Circumferential stapled procedure for bleeding ano-rectal varices is an effective treatment – experience in nine patients

Objective  The objective of this study was to demonstrate that stapled disruption of rectal varices is a feasible and suitable method of controlling bleeding varices.
Method  Patients known to have bleeding rectal varices secondary to liver failure were offered this procedure. All these patients had failed medical and endoscopic management. All nine patients underwent the procedure as an emergency, with the intention of controlling haemorrhage. The procedure was carried out under general anaesthetic by a colorectal surgeon experienced in using the stapled device for haemorrhoidectomy.
Results  Nine patients underwent this procedure, with successful control of bleeding achieved in all. Follow-up period from 4 to 24 months revealed no further re-bleeding.
Conclusion  We conclude that stapled disruption of bleeding rectal varices in patients with known portal hypertension is a very useful and effective procedure when carried out by an experienced colorectal surgeon.     

Bleeding after stapled haemorrhoidopexy using the PPH 03 stapler device. Experience and results in 100 consecutive patients

Bleeding after stapled haemorrhoidopexy using the PPH 01 device is a relatively frequent major complication. Using the new PPH 03 instrument may enable to achieve better control. From June 2004 to July 2005, 100 patients with 2nd and 3rd degree haemorrhoids and mucosal rectal prolapse were treated at our institution. In all of the cases the PPH 03 instrument was used and the operations were performed by two surgeons with expertise in stapled haemorrhoidopexy. During structural interviews, the patients assessed their symptoms before and after surgery, and surgical outcome was assessed at 1 and 2 weeks. Major bleeding (loss of Hb > 5 points) occurred in 2 patients in the first 10 cases and re-operation was necessary. Minor bleeding (loss of Hb < 3 points) occurred in 2 patients. We had 2 bleeds in the early postoperative period (2%) and 2 cases of late bleeding (2%). Stapled haemorrhoidopexy is an effective treatment for haemorrhoids and is a significantly less painful operation. Any postoperative bleeding that may occur is easy to resolve and its incidence depends on the careful haemostatic control at the staple line. The new PPH 03 stapler device seems to be more effective than the PPH 01 device for control of the staple line suture. We would suggest that colorectal surgeons who are familiar with the technique and aware of possible complications should perform stapled haemorrhoidopexy using the PPH 03 stapler.     

Prospective, randomized trial of the biofragmentable anastomosis ring. The BAR Investigational Group

A randomized trial was undertaken to compare the biofragmental anastomotic ring (BAR) with conventional intraperitoneal colorectal anastomotic techniques. Patients were randomized into one of two schemes: BAR versus sutured or BAR versus stapled anastomosis. There were 782 patients entered into the study and 283 patients (36%) had a sutured anastomosis, 104 patients (13%) had a stapled anastomosis, and 395 (51%) had the BAR. Comparison of the BAR with combined suture and stapled controls revealed no significant differences in wound complication, abscess rate, bleeding, anastomotic leaks, ileus, obstruction, or deaths. There were no differences in return of bowel function, return to normal diet, or hospital stay. Intraoperative difficulties occurred in 46 BAR patients (17%), and this was significantly higher (p less than 0.001) than for sutured (3%) but not for stapled anastomoses (11%). The occurrence of these problems did not adversely effect the outcome. The data suggest that the BAR is a safe, satisfactory alternative to sutured or stapled colorectal anastomoses.     

Laparoscopic disk resection for bowel endometriosis using a circular stapler and a new endoscopic method to control postoperative bleeding from the stapler line

BACKGROUND: Complete laparoscopic excision of endometriosis offers good longterm symptomatic relief, especially for those with severe or debilitating symptoms. Intestinal endometriosis affect between 3% and 36% of women with endometriosis and 50% of women with disease severe enough that intestinal surgery, with or without intestinal segmental resection, may be required. STUDY DESIGN: Between January 2003 and September 2006, we performed 35 laparoscopic complete excisions of endometriosis with full thickness disk resections of bowel endometriosis using the CEEA stapler (US Surgical) inserted transanally. RESULTS: The endometriotic nodule of the bowel was completely removed in all patients. No major or minor surgical complications occurred during the primary surgical procedure. One patient underwent a diverting temporary ileostomy because of air loss after insufflation of the rectosigmoid colon, which was closed successfully 1 month after surgery. In three of seven cases of rectal bleeding from the stapler line, for the first time, we successfully used conservative endoscopic management. CONCLUSIONS: In properly selected patients, full thickness disk excision using a circular stapler is a feasible procedure that avoids the potential morbidities of a low anastomosis. We suggest conservative management by endoscopic hemostasis before referring patients for a new operation in cases of rectal bleeding from the anastomotic site.     

Stapled anastomoses in colorectal surgery

The purpose of this paper was to analyze the advantages, indications and results of stapled circular anastomoses in colorectal surgery. In the last four years (1995-1998), fifteen patients underwent stapled anastomoses after Dixon's anterior rectal resection for cancers of upper and midrectum (11 patients), total colectomy with ileorectal anastomosis for malignant familial polyposis (1 patient), segmental colectomy of transverse and descending colon (1 patient with synchronous colic and rectal cancers, having concomitant rectal resection for cancer), previous Hartmann's resection for perforated upper rectal cancer (1 patient) or distal sigmoid diverticulitis (1 patient). The anastomoses have been performed in end-to-end fashion (11 patients), according to the Knight's technique (2 cases) or in side-to-end fashion (2 patients). As most frequent associated technique with stapled anastomoses, anterior rectal resection for cancer was performed with 2 cm of clearance beyond the macroscopic margin of tumor. Distal margin of resection was histologically verified and it proved to be free of tumor cells. There was no operative mortality. Anastomotic leakage occurred in three patients because of imperfection of stapled anastomosis (2 cases) or after local irradiation (1 case). Spontaneous closure was seen in one patients. The other two patients needed reoperation for suture or colostomy. Late clinical, endoscopic and X-ray controls did not discover local recurrences. Functional results were good in terms of stool frequency and continence. In conclusion, stapled fashioned anastomoses have the main indication in sphincter saving Dixon's and Hartmann's procedures. In these cases, stapled anastomoses are easier than manual technique, reduce operative time and improve suture reliability.     

Endoscopic band ligation therapy for upper gastrointestinal bleeding related to Mallory–Weiss syndrome

BACKGROUND: No consensus exists as to the best endoscopic treatment for Mallory-Weiss syndrome. Endoscopic band ligation is a readily available and easily learned technique. This prospective study evaluated the efficacy and safety of endoscopic band ligation therapy for Mallory-Weiss syndrome. METHODS: From August 1998 to June 2005, a clinical trial assessed 37 patients with a diagnosis of Mallory-Weiss syndrome who had active bleeding, exposed vessels, or both. Their lesions were treated using endoscopic band ligation. RESULTS: Endoscopic band ligation was successful in 36 of 37 cases, with a follow-up period ranging from 1 to 24 months. The remaining patient had severe liver failure and disseminated intravascular coagulation. The patient bled again at 12 h and subsequently died. Except for this case, no recurrent bleeding, perforation, or other complications occurred. CONCLUSIONS: The study results suggest that endoscopic band ligation is an effective, safe, and easily learned procedure for treating upper gastrointestinal bleeding related to Mallory-Weiss syndrome.     

The management and outcome of anastomotic leaks in colorectal surgery

Purpose  Anastomotic leaks in colorectal surgery are associated with significant morbidity and mortality and may result in poor functional and oncological outcomes. Diagnostic difficulties may delay identification and appropriate management of leaks. The aim of this study was to look at the diagnosis, clinical management and outcomes of anastamotic leaks in our department.
Method  A retrospective audit and case note review of all patients who underwent the formation of a colorectal anastomosis between January 1996 and December 2002 ( n  = 1421) was performed. An anastomotic leak was defined as sepsis identified to have arisen from an anastomosis that subsequently required surgery, radiological drainage or intravenous antibiotics. Forty-one patients (25 male, 16 female) with a median age of 60 years (range 7–89 years) were identified as having suffered an anastomotic leak.
Results  The median time to diagnosis of an anastomotic leak following surgery was 7 days (range 3–29). At re-operation, 21 patients (51%) underwent formation of a stoma, and any who required the anastomosis to be formally taken down have been left with a 'permanent' stoma. Currently only four of 12 patients (33%) who required a stoma for an anastomotic leak following anterior resection have undergone stoma reversal. Eleven of 16 patients (69%) who had received a stoma following another colorectal procedure had undergone stoma reversal. The mortality associated with an anastamotic leak in this series was 5% ( n  = 2).
Conclusion  Although anastomotic leaks following colorectal surgery are associated with significant morbidity and stoma formation, early and aggressive management should result in a low overall mortality. If an anastomosis is taken down following an anastomotic leak after anterior resection, this will usually result in a 'permanent' stoma.     

Symptomatic stenoses following stapler anastomosis of the large intestine]

Since 1978 the stapled colonic anastomosis belongs to the technical standard in surgery of the rectosigmoid. It is followed by an extension of indications for sphincter-preserving excisional treatment. The main advantages of the mechanical suturing are the shortening of operation time as well as the practical and easy management, especially when the anastomosis is located low in the pelvis. Early respectively late postoperative strictures represent the most frequent complications of stapled anastomosis. From 1989 to 1991, the stapling technique was used for colorectal anastomosis in 196 cases in our hospital. Clinical stenosis occurred in 5 cases, an incidence of 2.5%. Causative the size of the cartridge, the healing by second intention because of the metallic staples, a disturbed microcirculation depending on the tension around the anastomosis, missing normal fecal dilation because of protective colostomy and an incongruity of the combined lumina are discussed. Independent of localisation and grade of the stricture, repeated dilation was a successful therapy in all 5 cases.     

Portal hypertension: a surgical hepatologist's view of current management

Current strategies for management of acute esophageal variceal bleeding and for long-term treatment after an episode of variceal bleeding are outlined. Acute variceal bleeding is best managed by means of endoscopic therapy (sclerotherapy, band ligation, or “superglue”), whereas the role of pharmacologic agents remains controversial. In cases of failure of endoscopic therapy, a transjugular intrahepatic portosystemic shunt (TIPS) procedure, an emergency shunt, or a transection operation should be performed. Patients who experience an acute variceal bleeding episode require long-term management to prevent recurrent bleeding. Endoscopic treatment is preferred using either sclerotherapy or banding. The principal alternative is long-term pharmacologic therapy with beta-adrenergic receptor blocking agents. Major surgical procedures should be reserved for failures of endoscopic or pharmacologic therapy. The distal splenorenal shunt or the new narrow-diameter polytetrafluoroethylene portacaval shunt is preferred. All patients who are first seen with acute variceal bleeding should be considered for a liver transplant, although few will ultimately become transplant candidates. Patients with end-stage liver disease who are not transplant candidates should be identified and major high-cost therapy discontinued. Prophylactic therapy prior to variceal bleeding should be considered in selected patients. At present, only pharmacologic therapy is justified. The major problem remains identification of those patients at high risk for a first episode of variceal bleeding.     

Sutureless large bowel anastomosis: European experience with the biofragmentable anastomosis ring

Sutureless colonic anastomosis using a biofragmentable anastomosis ring (BAR) has been evaluated in a prospective randomized comparison with sutures and staples for elective colorectal surgery. One hundred and one patients underwent BAR anastomosis, 85 a sutured anastomosis, and 16 a stapled anastomosis. There were two anastomotic leaks in the patients undergoing BAR anastomosis, seven in patients having a sutured anastomosis, and one in a patient who had a stapled anastomosis. Wound infection occurred in ten BAR patients, ten sutured patients and no stapled patient. There was no statistically significant difference in these or in other postoperative complications between the groups. The BAR was easy to use and is a safe alternative to sutures and staples for large bowel anastomosis.     

Estenosis de la anastomosis gastroyeyunal en el bypass gástrico laparoscópico. Experiencia en una serie de 280 casos en 8 años

ObjetiveGastrojejunal stricture (GYS), not only is a common complication after laparoscopic gastric bypass, but its frequency is about 15% according to bibliography. Our aim is to present our experience after 280 laparoscopic gastric bypass.Patients and methodFrom January 2004 to December 2012, 280 patients underwent a laparoscopic Roux en Y gastric bypass with creation of the gastrojejunal anastomosis is performed with circular stapler type CEAA No 21 in 265 patients and with a linear stapler in 15 patients. In all patients with persistent feeding intolerance were performed barium transit and/or gastroscopy. When gastrojejunal stricture showed proceeded to endoscopic pneumatic dilation.ResultsTwenty cases (7.1%) developed a gastrojejunal stricture, in 4 of these cases the initial diagnosis was made by barium transit and all case were confirmed by endoscopy. Five patients had a history of digestive bleeding that required endoscopic sclerosis of the bleeding lesion. All cases were resolved by endoscopic dilatation. One patient suffered a perforation and a re-intervention. At follow-up has not been detected re-stricture.ConclusionStructure at the gastrojejunal anastomosis after gastric bypass is the commonest complication early after surgery. Endoscopic balloon dilatation is a safe and effective therapy.     

Effect of preoperative irradiation on healing of low colorectal anastomoses

The effect of preoperative irradiation on the healing of low colorectal anastomoses was studied experimentally. In 12 dogs in whom preoperative irradiation of 4,000 rads was given before low colorectal stapled anastomosis was performed, anastomotic leakage occurred in 66 percent. More than half of the anastomotic leaks were associated with either severe sepsis or death. In a matched group of control animals that underwent stapled anastomoses without irradiation, no anastomotic complications occurred. The clinical implications of this study are that stapled anastomoses in irradiated colon are at serious risk of anastomotic dehiscence and, therefore, should be protected with a proximal colostomy.     

Long-term follow-up of endoscopic stapled diverticulotomy

We report a consecutive series of 31 patients who underwent endoscopic stapled diverticulotomy. The patients' notes were reviewed retrospectively to gather data on their original admission and a postal survey was conducted to establish patient satisfaction, their ability to swallow and re-operation data. Three patients were lost to follow-up. Nine of the remaining 28 died at a median of 18 months. The remaining 21 were followed up for a median of 59 months. The data showed that, at 5 years, 94.4% of patients had an improvement in their swallowing, and 50% had an entirely normal swallow. In order to achieve this result, 19% of patients required a second procedure, and one patient (3.2%) required a third (open) procedure. Endoscopic stapled diverticulotomy has well-established, short-term advantages. This series shows that it has a good long-term outcome that is similar to established open techniques and probably better than other techniques of endoscopic diverticulotomy, i.e. diathermy or laser.     

前列腺切除术后大出血的原因和处理

目的：探讨前列腺切除术后大出血的原因和防治对策。方法：对本院1981年1月－2000年12月行前列腺切除术的758例患者临床资料进行回顾性分析。结果：758例患者中，25例术后发生大出血，其中术后早期出血16例，迟发性出血9例。18例经保守治疗治愈，3例经再次开放手术止血，4例经电切镜止血。结论：术中止血确切及术后保证引流通畅是预防前列腺切除术后大出血的关键；术后及时发现出血并正确处理可避免再次手术之苦；对膀胱内已充满血块不能吸出者需再次手术；电切镜下止血是一种安全而有效的方法。     

Diagnosis and management of a mediastinal leak following radical oesophagectomy

BACKGROUND: The aim of this study was to evaluate the diagnosis, management and outcome of mediastinal leaks following radical oesophagectomy with a stapled intrathoracic anastomosis. METHODS: Some 291 consecutive patients underwent two-phase subtotal oesophagectomy with gastric interposition for malignancy. Patients with clinical suspicion of a leak were investigated with contrast radiology and flexible upper gastrointestinal endoscopy. RESULTS: Nineteen patients (6.5 per cent) developed a proven mediastinal leak at a median of 8 (range 3-30) days following surgery. Contrast radiology and flexible upper gastrointestinal endoscopy identified that 13 patients had an isolated leak from the oesophagogastric anastomosis and two had widespread leakage secondary to gastrotomy-line dehiscence. Endoscopy revealed a further four patients with gastric necrosis in whom contrast radiology was normal. In six patients the diagnosis of leakage followed an apparently normal routine contrast examination on day 5-8. All 13 isolated anastomotic leaks were managed non-operatively with targeted mediastinal drainage, intravenous antibiotics and antifungal therapy, nasogastric decompression and enteral nutrition; the mortality rate was 15 per cent (two of 13). Patients with gastrotomy dehiscence or gastric necrosis had a more severe clinical picture; they were managed with repeat thoracotomy and either revision of the conduit or resection and exclusion. Despite early intervention four of the six patients died. CONCLUSION: Routine postoperative contrast radiology cannot be recommended. On clinical suspicion of a leak patients require both contrast radiology and endoscopic evaluation. Isolated anastomotic leaks can be managed successfully with non-operative treatment, whereas more extensive leaks from the gastric conduit require revisional surgery which carries a high mortality rate.     

Right hemicolectomy for colon cancer: does the anastomotic configuration affect short-term outcomes?

Objectives

Right hemicolectomy is a common colorectal operation for resection of cancers of the right colon. The ileocolic anastomosis may be created using a stapled end-to-side, stapled side-to-side or handsewn technique. Anastomotic leak and post-operative bleeding are uncommon but serious causes of morbidity and mortality, while post-operative ileus contributes to prolonged length of stay. The aim of this study was to evaluate differences in short-term outcomes between different anastomotic configurations following right hemicolectomy for colon cancer.

Methods

We conducted a retrospective study using data from the Bowel Cancer Outcomes Registry (BCOR), including 94 hospitals across Australia and New Zealand, of all patients who underwent right hemicolectomy or extended right hemicolectomy for colon cancer with formation of a primary anastomosis between 2007 and 2021.

Results

We included 8164 patients in the analysis. There was no significant difference in rates of anastomotic leak and anastomotic bleeding based on anastomotic technique. A stapled end-to-side anastomosis was associated with a lower rate of post-operative ileus than stapled side-to-side anastomosis (6.5% vs. 7.2%; P = 0.03).

Conclusion

Both handsewn and stapled anastomosis techniques may be utilized for oncologic right hemicolectomy, with comparable rates of anastomotic leak and post-operative bleeding. Stapled end-to-side anastomosis resulted in lower rates of prolonged ileus compared to stapled side-to-side anastomoses.     

Comparison of stapling and hand-suture for left-sided large bowel anastomosis

One hundred patients undergoing elective left-sided colonic or rectal resections were randomly allocated to have an anastomosis performed either with the EEA stapling gun or by hand suture using a single layer of interrupted sutures. In six patients the anastomosis could not be performed with the stapling gun. Clinical leakage occurred in two of the remaining 94 cases; both had hand-sutured anastomoses. Radiological leakage was demonstrated in 13 further cases (7 stapled, 6 sutured); there was no statistical difference in leakage rate with stapled and hand-sutured anastomoses.     

Duodenal varices as a cause of massive upper gastrointestinal bleeding

Duodenal varices are an uncommon but serious manifestation of portal hypertension. Our management of three patients with massive bleeding due to duodenal varices stimulated a review of this subject. Thirteen cases of this condition were previously reported. Endoscopic examination of the entire duodenal mucosa is essential to document bleeding from duodenal varices. Medical therapies, including vasopressin and endoscopic sclerotherapy, have had limited success in controlling active duodenal variceal bleeding. Duodenal varix suture ligation or resection also resulted in a high rate of rebleeding. End-to-side portocaval shunt was the most effective procedure in stopping acute and subsequent bleeding in patients with duodenal varices. Despite therapy with or without portosystemic shunt, mortality risk is high in Child's class C patients and in patients with emergency duodenal variceal bleeding.     

Utility of total mechanical stapled cervical esophagogastric anastomosis after esophagectomy: a comparison to conventional anastomotic techniques

BACKGROUND: Cervical esophagogastric anastomosis after esophagectomy is often troubled with anastomotic leak resulting in local sepsis, postoperative stricture, and prolonged hospitalization. We compared the anastomotic outcomes and clinical course of esophagectomy patients undergoing total mechanical stapled esophagogastric anastomosis versus a partial handsewn/mechanical stapled cervical anastomotic technique. METHODS: One hundred eighty-one patients underwent transhiatal (N=146) or 3-field (abdomen/chest/neck incisions) (N=35) esophagectomy. A total mechanical stapled anastomosis was accomplished in 125 patients. A handsewn/mechanical stapled anastomosis was performed in 56 patients. The total mechanical stapled anastomosis was accomplished by using the endoscopic gastrointestinal stapler to construct the posterolateral aspect and a linear stapler to close the anterior aspect of the anastomosis. Total mechanical stapled anastomosis patients had the endoscopic gastrointestinal stapler also used to divide the left gastric vessels and the short gastric mesentery for gastric mobilization. Anastomotic outcomes were analyzed by the leak rate (contrast study) and the need of serial dilations in each group. CONCLUSIONS: Total mechanical stapled technique after esophagectomy with cervical esophagogastric anastomosis appears to be effective in reducing hospitalization and anastomotic complications compared to partial or complete handsewn techniques. Liberal use of endoscopic staplers might shorten operative time. Esophageal surgeons should be aware of the advantages and become skilled with these techniques.     

Morbidity and mortality after closure of loop ileostomy

Background  A temporary loop ileostomy is commonly used to protect low pelvic anastomoses. Closure is associated with morbidity and mortality. This study investigated patterns of complications after loop ileostomy closure and factors associated with morbidity and mortality.
Method  A review was performed of patients who underwent loop ileostomy closure between 1999 and 2005.
Results  Three hundred and twenty-five patients underwent closure of loop ileostomy. Reasons for primary surgery were: anterior resection for cancer ( n  = 160, 49%), ileal pouch-anal anastomosis ( n  = 114, 35%), diverticular disease ( n  = 25, 8%), Crohn's colitis ( n  = 4, 1%) and other conditions ( n  = 22, 7%). Overall mortality was 2.5% ( n  = 8) and morbidity was 22.8% ( n  = 74). Thirty-two patients (10%) developed small bowel obstruction, of whom seven required operative intervention. Overall, the re-operation rate in this series was 28 patients (8.6%).
Thirteen (4%) patients had an anastomotic leak of whom 12 patients had re-operation. Preoperative anaemia was significantly associated with leakage (Hb < 11 g/dl; n  = 65, P  = 0.033). The leakage rate was lower after a stapled anastomosis than a hand-sutured anastomosis (4/203 vs 9/122; P  = 0.039). Hypo-albuminaemia (albumin < 34 g/l) was significantly associated with mortality ( n  = 46, P  < 0.001).
Conclusions  Loop ileostomy closure is associated with morbidity and mortality. Anaemia and hypo-albuminaemia may be associated with poor outcome.