were calculated to assess the strength of association. Results: Six studies were selected by our inclusion/exclusion criteria and represented a total of 739 patients in our meta-analysis of TS (n = 376) versus CS (n = 363). The TS group showed a lower incidence of anastomotic stricture (RR: 0.23 [95% CI: 0.08-0.63]; P = .004) and pulmonary complications (RR: 0.57 [95% CI: 0.37-0.87]; P = .01). However, the incidence of anastomotic leakage was similar for the two groups (RR: 0.66 [95% CI: 0.41-1.09]; P = .1). Subgroup analysis of four studies in which the surgical methods were minimally invasive demonstrated the TS group to have a lower incidence of lung complications (RR: 0.55 [95% CI: 0.35-0.87]; P = .01), anastomotic leakage (RR: 0.36 [95% CI: 0.18-0.74]; P = .005), and anastomotic stricture (RR: 0.23 [95% CI: 0.05-0.98]; P = .05). Conclusion: The TS method for cervical esophagogastric anastomosis after esophagectomy had a lower incidence of anastomotic stricture and postoperative lung complications.

Which Is the Safer Anastomotic Method for Colon Surgery? - Ten-year Results

BACKGROUND/AIM

In colon surgery, the anastomotic method is generally selected by surgeon's preferences or by local conditions. In this study, we retrospectively analyzed anastomotic complications to assess safe methods of anastomosis in colonic resection.

PATIENTS AND METHODS

We retrospectively analyzed a total of 684 cases, performed between July 2003 and June 2013 in our Hospital. Anastomosis complications, such as leakage, stricture and bleeding, were analyzed in relation to the three methods of anastomosis, hand-sewn (HS), functional end-to-end (FEEA) and triangulating anastomosis (TRI).

RESULTS

Univariate analysis indicated that the incidence of leakage was significantly lower in laparoscopic surgeries (p=0.034) and TRI (p=0.047). The results of the multivariable analysis indicated that anastomotic leakage was significantly less with TRI (p=0.029).

CONCLUSION

In colon surgery, TRI seems to be associated with a low risk of anastomotic leakage compared to HS and FEEA.

Efficacy and safety of a NiTi CAR 27 compression ring for end-to-end anastomosis compared with conventional staplers: A real-world analysis in Chinese colorectal cancer patients

OBJECTIVES

This study aimed to evaluate the safety and efficacy of a new nickel-titanium shape memory alloy compression anastomosis ring, NiTi CAR 27, in constructing an anastomosis for colorectal cancer resection compared with conventional staples.

METHODS

In total, 234 consecutive patients diagnosed with colorectal cancer receiving sigmoidectomy and anterior resection for end-to-end anastomosis from May 2010 to June 2012 were retrospectively analyzed. The postoperative clinical parameters, postoperative complications and 3-year overall survival in 77 patients using a NiTi CAR 27 compression ring (CAR group) and 157 patients with conventional circular staplers (STA group) were compared.

RESULTS

There were no statistically significant differences between the patients in the two groups in terms of general demographics and tumor features. A clinically apparent anastomotic leak occurred in 2 patients (2.6%) in the CAR group and in 5 patients (3.2%) in the STA group (p=0.804). These eight patients received a temporary diverting ileostomy. One patient (1.3%) in the CAR group was diagnosed with anastomotic stricture through an electronic colonoscopy after 3 months postoperatively. The incidence of postoperative intestinal obstruction was comparable between the two groups (p=0.192). With a median follow-up duration of 39.6 months, the 3-year overall survival rate was 83.1% in the CAR group and 89.0% in the STA group (p=0.152).

CONCLUSIONS

NiTi CAR 27 is safe and effective for colorectal end-to-end anastomosis. Its use is equivalent to that of the conventional circular staplers. This study suggests that NiTi CAR 27 may be a beneficial alternative in colorectal anastomosis in Chinese colorectal cancer patients.

Cervical triangulating stapled anastomosis: technique and initial experience

OBJECTIVE

To explore the safety and efficacy of modified cervical triangulating stapled anastomosis (TSA) for gastroesophageal anastomosis (GEA) in minimally invasive esophagectomy (MIE).

METHODS

From January 2013 to November 2013, eighty-four patients who underwent three-stage MIE was enrolled. During the cervical stage, either circular stapled (CS) or triangulating stapled (TS) anastomosis was applied for GEA. Clinical features were collected and compared to identify the differences between the two groups.

RESULTS

A total of 84 patients were included in this study. The clinical characteristics were close between the two groups. Intra-operatively, the duration of GEA was close between the two groups (18±3.4 vs. 17±2.7 min, P=0.139). Post-operatively, Cervical anastomotic leakage occurred in one (3.0%) of the 33 TS patients, but in six (11.8%) of the 51 CS patients (P=0.312). The incidence of anastomotic stenosis was 0.0% and 13.7% in the TS and CS groups, respectively (P=0.069). The overall incidence of postoperative complications was significantly lower in TS than that in CS (15.2% vs. 35.3%, P=0.043). There was no difference in the median length of hospital stay or perioperative mortality rate between the two groups.

CONCLUSIONS

TSA is a safe and effective alternative for GEA, which would probably lower the incidence of leakage and stenosis following MIE. Further studies based on larger volumes are required to confirm these findings.

Triangulating stapling technique for esophagogastrostomy after minimally invasive esophagectomy

BACKGROUND

The triangulating stapling technique is one of the reconstruction methods used that provides favorable surgical outcomes in several areas of the digestive tract. However, the results in the cervical esophagogastric anastomosis are not well documented.

METHODS

Using a prospectively maintained comprehensive database, we reviewed the surgical results of 160 consecutive patients who underwent minimally invasive esophagectomy followed by cervical triangulating stapling esophagogastrostomy during 2 periods from May 2002 to May 2012 so as to determine the efficacy of the triangulating stapling technique using 2 different types of stapling devices.

RESULTS

The rates of anastomotic leakage and stricture in this series were low (1% and 15%, respectively). The rate of anastomotic stricture was significantly reduced when a linear stapler with a cutting knife was used (9%). A logistic regression analysis showed a reduction of anastomotic stricture to be significantly associated with the use of only a linear stapler with a cutting knife.

CONCLUSION

Cervical esophagogastric anastomosis by the triangulating stapling technique is safe and feasible. We consider a linear stapling device equipped with a cutting knife to be more suitable for performing the triangulating stapling technique.

The triangulating stapling technique for cervical esophagogastric anastomosis after esophagectomy

PURPOSE

To evaluate the safety and feasibility of the triangulating stapling technique (TST) for cervical esophagogastric anastomosis after esophagectomy (CEGA).

METHODS

The subjects were 123 patients who underwent transthoracic esophagectomy with three-field lymph node dissection and reconstruction with a 3.5-cm wide gastric tube, for thoracic esophageal cancer. We performed the TST for CEGA in 33 patients operated on after December, 2006 (TST group) and hand-sewn anastomosis in 90 patients operated on between 2002 and 2006 (HSA group).

RESULTS

In the TST group, CEGA was performed in an end-to-end fashion using three linear staplers. The first anastomosis was applied to the posterior walls of the remnant esophagus and gastric tube in an inverted fashion. The second and the third anastomoses were done in an everted fashion to make the anterior wall. The end-to-end HSA was performed with interrupted sutures using 4-0 absorbable material. Anastomotic leakage occurred in only 1 (3.0%) of the 33 TST patients, but in 13 (14.4%) of the 90 HSA patients (P = 0.07). The frequency of anastomotic stenosis was 9.1% and 25.6% in the TST and HSA groups, respectively (P < 0.05).

CONCLUSIONS

Cervical esophagogastric anastomosis using TST may reduce the frequency of anastomotic leakage and stenosis. This technique is a safe and reliable alternative for CEGA after esophagectomy.

Intracorporeal Billroth 1 reconstruction by triangulating stapling technique after laparoscopic distal gastrectomy for gastric cancer

As the laparoscopic operations for gastric cancer have increased, the intracorporeal reconstruction of the digestive tract has received attention because the procedure offers a good visual field regardless of the patient's figure. We performed laparoscopic gastrectomies with regional lymph node dissection on 586 gastric cancer patients between March 1998 and June 2006: 465 distal gastrectomies, 42 proximal gastrectomies, and 79 total gastrectomies. Intracorporeal anastomosis was carried out in 303, 36, and 69 of the above cases, respectively. The intracorporeal Billroth 1 reconstruction was performed in 226 out of the 303 cases who underwent distal gastrectomy and intracorporeal anastomosis. The "triangulating stapling technique" (TST) that uses laparoscopic linear stapling devices was adopted for 196 of these 226 cases; in the remaining 30, circular stapling devices for conventional open gastrectomy (CEEA) were used. In the initial 115 cases of distal gastrectomy, hand-assisted laparoscopic surgery (HALS) was used, and then we shifted to totally laparoscopic distal gastrectomy (TLDG) without HALS. In this paper, we concentrated on the techniques and results of intracorporeal Billroth 1 reconstruction by TST. Reducing postoperative wounds was possible TLDG by TST, compared with HALS and the extracorporeal anastomosis, that is, laparoscopy-assisted distal gastrectomy. Complications from anastomosis resulted in leakage in 2 HALS-TST patients and in 1 TLDG-TST patient, and anastomotic stenosis and bleeding were observed in each 1 case of reconstruction that used CEEA. Intracorporeal Billroth 1 reconstruction by TST is a safe procedure that provides a good visual field regardless of the patient's figure and a feasible technique for reconstruction after laparoscopic distal gastrectomies.

Internal hernia with strangulation through a mesenteric defect after laparoscopy-assisted transverse colectomy: report of a case

A 58-year-old woman underwent laparoscopy-assisted transverse colectomy for transverse colon cancer. On postoperative day 7, she experienced sudden abdominal pain accompanied by vomiting and fever. Computed tomography showed a small bowel obstruction caused by an internal hernia. Laparotomy revealed an internal hernia through the mesenteric defect at the anastomotic colonic stumps, which had not been closed in the previous operation. Almost the entire small bowel protruding through the mesenteric defect was found in the omental bursa. We resected part of the jejunal loop, which was strangulated and congested by an adherent band. Our experience suggests that if the mesenteric defect is relatively small, it should be closed completely during laparoscopy-assisted colectomy; however, more studies are required to determine the indications for closure of the mesenteric defect to prevent this complication.

Laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer

BACKGROUND

Recent advances in surgical techniques have led to widespread acceptance of laparoscopic gastrectomy for gastric cancer. We performed distal gastrectomy with regional lymph node dissection in 235 patients with gastric cancer located in the middle and lower third of the stomach.

METHODS

In 171 cases, reconstruction was done using the Billroth I method intracorporeally and the aid of laparoscopic linear stapling devices. The Billroth II and Roux-en-Y methods were used in the remaining 56 and eight patients, respectively,

RESULTS

Patients who underwent laparoscopic distal gastrectomy had a more rapid postoperative recovery than those treated via the open approach. Postoperative complications with this technique were within a permissible range. In terms of the survival curve, there was no statistical difference between the laparoscopic group diagnosed as clinical T2N0 (c T2N0) Preoperatively and the open group.

CONCLUSION

The laparoscopic technique is not only less invasive, but is also similarly safe and curative compared to open gastrectomy.

Laparoscopic distal gastrectomy with regional lymph node dissection for gastric cancer

Recently, a minimally invasive operation for gastric malignancies has been advocated, and the laparoscopic operation is noted as a technique that increases the quality of life. We performed distal gastrectomy with regional lymph node dissection on 160 cases of gastric cancer located in the middle or lower third of the stomach. In 123 cases, Billroth I reconstruction was performed intracorporeally using the quadrilateral (square) stapling technique with a laparoscopic linear stapling device to prevent postoperative anastomotic bleeding and stenosis. In the remaining 37 cases, the Billroth II method was performed with a linear stapling device [1]. This technique is not only less invasive but also as safe as open gastrectomy, which was performed on 100 gastric cancer cases of similar staging.

Keyhole procedure: a new technique for intestinal anastomosis with a large opening and less tissue trauma, using both circular and linear staplers

BACKGROUND

We designed a new technique, termed the keyhole procedure, that uses a linear stapler to enlarge the anastomotic opening made with a circular stapler. The present study was performed to evaluate this technique in terms of maximum bursting pressure and area of anastomotic opening and compare it with conventional anastomosis using a circular stapler in an animal model.

METHODS

Anastomoses were created by the new technique or by the conventional method in swine small intestine. Anastomosis integrity was assessed by the air leakage test. Anastomotic openings were photographed and measured with an image analyzer.

RESULTS

It was found that the area of the anastomotic opening obtained with the new technique was more than 3 times that of the control (P <.001). There was no significant difference between the methods in maximum bursting pressure.

CONCLUSIONS

The keyhole procedure provides a larger anastomotic opening than conventional anastomosis with a circular stapler, without impairing the integrity of anastomosis.

Use of the circular stapler in 1000 consecutive colorectal anastomoses: experience of one surgical team

BACKGROUND

This study was performed to assess the exact performance of the conventional way of stapling colorectal anastomoses. Information collected from 1000 consecutive anastomoses performed by one surgical team could be considered as reliable reference with which results obtained by new approaches could be compared.

METHODS

One thousand consecutive anastomoses were performed from 1979 to 1992. Characteristics of the procedure, intraoperative events, mortality rate, complications, and clinical outcome were detailed.

RESULTS

There were 528 men and 472 women (age range, 20 to 90 years; average age, 63 years). Anastomoses were constructed by means of a circular stapler loaded with the largest cartridge in 82.3% of the cases. Imperfections were identified during operation in 124 cases. A diverting colostomy was performed in 127 cases. Postoperative mortality rate averaged 2.2%. Clinical anastomotic leaks developed in 35 patients: in 11.4% after low stapling (less than 5 cm from the dentate line) and in 2.2% after high stapling. The presence of a diverting colostomy influenced the leakage rate in patients with very low anastomoses. Total failure rate (death, definitive colostomy) as a result of anastomotic leak was 1.6%. Among the 933 survivors who had follow-up examination, the incidence of bad functional results decreased from 10% at the first attendance to 4.3% at the last one. Transanal dilatation and restapling were required for symptomatic narrowing in three and one patients, respectively.

CONCLUSIONS

The conventional way of stapling colorectal anastomoses in reliable, but it requires strict observance of the rules for anastomosing intestine and a careful check of the stapled sutures. Results obtained by new approaches could be compared with these data.

Different techniques of laparoscopic end-to-end small-bowel anastomoses

The aim of the study was to prove that laparoscopic stapling devices can be used to create a bowel anastomosis. Three groups with n = 6 pigs each were subjected to different techniques of small-bowel anastomoses. In groups I and II anastomosing of the bowel ends was carried out with singly placed staples using a hernia stapler. (Group I: Two-thirds of the circumference became inverted and one-third everted. Group II circumferentially everted). In group III triangular everted anastomoses were produced using a linear noncutting stapler. All animals survived the observation period of 14 days and were postmortally examined. Average construction time was 59 min for groups I and III and 47 min for group II. Average diameters were 14 mm, 16 mm, and 18 mm for groups I, II, and III, respectively. There were no significant differences between the techniques concerning the stability of the anastomoses as expressed by bursting pressures. There were two stenoses in group I animals caused by electrocautery during preparation of the bowel ends prior to anastomosing. Anastomotic insufficiencies or fistulas were not observed clinically or with Gastrografin studies. We conclude that anastomoses in the pig can laparoscopically be constructed by employing singly placed staples as well as a linear stapler. Further investigations of these techniques on large bowel and human specimens are required prior to their clinical use in humans.