An Assessment of the Clinical and Economic Impact of Establishing Ileocolic Anastomoses in Right-Colon Resection Surgeries Using Mechanical Staplers Compared to Hand-Sewn Technique

Usefulness of the one-step technique in functional end-to-end anastomosis for colonic surgery: results of a prospective multicentre cohort study from the Japanese KYCC group

BACKGROUND

Although functional end-to-end anastomosis (FEEA) using a stapler in the colorectal field has been recognised worldwide, the technique varies by surgeon, and the safety of anastomosis using different techniques is unknown.

METHODS

This multicentre prospective observational cohort study was conducted by the KYCC Study Group in Yokohama, Japan, and included patients who underwent colonic resection at seven centres between April 2020 and March 2022. This study compared the incidence of surgery-related abdominal complications (SAC: anastomotic leakage [AL], anastomotic bleeding, intra-abdominal abscess, enteritis, ileus, surgical site infection, and other abdominal complications) between two different methods of FEEA (one-step [OS] method: simultaneous anastomosis and bowel resection; two-step [TS] method: anastomosis after bowel resection). Complications of Clavien-Dindo classification grade 2 or higher were assessed.

RESULTS

Among 293 eligible cases, the OS and TS methods were used in 194 (66.2%) and 99 (33.8%) patients, respectively. The baseline characteristics were similar between the groups. The OS method used fewer staplers (three vs. four staplers, p < 0.00001). There were no significant differences in SAC rate between the OS (19.1%) and the TS (16.2%) groups (p = 0.44). The OS group had four cases (2.1%) of AL (two patients; grade 3, two patients; grade 2) while the TS group had one case (1.0%) of grade 2 AL (p = 0.67). Multivariate logistic regression analysis showed that male sex (odds ratio [OR] 3.95; p < 0.00001), an open surgical approach (OR 2.36; p = 0.03), and longer operative duration (OR,2.79; p = 0.002) were independent predictors of complications, whereas the OS method was not an independent predictor (OR 1.17; p = 0.66).

CONCLUSIONS

The OS and the TS technique for stapled colonic anastomosis in a FEEA had a similar postoperative complication rate.

TRIAL REGISTRATION NUMBER

UMIN000039902 (registration date 23 March 2020).

A discrete-event simulation model for assessing operating room efficiency of thoracic, gastrointestinal, and orthopedic surgeries

BACKGROUND

In hospital management, pinpointing steps that most enhance operating room (OR) throughput is challenging. While prior literature has utilized discrete event simulation (DES) to study specific strategies such as scheduling and resource allocation, our study examines an earlier planning phase, assessing all workflow stages to determine the most impactful steps for subsequent strategy development.

METHODS

DES models real-world systems by simulating sequential events. We constructed a DES model for thoracic, gastrointestinal, and orthopedic surgeries summarized from a tertiary Chinese hospital. The model covers preoperative preparations, OR occupation, and OR preparation. Parameters were sourced from patient data and staff experience. Model outcome is OR throughput. Post-validation, scenario analyses were conducted for each department, including: (1) improving preoperative patient preparation time; (2) increasing PACU beds; (3) improving OR preparation time; (4) use of new equipment to reduce the operative time of a selected surgery type; three levels of improvement (slight, moderate, large) were investigated.

RESULTS

The first three improvement scenarios resulted in a 1%-5% increase in OR throughput across the three departments. Large reductions in operative time of the selected surgery types led to approximately 12%, 33%, and 38% increases in gastrointestinal, thoracic, and orthopedic surgery throughput, respectively. Moderate reductions resulted in 6%-17% increases in throughput and slight reductions of 1%-7%.

CONCLUSIONS

The model could reliably reflect OR workflows of the three departments. Among the options investigated, model simulations suggest that improving OR preparation time and operative time are the most effective.

Experimental study of the quantification of indocyanine green fluorescence in ischemic and non-ischemic anastomoses, using the SERGREEN software program

Tissue ischemia is a key risk factor in anastomotic leak (AL). Indocyanine green (ICG) is widely used in colorectal surgery to define the segments with the best vascularization. In an experimental model, we present a new system for quantifying ICG fluorescence intensity, the SERGREEN software. Controlled experimental study with eight pigs. In the initial control stage, ICG fluorescence intensity was analyzed at the level of two anastomoses, in the right and in the left colon. Control images of the two segments were taken after ICG administration. The images were processed with the SERGREEN program. Then, in the experimental ischemia stage, the inferior mesenteric artery was sectioned at the level of the anastomosis of the left colon. Fifteen minutes after the section, sequential images of the two anastomoses were taken every 30 min for the following 2 h. At the control stage, the mean scores were 134.2 (95% CI 116.3–152.2) for the right colon and 147 (95% CI 134.7–159.3) for the left colon (p = 0.174) (Scale RGB—Red, Green, Blue). The right colon remained stable throughout the experiment. In the left colon, intensity fell by 47.9 points with respect to the pre-ischemia value (p < 0.01). After the first post-ischemia determination, the values of the ischemic left colon remained stable throughout the experiment. The relative decrease in ICG fluorescence intensity of the ischemic left colon was 32.6%. The SERGREEN program quantifies ICG fluorescence intensity in normal and ischemic situations and detects differences between them. A reduction in ICG fluorescence intensity of 32.6% or more was correlated with complete tissue ischemia.

Fashioning enterotomy closure after totally laparoscopic ileocolic anastomosis for right colon cancer: a multicenter experience

BACKGROUND

Laparoscopic right hemicolectomy is a commonly performed procedure. Little is known on how to perform the enterotomy closure after stapled side-to-side intracorporeal anastomosis.

METHOD

A multicentric case-controlled study has been designed to compare different ways to fashion enterotomy closure: double layer versus single layer, sewn versus stapled, and robotic versus laparoscopic approach. Furthermore, additional characteristics including sutures' materials, interrupted versus running suture and the presence of deep corner suture has been investigated.

RESULTS

We collected data for 1092 patients who underwent right hemicolectomy at ten centers. We analyzed 176 robotic against 916 laparoscopic anastomosis: no significant differences were found in terms of bleedings (p = 0.455) and anastomotic leak (p = 0.405). We collected data from 126 laparoscopic sewn single-layer versus 641 laparoscopic sewn double-layer anastomosis: a significant reduction was recorded in terms of leaks in double-layer group (p = 0.02). About double-layer characteristics, we found a significant reduction of bleedings (p = 0.008) and leaks (p = 0.017) with a running suture; similarly, a reduction of bleedings (p = 0.001) and leaks (p = 0.005) was observed with the usage of deep corner closure. The presence of a barbed suture thread seemed to significantly reduce both bleedings (p = 0.001) and leaks (p = 0.001). We found no significant differences in terms of bleedings (p = 0.245) and anastomotic leak (p = 0.660) comparing sewn versus stapled anastomosis.

CONCLUSIONS

Fashioning a stapled ileocolic intracorporeal anastomosis, we can recommend the adoption of a double-layer enterotomy closure using a running barbed suture in the first layer. Totally, stapled closure and robotic assistance have to be considered a non-inferior alternative.