A comparison of gastrojejunal anastomoses with or without buttressing in a porcine model

An off-the-shelf bioadhesive patch for sutureless repair of gastrointestinal defects

Surgical sealing and repair of injured and resected gastrointestinal (GI) organs are critical requirements for successful treatment and tissue healing. Despite being the standard of care, hand-sewn closure of GI defects using sutures faces limitations and challenges. In this work, we introduce an off-the-shelf bioadhesive GI patch capable of atraumatic, rapid, robust, and sutureless repair of GI defects. The GI patch integrates a nonadhesive top layer and a dry, bioadhesive bottom layer, resulting in a thin, flexible, transparent, and ready-to-use patch with tissue-matching mechanical properties. The rapid, robust, and sutureless sealing capability of the GI patch is systematically characterized using ex vivo porcine GI organ models. In vitro and in vivo rat models are used to evaluate the biocompatibility and degradability of the GI patch in comparison to commercially available tissue adhesives (Coseal and Histoacryl). To validate the GI patch's efficacy, we demonstrate successful sutureless in vivo sealing and healing of GI defects in rat colon, stomach, and small intestine as well as in porcine colon injury models. The proposed GI patch provides a promising alternative to suture for repair of GI defects and offers potential clinical opportunities for the repair of other organs.

Comparison of two different barbed suture materials for end-to-end jejuno-jejunal anastomosis in pigs

BACKGROUND

Hand-sewn intestinal anastomoses are a fundamental procedure in both open and laparoscopic intestinal surgery. Self-retaining barbed suture devices have been tested for a variety of surgical applications. With the exception of clinical reports and various experimental studies on enterotomy, little has been published so far on the use of barbed suture for end-to-end intestinal anastomoses. The aim of the study was to compare two different barbed suture materials for end-to-end jejuno-jejunal anastomosis in pigs. End-to-end jejuno-jejunal anastomosis were performed with unidirectional barbed (A group), bidirectional barbed (B group) or normal (C group) sutures in each animal. A comparison was then made between the groups based on adhesions scoring, suturing time, bursting pressure and histopathology.

RESULTS

Mean construction times in the A group (518 ± 40 s) and in the B group (487 ± 45 s) were significantly lower than in the C group (587 ± 63 s) but were not different between A and B group (P = 0.10). Mean bursting pressures were significantly higher in the intact intestine (197 ± 13 mmHg) than in any other group (group A 150 ± 16 mmHg, group B 145 ± 22 mmHg, group C 145 ± 24 mmHg). Among anastomotic techniques, the bursting pressures were not significantly different. Histologically no difference could be detected in the grade of inflammation, collagen deposition and neovascularization at the anastomotic sites.

CONCLUSIONS

Barbed sutures can be effectively used for handsewn end-to-end jejunojejunal anastomosis in pigs. They are comparable to normal suture but could provide a shorter surgical time.

Buttressing of the EEA stapler during gastrojejunal anastomosis decreases rate of bleeding-related complications for laparoscopic gastric bypass

BACKGROUND

Bariatric surgery is a well-tolerated and effective treatment for severe obesity. Newer surgical techniques and equipment have improved safety standards surrounding bariatric surgery. In particular, buttressing of the staple line in sleeve gastrectomy has decreased rates of clinically significant postoperative bleeding. The present study investigates the effectiveness of buttressing the circular stapled anastomosis during laparoscopic Roux-en-Y gastric bypass (LRYGB).

SETTING

Academic, accredited hospital.

METHODS

A total of 253 patients undergoing LRYGB at a single academic institution were included in this retrospective study between 2014 and 2015. Buttressing material was used in 125 of these cases. Demographic information was collected from both groups preoperatively. Surgical characteristics were also obtained analyzed using unpaired t or χ² tests.

RESULTS

Patients in both buttressing and nonbuttressing groups were on average 46 years old and predominantly female (79.2% versus 74.2% female, respectively), with a body mass index of approximately 48 kg/m². Postoperative weight loss did not significantly differ between groups at any time point (buttressing versus nonbuttressing percentage of excess weight loss: 39.5% versus 41.5% at 3 mo, P = .3860; 56.4% versus 56.7% at 6 mo, P = .9341). There were no significant differences for operating time, length of stay, readmissions, or reoperations. Complications due to strictures were found to be lower for the buttressing group (0% buttressing versus 2.3% nonbuttressing, P = .0851). Specific rates of bleeding-related complications were significantly lower for the group in which buttressing was used (0% buttressing versus 3.1% nonbuttressing, P = .0463).

CONCLUSION

Buttressing of the gastrojejunal anastomosis during LRYGB significantly reduces bleeding-related complications and increases tolerability of the procedure.

The effect of serosal suture reinforcement on burst pressure in sleeve gastrectomy specimens

PURPOSE

Staple-line leak is a life-threatening complication of laparoscopic sleeve gastrectomy. Reinforcement materials have been reported to lower the risk of staple-line bleeding, but their effects on leak risk have not been elucidated. The aim of this study was to compare the effects of 2 supportive techniques on burst pressures in sleeved gastrectomy specimens.

METHODS

A total of 30 patients who underwent laparoscopic sleeve gastrectomy were evaluated. The resected sleeve gastrectomy specimens were categorized into 3 groups: group 1 had no extra support in the staple-line, group 2 had interrupted serosal suture on the staple-line, and group 3 had serosal suture on staple-line junction points. The endpoint was the first detectable leakage, at which point the leak pressure and anatomic site of the leakage were recorded.

RESULTS

A total of 30 sleeved gastrectomy specimens were included (each group included 10 specimens). There were no differences between groups in terms of age, sex, and body mass index. The leak pressure was significantly higher (56.2±6.4 mm Hg) in group 2 (P<0.01). Leaks occurred significantly more frequently in the staple-line than in the staple-line junction points (P<0.01).

CONCLUSIONS

Interrupted serosal suture significantly increased the burst pressure. Increases in intraluminal pressure are known to be significant in leak etiology. Thus, we concluded that interrupted serosal suture may be beneficial in the prevention of leaks.

Simulation training improves resident performance in hand-sewn vascular and bowel anastomoses

BACKGROUND

Surgical training has recently emphasized simulation-based training of core surgical skills and tasks such as bowel and vascular anastomoses. This may increase efficiency of training within the operating room. Objective data regarding the effectiveness of instruction or monitoring progress in simulating vascular and bowel anastomoses are lacking. The aim of this study is to provide subjective and objective assessments of simulation-based training among residents in hand-sewn vascular and bowel anastomoses.

METHODS

Residents received vascular and bowel anastomoses training. Each resident fashioned anastomoses on both cadaveric saphenous veins and small bowel. The residents repeated the anastomoses 1 week later. Performances were assessed subjectively and objectively by questionnaire, operative time, objective structured assessment of technical skills (OSATS) score, and leak pressures of the finished anastomosis.

RESULTS

Of 14 residents, 12 felt more confident with bowel anastomoses after the laboratory session, and 10 were more confident with vascular anastomoses. For vascular anastomoses, the operating time decreased (15.4 vs 14.2 minutes, p = 0.3), OSATS scores improved (14.9 vs 15.6, p = 0.15), and leak pressures improved (38.9 vs 71.8psi, p = 0.001) from the first to the second workshop. For bowel anastomoses, the operating time decreased (23 vs 18 minutes, p < 0.001), OSATS scores improved (12.9 vs 14.4, p < 0.001), and leak pressures improved (17.7 vs 26.9psi, p < 0.001).

DISCUSSION

After simulation-based training, residents performed vascular and bowel anastomoses more adeptly, quickly, and with a higher quality end product. Laboratory training can effectively improve residents' ability to perform anastomoses, which may result in increased efficiency of teaching in the operating room.

A novel one-shot circular stapler closure for atrial septal defect in a beating-heart porcine model

PURPOSE

In surgical atrial septal defect (ASD) closure, there are no techniques or devices that can close the ASD accurately in a short time under a beating heart. We have developed a simple and automatic ASD closure technique using a circular stapler. This study assessed the feasibility and efficacy of a new circular stapler closure for ASD.

DESCRIPTION

Under a continuous beating heart, hand-sewn patch plasty ASD closure was performed in 6 pigs (group A) and circular stapler ASD closure was performed in 6 pigs (group B). The time to close the ASD and the effectiveness of the closure were compared.

EVALUATION

Closure was significantly faster in group B (10.5 ± 1.0 seconds) than in group A (664 ± 10 seconds; p < 0.05). There was no leakage at the closure site, and sufficient tolerance was confirmed.

CONCLUSIONS

A circular stapler can be used to treat ASD faster than hand-sewn patch plasty, with sufficient pressure tolerance in a beating heart porcine model.

Endoscopic full-thickness resection and clip defect closure in the colon with the new FTRD system: experimental study

BACKGROUND

The benefit of endoscopic full-thickness resection is the improved diagnostic work-up with an integral wall specimen which allows a precise determination of the tumor or its precursor and its infiltration depth into the wall.

MATERIALS AND METHODS

A new endoscopic full-thickness resection device (FTRD), which is a combination of a modified over-the-scope-clip (OTSC) system with an electrocautery snare, has been tested in an experimental setting. In eleven pigs, divided into three groups, endoscopic full-thickness resection was performed in the colon at one or two sites, respectively. Seven days (n = 7) or 28 days (n = 4) after the intervention, the animals were euthanized following endoscopic examination of the resection and clip application sites. Furthermore, two different clips were tested during these animal trials in order to evaluate the most effective clip design.

RESULTS

The average diameter of the tissue resected with the FTRD was 3.1, 3.6, and 5.4 cm in the three groups. On follow-up endoscopy 7 days after the intervention, fibrin coating and stool residues were found at all clips, causing minor inflammatory reactions. However, the colon wall under the clip was non-inflamed. After 28 days, the serosa had primarily healed in all cases. There were also stool residues at all clips; however, no acute inflammatory reactions were seen anymore, due to complete healing. Histological assessment did not show any signs of dehiscence in the region of the scar, or ischemia in the clip area. In addition, no wound infections, such as abscess formation, were observed.

CONCLUSIONS

This study demonstrates the safety and efficacy of the clip-and-cut technique using the new FTRD system. With the device, a local full-thickness colon resection can be easily created, and the resulting wall defect is reliably sealed by the endoluminal application of a modified OTSC clip.

The application of the V-Loc closure device for gastrointestinal sutures: a preliminary study

BACKGROUND

Leakage is one of the major complications in gastrointestinal surgery. This preliminary study compared a new barbed absorbable thread for gastrointestinal sutures with monofil suture material in a cadaver model.

METHODS

In this study, mechanical experiments were performed in 20 recently deceased individuals. Incisions were made in the small intestine, colon, and stomach, and then sutures were created with the V-Loc closure device and monofil suture material. Intestinal bursting pressure was measured by inserting a balloon and slowly filling it with air until there was a dehiscence, or wall or suture rupture.

RESULTS

The bursting pressures differed significantly between the two sutures in the small intestine, showing the advantage of the V-Loc closure device, which had a mean bursting pressure of 116.2 mmHg compared with 110 mmHg for the monofil suture (p = 0.003). The mean bursting pressure did not differ significantly between the two sutures in the colon and the stomach. The mean bursting pressures for the V-Loc closure device were 141.3 mmHg (stomach) and 137.2 mmHg (colon) compared with the monofil suture material bursting pressures of 133 mmHg (stomach) and 134.8 mmHg (colon).

CONCLUSIONS

Because the bursting strength of the sutures created with monofil suture material differs significantly from that of the V-Loc closure device, the V-Loc suture material should be used for gastrointestinal sutures. Although the two sutures did not differ significantly in the colon or the stomach, the V-Loc closure device should be used for these as well because its advantages may overrule those of the monofil suture. No knot tying is required, and the operating time can be shorter. Especially for laparoscopic surgery, the V-Loc closure device is recommended.

Burst strength testing of porcine intestinal anastomoses following negative pressure therapy

The effect of negative pressure therapy (NPT; The ABThera™ Open Abdomen Negative Pressure Therapy System, KCI USA, Inc., San Antonio, TX) on the integrity of small intestinal anastomoses was evaluated using in situ burst strength testing in a domestic pig model. In each of 3 swine, 8 anastomoses were created, 4 using sutures and 4 using staples. After 24 hours of continuous NPT, each anastomosis was subjected to burst strength testing in situ. Mean ratios of burst strength of sutured anastomoses to baseline intraluminal pressure were 9.0 to 10.9. Stapled anastomoses had significantly lower burst strength than sutured anastomoses, but mean values were still at least 4.6 times greater than baseline. No differences were seen between anastomoses that were located in close proximity with treatment and those remotely placed or when measured with negative pressure on or off at burst assessment. NPT had no acute adverse effect on intestinal anastomoses in swine.

Reinforced circular stapler in bariatric surgery

In this study, the application of reinforced circular staplers reduced the incidence of gastrojejunal anastomotic complications in patients undergoing Roux-en-Y gastric bypass.

Background:

Roux-en-Y gastric bypass (RYGBP) is the most common procedure for weight loss surgery but has multiple complications. This study evaluates the use of reinforced circular staplers (RCS) and their effects on reducing gastrojejunal anastomotic complications.

Methods:

We conducted a retrospective chart review from January 2007 to November 2008. Laparoscopic RYGBP were performed in 287 patients. A comparison was made of the complications with and without the use of reinforced circular staplers. The comparison was between a nonreinforced circular stapler (NRCS) group comprising 182 patients and an RCS group comprising 105 patients.

Results:

Complications at gastrojejunal anastomosis were experienced by 15.3% of the patients; 9.5% were in the RCS group and 18.7% were in the NRCS group (P=0.026). Neither group had anastomotic leaks. Bleeding rate was 4.8% in the RCS group vs. 6.6% in the NRCS group. Ulcers occurred in 2.9% of the RCS group vs. 6.0% of the NRCS group. Stricture rate was 1.9% in the RCS group vs. 6.6% in the NRCS group.

Conclusion:

The application of RCS reduced the incidence of gastrojejunal anastomotic complications. Patients are twice as likely to develop complications when no RCS device is used (95% CI 1.03, 4.623). Therefore, it is beneficial to utilize RCS for the gastrojejunal anastomosis in RYGBP procedures.