Lessons Learned From the First-In-Human Compassionate Use of Connect-EA™ in Ten Patients With Esophageal Atresia

INTRODUCTION

Delayed primary repair of esophageal atresia in patients with high-risk physiologic and anatomic comorbidities remains a daunting challenge with an increased risk for peri-operative morbidity and mortality via conventional repair. The Connect-EA device facilitates the endoscopic creation of a secure esophageal anastomosis. This follow-up study reports our long-term outcomes with the novel esophageal magnetic compression anastomosis (EMCA) Connect-EA device for EA repair, as well as lessons learned from the ten first-in-human cases. We propose an algorithm to maximize the advantages of the device for EA repair.

METHODS

Under compassionate use approval, from June 2019 to December 2022, ten patients with prohibitive surgical or medical risk factors underwent attempted EMCA with this device. All patients underwent prior gastrostomy, tracheoesophageal fistula ligation (if necessary), and demonstrated pouch apposition prior to EMCA.

RESULTS

Successful device deployment and EMCA formation were achieved in nine patients (90%). Mean time to anastomosis formation was 8 days (range 5-14) and the device was retrieved endoscopically in five (56%) cases. At median follow-up of 22 months (range 4-45), seven patients (78%) are tolerating oral nutrition. Balloon dilations (median 4, range 1-11) were performed either prophylactically for radiographic asymptomatic anastomotic narrowing (n = 7, 78%) or to treat clinically-significant anastomotic narrowing (n = 2, 22%) with no ongoing dilations at 3-month follow up post-repair.

CONCLUSION

EMCA with the Connect-EA device is a safe and feasible minimally-invasive alterative for EA repair in high-risk surgical patients. Promising post-operative outcomes warrant further Phase I investigation.

LEVEL OF EVIDENCE

IV, Case series of novel operative technique without comparison group.

Evaluation of a Magnetic Compression Anastomosis for Jejunoileal Partial Diversion in Rhesus Macaques

PURPOSE

Metabolic surgery remains underutilized for treating type 2 diabetes, as less invasive alternative interventions with improved risk profiles are needed. We conducted a pilot study to evaluate the feasibility of a novel magnetic compression device to create a patent limited caliber side-to-side jejunoileal partial diversion in a nonhuman primate model.

MATERIALS AND METHODS

Using an established nonhuman primate model of diet-induced insulin resistance, a magnetic compression device was used to create a side-to-side jejunoileal anastomosis. Primary outcomes evaluated feasibility (e.g., device mating and anastomosis patency) and safety (e.g., device-related complications). Secondary outcomes evaluated the device's ability to produce metabolic changes associated with jejunoileal partial diversion (e.g., homeostatic model assessment of insulin resistance [HOMA-IR] and body weight).

RESULTS

Device mating, spontaneous detachment, and excretion occurred in all animals (n = 5). There were no device-related adverse events. Upon completion of the study, ex vivo anastomoses were widely patent with healthy mucosa and no evidence of stricture. At 6 weeks post-device placement, HOMA-IR improved to below baseline values (p < 0.05). Total weight also decreased in a linear fashion (R2 = 0.97) with total weight loss at 6 weeks post-device placement of 14.4% (p < 0.05).

CONCLUSION

The use of this novel magnetic compression device to create a limited caliber side-to-side jejunoileal anastomosis is safe and likely feasible in a nonhuman primate model. The observed glucoregulatory and metabolic effects of a partial jejunoileal bypass with this device warrant further investigation to validate the long-term glucometabolic impact of this approach.

Endoscopic gastrointestinal bypass anastomosis using deformable self-assembled magnetic anastomosis rings (DSAMARs) in a pig model

BACKGROUND

To investigate the feasibility of a deformable self-assembled magnetic anastomosis ring (DSAMAR), designed and developed by us, for endoscopic gastrointestinal bypass anastomosis.

METHODS

Ten experimental pigs were used as model animals. The DSAMAR comprises 10 trapezoidal magnetic units, arranged in a straight line under the constraint of a guide wire. When the desired anastomosis site is reached under the guidance of an endoscope, the catheter pushes the magnetic unit along the guide wire. The linear DSAMAR can be assembled into a circular DSAMAR. Two DSAMARs were inserted, one at the end of the duodenum and the other into the stomach successively. They attracted each other and compressed the wall of the stomach and duodenum to establish gastrointestinal bypass anastomosis. The experimental pigs were euthanized 4 weeks after the operation, and the gastrointestinal bypass anastomosis specimens were obtained. The anastomosis formation was evaluated by the naked eye and histology.

RESULTS

Gastrointestinal bypass anastomosis with DSAMARs was successfully performed. The average operation time under an endoscope was 70.30 ± 19.05 min (range: 43-95 min). The DSAMARs were discharged through the anus 10-17 days after surgery. There were no complications such as gastrointestinal bleeding, perforation, anastomotic fistula, and gastrointestinal obstruction during and after the operation. Gastroscopy and gross specimen of the anastomosis showed a well-formed magnetic anastomosis. Histological observation showed good continuity of the serous membrane and the mucosa of magnetic anastomosis.

CONCLUSION

The DSAMAR is a safe and feasible device for fashioning gastrointestinal bypass anastomosis in this animal model.

Magnetic compression anastomosis for sigmoid stenosis treatment: A case report

BACKGROUND

Endoscopic balloon dilation is a minimally invasive treatment for colorectal stenosis. Magnetic compression anastomosis can be applied against gastrointestinal anastomosis. When combined with endoscopy, it offers a unique approach to the recanalization of colorectal stenosis.

CASE SUMMARY

We have reported here the case of a 53-year-old female patient who underwent a descending colostomy due to sigmoid obstruction. Postoperative fistula restoration was not possible in her due to sigmoid stenosis. Accordingly, endoscopic-assisted magnetic compression anastomosis for sigmoid stenosis was performed, and the sigmoid stenosis was recanalized 15 d after the surgery. Subsequently, a reduction colostomy was successfully performed after 10 d.

CONCLUSION

This case report proposes a novel minimally invasive treatment approach for colorectal stenosis.

A Novel Deformable Self-Assembled Magnetic Anastomosis Ring (DSAMAR) for Esophageal Stenosis Recanalization without Temporary Gastrostomy in Beagle Dogs

BACKGROUND

To assess the feasibility of a deformable self-assembled magnetic anastomosis ring (DSAMAR) in the treatment of esophageal stenosis in beagle dogs via transoral access without temporary gastrostomy.

METHODS

Experimental esophageal stenosis was created in 10 beagle dogs by partial cervical esophageal ligation. The DSAMAR was inserted into the distal esophagus via the narrow section of the esophagus using a gastroscope. A circular DSAMAR was placed in the proximal esophagus. The magnetic rings on both sides of the experimental stenosis automatically attracted each other. We then recorded the operation time, postoperative complications, anastomotic formation time, and magnetic ring discharge time. The dogs were euthanized 4 weeks postoperatively; subsequently, we obtained the esophageal anastomotic specimens and observed the anastomotic formation via the naked eye and by light microscopy.

RESULTS

Our esophageal stenosis model produced reproducible stenoses in all dogs, which was confirmed via endoscopy and esophagography. DSAMAR was successfully implanted in all experimental animals under endoscopic and X-ray monitoring, and all linear DSAMARs were successfully transformed into rings. The magnets at both ends of the esophageal stenosis were automatically attracted. All animals survived until euthanasia. No complications, including esophageal perforation, bleeding, and gastrointestinal obstruction, were noted during the perioperative period. The mean operation time of endoscopic magnetic anastomosis was 15.6 ± 2.41 (range, 12-19) min. The mean esophageal anastomotic formation time was 8.8 ± 1.03 (range, 7-10) days, and the mean expulsion time of DSAMAR was 13.94 ± 2.88 (range, 10-19) days. Gastroscopy and esophagography were performed at 4 weeks postoperatively; the esophageal patency was good. Macroscopic observation of the esophageal anastomotic specimens revealed that the esophageal mucosal layer of the anastomosis had good continuity and the anastomosis was smooth.

CONCLUSION

DSAMAR is a feasible option for magnetic recanalization of esophageal stricture via transoral access without temporary gastrostomy.

Novel deformable self-assembled magnetic anastomosis ring for endoscopic treatment of colonic stenosis via natural orifice

BACKGROUND

Although endoscope-assisted magnetic compression anastomosis has already been reported for colonic anastomosis, there is no report on a single-approach operation using the natural orifice.

AIM

To design a deformable self-assembled magnetic anastomosis ring (DSAMAR) for colonic anastomosis for use in single-approach operation and evaluate its feasibility and safety through animal experiments.

METHODS

The animal model for colonic stenosis was prepared by partial colonic ligation in eight beagles. The magnetic compression anastomosis of their colonic stricture was performed by endoscopically assisted transanal implantation of the DSAMAR. The anastomotic specimen, obtained 2 wk after the operation, was observed by both the naked eye and a light microscope.

RESULTS

The DSAMAR was successfully inserted into the proximal end of colon stenosis through the anus. The DSAMAR of seven dogs was successfully transformed into rings, while that of the remaining dog was removed after the first deformation failed. The rings were successfully retransformed after optimization. All animals underwent colonic anastomosis using the DSAMAR. No device-related or procedure-related adverse events were observed. The colostomy specimens of the experimental dogs were obtained 2 wk after the operation. Both gross and histological observations showed good anastomotic healing.

CONCLUSION

The DSAMAR is a safe and feasible option for the treatment of colon stenosis. Its specific deformation and self-assembly capability maximize the applicability of the minimally invasive treatment.

Magnamosis for long gap esophageal atresia: Minimally invasive "fatal attraction"

BACKGROUND

Aim of study is to report our preliminary experience with magnetic anastomosis (magnamosis) treating long-gap esophageal atresia (LGEA), the most challenging condition of esophageal atresia continuum. Magnamosis has been reported in 20 patients worldwide as an innovative and marginally invasive option.

METHODS

Prospective evaluation of all LGEA patients treated with magnamosis was performed (study registration number: 2535/2021). Main outcomes considered were demographic and surgical features, postoperative complications and feeding within 6-month of follow-up.

RESULTS

Between June 2020 and January 2021, 5 LGEA patients (Type A, Gross classification) were treated. Median preoperative gap was 5 vertebral bodies. Magnetic bullets were placed at an average age of 81 days of life, leading to successful magnamosis in all cases: 4 infants had primary magnetic repair (one after thoracoscopic mobilization of the pouches), 1 patient had a delayed magnamosis after Foker's procedure. Esophageal anastomosis was achieved after an average of 8 days. No anastomotic leak was found. All patients developed anastomotic stenosis at 6-month follow-up, requiring a mean of 6 dilations each. Full oral feeding was achieved in 3 patients, while 2 were still on oral-gastrostomy feeding. One patient experienced small esophageal perforation after dilation (3 months after magnamosis), distal to the anastomotic stricture and subsequently developed oral aversion.

CONCLUSIONS

Our preliminary results suggest magnamosis a safe and effective minimally invasive option in patients with LGEA. Absence of postoperative esophageal leaks may represent a major advantage of magnamosis over conventional surgery, although possible high rate of esophageal stenosis should be further evaluated.

LEVELS OF EVIDENCE

IV (Case series with no comparison group).

The novel application of an emerging device for salvage of primary repair in high-risk complex esophageal atresia

INTRODUCTION

Preservation of native esophagus is a tenet of esophageal atresia (EA) repair. However, techniques for delayed primary anastomosis are severely limited for surgically and medically complex patients at high-risk for operative repair. We report our initial experience with the novel application of the Connect-EA, an esophageal magnetic compression anastomosis device, for salvage of primary repair in 2 high-risk complex EA patients. Compassionate use was approved by the FDA and treating institutions.

OPERATIVE TECHNIQUE

Two approaches using the Connect-EA are described - a totally endoscopic approach and a novel hybrid operative approach. To our knowledge, this is the first successful use of a hybrid operative approach with an esophageal magnetic compression device.

OUTCOMES

Salvage of delayed primary anastomosis was successful in both patients. The totally endoscopic approach significantly reduced operative time and avoided repeat high-risk operation. The hybrid operative approach salvaged delayed primary anastomosis and avoided cervical esophagostomy.

CONCLUSION

The Connect-EA is a novel intervention to achieve delayed primary esophageal repair in complex EA patients with high-risk tissue characteristics and multi-system comorbidities that limit operative repair. We propose a clinical algorithm for use of the totally endoscopic approach and hybrid operative approach for use of the Connect-EA in high-risk complex EA patients.

Creation of gastroenteric anastomosis through natural orifice in rats by magnetic compression technique

BACKGROUND

Being one of the core techniques of magnetic surgery, magnetic compression technique (MCT) has been used for digestive tract anastomosis reconstruction in experimental studies. This study verified the feasibility of gastroenteric anastomosis through natural orifice using MCT in rats.

METHODS

The parent and daughter magnets were designed and manufactured for oral and anal insertion in 20 Sprague-Dawley rats. After anesthesia, the parent magnet was inserted into the colon spleen area through the anus, and the daughter magnet was inserted into the stomach through the mouth. Then the two magnets were positioned to attract each other and bind together. The position of the two magnets was monitored using X-ray. The time required for the formation of the anastomosis and expulsion of the magnets were recorded. 2 weeks later, the animal was sacrificed and the anastomotic specimen was obtained which was observed under naked eye and microscope.

RESULTS

The gastroenteric anastomosis was successfully performed via natural orifices in 18 out of 20 rats. The mean time to construct the anastomosis was 3.78 ± 0.88 min. X-ray examination showed that the magnets were in the appropriate position in 17 rats. The magnets were excreted in 9.47 ± 1.62 days after surgery. The gross and microscopic examination of the specimen showed that the anastomoses were patent and the mucosa at the anastomotic was smooth. The mean bursting pressure of the anastomosis was 136.94 ± 6.79 mmHg.

CONCLUSION

It is feasible to perform gastroenteric anastomosis through natural orifices by MCT.

Cautionary tales in the use of magnets for the treatment of long gap esophageal atresia

BACKGROUND

The use of magnets for the treatment of long gap esophageal atresia or "magnamosis" is associated with increased incidence of anastomotic strictures; however, little has been reported on other complications that may provide insight into refining selection criteria for appropriate use.

METHODS

A single institution, retrospective review identified three cases referred for treatment after attempted magnamosis with significant complications. Their presentation, imaging, management, and outcomes were reviewed.

RESULTS

All three patients had prior cervical or thoracic surgery to close a tracheoesophageal fistula prior to magnamosis, creating scar tissue that can prevent magnet induced esophageal movement, leading to either magnets not attracting enough or erosion into surrounding structures. Two patients had a reported four centimeter esophageal gap prior to attempted magnamosis, both failing to achieve esophageal anastomosis, suggesting that these gaps were either measured on tension with variability in gap measurement technique, or that the esophageal segments were fixed in position from scar tissue and unable to elongate. One patient had severe tracheobronchomalacia requiring tracheostomy, with improvement in his airway after eventual tracheobronchopexies, highlighting that magnamosis does not address comorbidities often associated with this patient population.

CONCLUSIONS

We propose the following inclusion criteria and considerations for magnamosis: an esophageal gap truly less than four centimeters off tension with standardized measurement across centers, cautious use with a history of prior thoracic or cervical esophageal surgery, no associated tracheobronchomalacia or great vessel anomaly that would benefit from concurrent repair, and ideally to be used in centers equipped to manage potential complications.

LEVEL OF EVIDENCE

Level IV treatment study.

Esophageal Magnetic Anastomosis Device (EMAD) to simplify and improve outcome of thoracoscopic repair for esophageal atresia with tracheoesophageal fistula: A proof of concept study

BACKGROUND

We designed a new Esophageal Magnetic Anastomosis Device (EMAD) for thoracoscopic repair of esophageal atresia (EA) with tracheoesophageal fistula (TEF) without the need of handheld suturing or additional gastrostomy.

METHODS

Synthetic EA-TEF model: Spherical and tubular shaped rubber balloons and a term infant sized plastic doll were used. Medical students (n = 10) and surgical trainees (n = 10) were asked to perform thoracoscopic repair of an "EA" with a hand sutured anastomosis (HA) and with the EMAD. Euthanized animal model: The esophagus in 5 piglets (3-4 kg) was dissected and a thoracoscopic esophageal magnetic anastomosis (EMA) was performed. Bursting pressure (BP) and pulling force (PF): HA and EMA were created on ex vivo New Zealand white rabbit (2.5-3 kg) esophagi (n = 25 in each test series). BP and PF were measured and compared against each other.

RESULTS

Medical students were unable to complete HA, but were successful with the EMAD in 11.1 ± 2.78 min. Surgical trainees completed EMA in 4.6 ± 2.06 min vs. HA 30.8 ± 4.29 min (p<0.001). The BP following a HA (14.1 ± 3.32 cmH₂O) was close to the physiological intraluminal pressure reported in a neonatal esophagus (around 20 cmH₂O), whereas the BP with the EMAD was extremely high (>90 cmH₂O) (p<0.001). The PF of an EMA (1.8 ± 0.30 N) was closer to the safety limits of anastomotic tension reported in the literature (i.e. 0.75 N) compared with the HA (3.6 ± 0.43 N) (p<0.0001).

CONCLUSION

The EMAD could simplify, shorten, and potentially improve the outcome of thoracoscopic repair for EA with TEF in the future. A high BS and a relative low PF following EMAD application may lower the risk of postoperative complications such as esophageal leakage and stricture formation.

Construction of Esophagogastric Anastomosis in Rabbits with Magnetic Compression Technique

PURPOSE

The magnetic compression technique (MCT) is a new surgical method that has been used for gastrointestinal anastomosis, choledochojejunostomy, and intestinal anastomosis, but there are no reports on its use for esophagogastric anastomosis. This study aimed to investigate the feasibility of using MCT to fashion esophagogastric anastomoses in rabbits.

METHODS

Twenty rabbits were randomized into an MCT group (study group, n = 10) and a hand-sewn group (control group, n = 10). The magnetic compression anastomosis device used in this study was made of neodymium iron boron (NdFeB) and possessed parent (PMR) and daughter (DMR) magnetic rings. To fashion the anastomosis, the PMR and DMR were inserted into the lower esophagus and gastric fundus, respectively. The coupled magnets automatically compressed the sandwiched tissues and were expelled once the anastomosis was installed. The two groups were further compared in terms of the anastomosis construction time, survival rate, and postoperative complications. One month after the anastomosis was installed, the burst pressure and gross appearance of the anastomoses were evaluated.

RESULTS

The anastomosis construction time in the study group was significantly shorter than that in the control group (10.50 ± 1.58 min vs. 18.60 ± 2.22 min; P < 0.05), and the magnetic rings were defecated out in 10.70 ± 3.49 days. The incidence of anastomotic blockage in both the study and control groups did not differ significantly (0%, 0/10 vs. 20%, 2/10; P > 0.05). Anastomotic leakage was not found in either of the groups, and the anastomoses burst pressures were similar in the two groups. However, the magnetically compressed anastomoses in the study group had a relatively smoother gross appearance than the hand-sewn anastomoses.

CONCLUSION

The magnetic compression anastomosis device is a safe and feasible tool for fashioning esophagogastric anastomoses in this animal model.

Magnamosis for esophageal atresia is associated with anastomotic strictures requiring an increased number of dilatations

BACKGROUND/PURPOSE

Magnamosis is a novel technique which utilizes high power magnets to anastomose the esophageal ends in children with esophageal atresia (EA) with or without a tracheoesophageal fistula (TEF), theoretically avoiding the need for thoracotomy. The objective of this study was to compare anastomotic stricture formation requiring dilatation after magnamosis versus after conventional anastomosis.

METHODS

Our center treated the first 3 cases of EA ± TEF with magnamosis in Canada. One was unsuccessful and excluded from our study. The number of postintervention dilatations was compared to controls from our database, which includes all children with EA ± TEF treated between 1991 and 2015. The controls had EA ± TEF treated with pouch-to-end anastomosis or colonic interposition (n = 65). Mann-Whitney U tests were used with p < 0.05 being significant.

RESULTS

The 2 magnamosis cases had a mean of 13.5 dilatations, compared to 2.6 for the controls. Those managed with pouch-to-end anastomosis or colonic interposition had a mean of 2.3 and 2.7 dilatations, respectively. We found that the cases required more dilatations than controls (p = 0.022) and pouch-to-end anastomosis (p = 0.021), but not than colonic interposition (p = 0.106).

CONCLUSION

Our results indicate that magnamosis is associated with more postintervention dilatations than conventional anastomotic techniques, suggesting that magnamosis results in more frequent and/or more resilient anastomotic strictures.

LEVEL OF EVIDENCE

3.

Magnetic Anastomosis Rings to Create Portacaval Shunt in a Canine Model of Portal Hypertension

PURPOSE

This study evaluated a novel magnetic compression technique (magnamosis) for creating a portacaval shunt in a canine model of portal hypertension, relative to traditional manual suture.

METHODS

Portal hypertension was induced in 18 dogs by partial ligation of the portal vein (baseline). Six weeks later, extrahepatic portacaval shunt implantation was performed with either magnetic anastomosis rings, or traditional manual suture (n = 9, each). The two groups were compared for operative time, portal vein pressure, and serum biochemical indices. Twenty-four weeks post-implantation, the established anastomoses were evaluated by color Doppler imaging, venography, and gross and microscopic histological examinations.

RESULTS

Anastomotic leakage did not occur in either group. The operative time to complete the anastomosis for magnamosis (4.12 ± 1.04 min) was significantly less than that needed for manual suture (24.47 ± 4.89 min, P < 0.01). The portal vein pressure in the magnamosis group was more stable than that in the manual suture group. The blood ammonia level at the end of the 24-week post-implantation observation period was significantly lower in the magnamosis group than in the manual suture group. Gross and microscopic histological examinations revealed that better smoothness and continuity of the vascular intima had been achieved via magnamosis than with manual suture.

CONCLUSION

Magnamosis was superior to manual suture for the creation of a portacaval shunt in this canine model of portal hypertension.

Magnetic compression anastomosis (magnamosis) in a porcine esophagus: Proof of concept for potential application in esophageal atresia

BACKGROUND

Magnetic compression anastomosis (magnamosis) is the process of forming a sutureless anastomosis of the gastrointestinal tract using two magnetic Harrison rings. It has been shown to be effective in stomach, small bowel and colon, but has not been implemented in the esophagus. A pure esophageal atresia porcine model was developed to test the concept.

METHODS

Five pigs weighing between 35 and 65 kg were used. In all pigs, a percutaneous endoscopic gastrostomy (PEG) tube was placed, and a right thoracotomy was performed. Esophageal atresia was simulated by transecting the esophagus with a cutting stapler, and magnets were placed endoscopically to approximate the two ends of the esophagus. In the first pig, the tissue within the magnetic ring was excised endoscopically to achieve immediate patency. In the second pig, approximation of the blind esophageal ends was reinforced with 3-4 externally-placed sutures but immediate patency was not performed. In the last three pigs, both external suture reinforcement and immediate patency were performed. The pigs survived for 10-14 days and received nutrition through PEG tube. At necropsy, an esophagram was performed, the specimen was explanted and a leak test was performed.

RESULTS

The first pig died in the early postoperative period from a leak owing to separation of the magnets. The second pig died from aspiration before the anastomosis formed. The last three pigs survived until the study endpoint. The third pig had a contained leak owing to the staple line being placed between the magnets; this was not clinically significant. The last two pigs had well-formed anastomoses. Burst tests showed no leak when injecting saline up to 30 mmHg.

CONCLUSION

Magnamosis is technically feasible for esophagoesophageal anastomoses. A survival model for pure esophageal atresia was developed and refined in pigs. Further work in this area may lead to clinical use in humans.

Laparoscopic Magnetic Compression Biliojejunostomy: A Preliminary Clinical Study

BACKGROUND

Magnetic compression anastomosis is a feasible and effective method for bilioenteric anastomosis (BEA) in animal model. The objective of the present study was to report our initial clinical experience in laparoscopically magnetic compression bilioenteric anastomosis (LMC-BEA).

METHODS

Patients with obstructive jaundice who were candidates for LMC-BEA were prospectively enrolled from 2013 to 2015. All the procedures were performed laparoscopically. A mother magnet and drainage tube were placed in the proximal bile duct and tightened by a purse suture after dissection of the common bile duct. The drainage tube was introduced into the jejunal lumen at the anastomotic site and guided a daughter magnet to approximate the mother magnet. The two magnets mated at the anastomotic site. All the patients were routinely followed up for magnets discharge till the end of the study.

RESULTS

In total, four patients with malignant obstructive jaundice and one patient with benign biliary stricture were included. The median age was 70 y (range, 49-74 y). The median time for LMC-BEA was 12 min (range, 8-15 min). A complete anastomosis was confirmed after a median time of 21 d (range, 5-25 d) postoperatively by cholangiography via drainage tube. The magnets were expulsed around 41 d after surgery (range, 12-47 d) postoperatively. With a median follow-up of 313 d (range, 223-1042 d), no complications associated with magnetic anastomosis was documented, such as bile leakage or anastomotic stricture.

CONCLUSIONS

Magnetic compression is a promising alternate method for laparoscopic BEA. Among the five patients undergoing LMC-BEA, no one developed anastomotic complications.

Repair of esophageal atresia with proximal fistula using endoscopic magnetic compression anastomosis (magnamosis) after staged lengthening

We describe the treatment of a patient with long-gap esophageal atresia with an upper pouch fistula, mircogastria and minimal distal esophageal remnant. After 4.5 months of feeding via gastrostomy, a proximal fistula was identified by bronchoscopy and a thoracoscopic modified Foker procedure was performed reducing the gap from approximately 7-5 cm over 2 weeks of traction. A second stage to ligate the fistula and suture approximate the proximal and distal esophagus resulted in a gap of 1.5 cm. IRB and FDA approval was then obtained for endoscopic placement of 10-French catheter mounted magnets in the proximal and distal pouches promoting a magnetic compression anastomosis (magnamosis). Magnetic coupling occurred at 4 days and after magnet removal at 13 days an esophagram demonstrated a 10 French channel without leak. Serial endoscopic balloon dilation has allowed drainage of swallowed secretions as the baby learns bottling behavior at home.

Magnamosis combined with endoscopy: A new endoscopic technique in digestive surgery

Conventional hand-sewn technique is the basic method for anastomosis in the gastrointestinal tract. However, with the rapid development of minimally invasive surgery and the spread of fast track surgery, hand-sewn technique cannot satisfy the requirements of modern surgery. The common goal that the majority of surgeons seek to achieve has changed: to reduce surgical invasion and operative time as minimally as possible, on the premise that therapeutic and anastomotic effects can be guaranteed. Therefore, after more than 30 years of exploration and development, magnamosis as a novel anastomosis technique shows its significant superiority in anastomosis or recanalization in the gastrointestinal tract. Furthermore, the combination of magnamosis and endoscopy may transform part of the surgical procedures into endoscopic procedures. This review aims to elucidate the application and future development of magnamosis combined with endoscopy in anastomosis or recanalization in the gastrointestinal tract.