The Use of a Circular Side Stapling Technique in Laparoscopic Low Anterior Resection for Rectal Cancer: Experience of 30 Serial Cases

The double-stapling technique using a circular stapler (CS) to create an end-to-end anastomosis is currently used widely in laparoscopic-assisted rectal surgery. However, a high rate of anastomotic failure has been reported. We report new side-to-side anastomosis creation using a CS, the so-called circular side stapling technique (CST). After excising the rectum at the oral and anal sides of the tumor with a linear stapler, a side-to-side colorectal anastomosis was made on the anterior wall of the rectosigmoid colon and the anterior or posterior wall of the rectum with a CS. Between 2012 and 2013, we recorded 30 serial cases of rectal-sigmoid or rectal cancer that were treated with laparoscopic-assisted surgeries using this method. In the 30 cases, the mean age was 68 ± 12 years, operating time was 288 ± 80 minutes, and blood loss was 66 ± 67 mL. None of the patients suffered from anastomosis leakage or postoperative anastomotic bleeding, and none complained of their stool habits. Three months after the last surgery in this cohort, no anastomosis strictures were reported. Based on these results, we propose an alternative method of side-to-side anastomosis for low anterior resection by using a CS to prevent staple overlap. Our experience indicates that the CST is easy and safe. Therefore, this method is a useful alternative to the current method used in laparoscopic surgery.Key words: Laparoscopy, Circular stapler, Colorectal cancer, Low anterior resectionLaparoscopic surgery for the treatment of colorectal disease has proven to be a safe and effective method compared with an open procedure.^1–3 Laparoscopy has the advantages of reduced blood loss, hospital stay, and use of anesthetics as well as a better cosmetic outcome. Although many clinical studies have demonstrated the advantages and low complication rates of laparoscopic colectomy and low anterior resection,^1–5 a high rate of anastomotic leakage has been reported in laparoscopic rectal surgeries. The reported incidence of leakage after laparoscopic surgery for the treatment of rectum varies from 6% to 17%.^1–3 Additionally, anastomotic leakage might raise concerns about local recurrence and may limit the patients prognosis.^6–8 Therefore, despite great advances in laparoscopic surgery, the risks of anastomotic complications persist to a greater extent than those for other colonic resections.^6,7Recent reports have included proposed methods for reducing anastomotic leakage, and recently a transanal drainage tube has been recommended, because the high pressure experienced in the rectum could cause anastomotic failure.⁹ Another group reported the use of anti-traction sutures supporting the anastomosis to reduce anastomotic leakage.¹⁰ Despite these proposals, anastomotic failure has not been completely resolved.In typical laparoscopic rectal surgery, a double-stapling technique (DST) with a circular stapler is used to create the anastomosis. This method is thought to be the only method available to complete an intracorporeal anastomosis of the rectum. However, the DST requires the excision of the stump of the staple line created by the linear stapler. Our previous endoscopic experience with anastomotic leakage shows that leakage occurs frequently at the point where the staples overlap in the DST.¹¹ In this study we demonstrate a new circular side stapling technique (CST), which does not require the excision of the linear staple line in a laparoscopic low anterior resection.     

Correlation between mechanical stress by finite element analysis and 18F‐fluoride PET uptake in hip osteoarthritis patients

¹⁸F‐fluoride positron emission tomography (¹⁸F‐fluoride PET) is a functional imaging modality used primarily to detect increased bone metabolism. Increased ¹⁸F‐fluoride PET uptake suggests an association between increased bone metabolism and load stress at the subchondral level. This study therefore examined the relationship between equivalent stress distribution calculated by finite element analysis and ¹⁸F‐fluoride PET uptake in patients with hip osteoarthritis. The study examined 34 hips of 17 patients who presented to our clinic with hip pain, and were diagnosed with osteoarthritis or pre‐osteoarthritis. The hips with trauma, infection, or bone metastasis of cancer were excluded. Three‐dimensional models of each hip were created from computed tomography data to calculate the maximum equivalent stress by finite element analysis, which was compared with the maximum standardized uptake value (SUV_max) examined by ¹⁸F‐fluoride PET. The SUV_max and equivalent stress were correlated (Spearman's rank correlation coefficient ρ = 0.752), and higher equivalent stress values were noted in higher SUV_max patients. The correlation between SUV_max and maximum equivalent stress in osteoarthritic hips suggests the possibility that ¹⁸F‐fluoride PET detect increased bone metabolism at sites of stress concentration. This study demonstrates the correlation between mechanical stress and bone remodeling acceleration in hip osteoarthritis. © 2014 Orthopaedic Research Society. Published by Wiley Periodicals, Inc. J Orthop Res 33:78–83, 2015.