A hinged metalloplastic anastomotic device: a novel method for choledochoduodenostomy

Endoscopic applications of magnets for the treatment of gastrointestinal diseases

Endoscopic treatment of gastrointestinal diseases has developed rapidly in recent years, due to its minimally invasive nature. One of the main contributing factors for this progress is the improvement of endoscopic instruments, which are essential for facilitating safe and effective endoscopic interventions. However, the slow learning curve required in the implementation of many advanced endoscopic procedures using standard devices is associated with a high risk of complications. Other routine procedures may also be complicated by unexpected difficulties. Based on the ferromagnetic properties of many objects, both internal and external magnetic devices have been developed and applied for multiple endoscopic interventions. The applications of magnets, mainly including compression, anchoring and traction, facilitate many difficult procedures and make it feasible to operate procedures that were previously impossible. Other novel endoscopic applications, such as magnetic nanoparticles, are also under development. In this article, we reviewed published studies of endoscopic applications of magnets for the treatment of gastrointestinal diseases such as precancerous lesions and cancer, obstruction, stricture, congenital and acquired malformations, motility disorders, and ingestion of foreign bodies. Since several endoscopic applications of magnets may also be relevant to surgery, we included them in this review.

Optimized force range of magnetic compression anastomosis in dog intestinal tissue

BACKGROUND

Magnetic compression anastomosis (MCA) is a commonly used anastomosis method. MCA was widely used in tissues repair, gastroenterostomy, choledochoenterostomy, and so on. It is safer and more effective than stapler and manual surgical suturing. However, there are few detailed studies on the biomechanical characteristics and tissue transformation mechanisms of the anastomosis process. In this research, taking intestinal tissue as research object, we need to determine an optimal compressive force range to provide a biomechanical reference for the design of anastomats.

METHODS

Magnets with different magnetic force groups (2.06, 3.21, 6.27, 13.3 and 19.2 N) were implanted into each dog to form intestinal tissue side-to-side anastomoses. Five dogs were euthanized on each of postoperative day 1, day 3, and day 7. Anastomoses were then harvested and compared with respect to postoperative complications, histology and tear-resistance load capacity (TRLC).

RESULTS

The TRLC of anastomotic tissue formed by magnets with different magnetic forces differed markedly, but with the tissue growth, the TRLC differences between groups were decreased. Histology of anastomotic tissue showed that, in the initial stage, the anastomoses compressed by 2.06-N magnets did not form effectively, while the leakage appeared in the anastomoses compressed by 19.2-N magnets, in the rest groups, with magnetic force increasing, severity of ischemia and necrosis of compressed tissue increased and healing speed of anastomotic tissue improved. In the late stage, the influence of magnetic force for anastomotic tissue was gradually diminished.

CONCLUSIONS

The magnetic force applied on the magnetic compression anastomats affects the necrosis speed of compressed tissue and the healing speed of anastomotic tissue. The optimal compressive force range for intestinal compression anastomosis is 6.27 N to 13.3 N, and the actual optimal compression pressure is 79.8 kPa - 169 kPa.

LEVEL OF EVIDENCE

Magnetic compression anastomosis (MCA) is a commonly used anastomosis method. MCA was widely used in tissues repair, gastroenterostomy, choledochoenterostomy, and so on. It is safer and more effective than stapler and manual surgical suturing. However, there are few detailed studies on the biomechanical characteristics and tissue transformation mechanisms of the anastomosis process. In this research, taking intestinal tissue as research object, we need to determine an optimal compressive force range to provide a biomechanical reference for the design of anastomats.

Surgical Endoscopy Versus Endoscopic Surgery for Obesity

BACKGROUND

Obesity treatment options are of great interest worldwide with major developments in the past 20 years. From general surgery to natural orifice transluminal endoscopic surgery intervention nowadays, obesity surgical therapies have surely developed and are now offering a variety of possibilities.

AREAS OF UNCERTAINTY

Although surgery is the only proven approach for weight loss, a joint decision between the physician and patient is required before proceeding to such a procedure. With a lot of options available, the treatment should be individualized because the benefits of surgical intervention must be weighed against the surgical risks.

DATA SOURCES

Medline search to locate full-text articles and abstracts with obvious conclusions by using the keywords: obesity, surgical endoscopy, gastric bypass, bariatric surgery, and endoscopic surgery, alone and in various combinations. Additional relevant publications were also searched using the reference lists of the identified articles as a starting point.

RESULTS

Laparoscopic Roux-en-Y gastric bypass still is the most effective, less invasive, bariatric surgical intervention, although there are various complications encountered, such as postoperative hemorrhage (1.9%-4.4%), internal hernias, anastomotic strictures (2.9%-23%), marginal ulcerations (1%-16%), fistulas (1.5%-6%), weight gain, and nutritional deficiencies. However, the absence of parietal incisions, less pain, decreased risk of infection, and short hospital stay make room for endoscopic surgery as a possible valid option for obesity for both the doctors' and the patients' perspective.

CONCLUSIONS

The current tendency is to promote surgical treatment of obesity to a status of less invasive scars therefore promoting minimally invasive surgical techniques.

Endoscopic ultrasonography guided biliary drainage: Summary of consortium meeting, May 7th, 2011, Chicago

Endoscopic retrograde cholangiopancreatography (ERCP) has become the preferred procedure for biliary or pancreatic drainage in various pancreatico-biliary disorders. With a success rate of more than 90%, ERCP may not achieve biliary or pancreatic drainage in cases with altered anatomy or with tumors obstructing access to the duodenum. In the past those failures were typically managed exclusively by percutaneous approaches by interventional radiologists or surgical intervention. The morbidity associated was significant especially in those patients with advanced malignancy, seeking minimally invasive interventions and improved quality of life. With the advent of biliary drainage via endoscopic ultrasound (EUS) guidance, EUS guided biliary drainage has been used more frequently within the last decade in different countries. As with any novel advanced endoscopic procedure that encompasses various approaches, advanced endoscopists all over the world have innovated and adopted diverse EUS guided biliary and pancreatic drainage techniques. This diversity has resulted in variations and improvements in EUS Guided biliary and pancreatic drainage; and over the years has led to an extensive nomenclature. The diversity of techniques, nomenclature and recent progress in our intrumentation has led to a dedicated meeting on May 7^th, 2011 during Digestive Disease Week 2011. More than 40 advanced endoscopists from United States, Brazil, Mexico, Venezuela, Colombia, Italy, France, Austria, Germany, Spain, Japan, China, South Korea and India attended this pivotal meeting. The meeting covered improved EUS guided biliary access and drainage procedures, terminology, nomenclature, training and credentialing; as well as emerging devices for EUS guided biliary drainage. This paper summarizes the meeting’s agenda and the conclusions generated by the creation of this consortium group.

EUS-guided anastomosis

Although some technical challenges in the development of dedicated devices need to be overcome, endoscopic ultrasonography (EUS)-guided anastomosis is promising as a minimally invasive technique for pancreatobiliary diseases.

Roux-en-Y choledochojejunostomy using novel magnetic compressive anastomats in canine model of obstructive jaundice

BACKGROUND

The traditional hand-sewn Roux-en-Y choledochojejunostomy is technically complicated, and the incidence of postoperative complications has remained high. A set of novel magnetic compressive anastomats was introduced to facilitate choledochojejunostomy and improve the prognosis of patients.

METHODS

After ligating the common bile duct for 7 days, 16 dogs were randomly divided into two groups (n=8 per group). Anastomats were used in the study group, and the traditional hand-sewn method was used in the control group for standard Roux-en-Y choledochojejunostomy. We compared the operation time, incidence of complications, gross appearance, and pathological disparity in stoma between the two groups in 1-month and 3-month follow-up examinations.

RESULTS

The time spent on constructing the anastomosis for the study group was significantly shortened. Although no anastomotic stenosis occurred in the two groups, the narrowing rate of biliary-enteric anastomosis was much higher in the control group. There was one case of bile leakage in the control group, whereas no bile leakage occurred in the study group. A smoother surface, an improved layer apposition, and a lower local inflammatory response were identified in the anastomosis of the study group.

CONCLUSION

The structures of the novel magnetic compressive anastomats are simple, and they are time-saving, safe and efficient for performing Roux-en-Y choledochojejunostomy procedures in a canine model of obstructive jaundice.

Endoscopic magnetic gastroenteric anastomosis for palliation of malignant gastric outlet obstruction: a prospective multicenter study

BACKGROUND

Palliation of malignant gastric outlet obstruction remains challenging. Although there are 2 established treatment options, ie, surgical gastrojejunostomy and endoscopic duodenal stent insertion, there is an ongoing search for a technique that would combine the safety and rapid effect of duodenal stent placement with the long-term efficacy and low reintervention rate of a surgical gastrojejunostomy.

OBJECTIVE

To investigate the safety and success rate of endoscopic creation of a gastroenteric anastomosis formed by magnetic compression and stent placement.

DESIGN

Prospective, multicenter cohort study.

SETTING

Four referral centers.

PATIENTS

The expected number of patients with symptomatic malignant gastric outlet obstruction to be included at the participating hospitals during a year was 40. Because of a serious adverse device event, the study was terminated after inclusion of 18 patients.

INTERVENTION

Creation of an endoscopic gastroenteric anastomosis by using the Cook Magnetic Anastomosis Device with transanastomotic deployment of a self-expandable stent.

MAIN OUTCOME MEASUREMENTS

Primary endpoints were safety and success rate associated with the creation of an endoscopic gastrojejunostomy by using a magnetic anastomotic device with transanastomotic deployment of a self-expandable stent.

RESULTS

Because of a serious adverse event, the study was terminated prematurely. A success rate of 66.7% (12 of 18 patients) was achieved; 1 serious adverse event (stent perforation) occurred leading to the death of the patient. Three patients (25%) experienced an adverse device effect (stent migration).

LIMITATIONS

Small sample size, lack of a control group.

CONCLUSION

Endoscopic creation of a gastroenteric anastomosis by magnetic compression is feasible and safe; however, the necessity of a stent led to serious morbidity and even mortality in this study. The current system can therefore not be recommended for clinical use.