Modified stapling technique of esophagojejunal anastomosis

The most dangerous complication of total gastrectomy, often causing postoperative death, is dehiscence of esophagojejunal anastomosis. After analyzing more then 300 patients undergoing surgery for gastric and/or cardiac carcinoma at our department in the period 1992-96, we concluded that the main cause of anastomotic dehiscence was a technically insufficient anastomosis, and the main risk factor was hypertrophied muscular layer of the esophagus (predominantly in advanced cardiac carcinoma). In this paper we discuss indications for, and the surgical technique of, our own modification of mechanical esophagojejunal anastomosis. In the period between 1 January 1997 and 1 March 2001, 148 procedures were performed using the modified anastomotic technique. In only two patients (1.35%) were radiological signs of small anastomotic leakage observed. The described modification of mechanical esophagojejunal anastomosis is safe and is not a time-consuming procedure. It is highly recommended in the treatment of the obstructive cardiac carcinoma with a compensatory hypertrophied muscular layer of the esophagus.     

Anal sphincter reconstruction with a pudendal nerve anastomosis following abdominoperineal resection

PURPOSE AND METHODS: We report herein a case of a patient with rectal carcinoma in whom a new anus was constructed following an abdominoperineal resection of the anorectum. This is the first reported case in which reconstruction of the anal sphincter was performed using the lower part of the gluteus maximus muscle with a pudendal nerve anastomosis. The pudendal nerve anastomosis maneuver was designed to achieve proper innervation and function of the external anal sphincter. This newly reconstructed sphincter was physiologically evaluated after surgery. RESULTS: The patient's defunctioning colostomy was not closed following his initial surgery because part of the transposed muscle was devitalized by infection following blood flow damage. However, purposeful contraction of the new sphincter was easy to achieve without special training. The patient's rectal sensation for the desire to defecate was satisfactory. Electromyographic studies demonstrated that the newly reconstructed anal sphincter had characteristics of the original external anal sphincter. CONCLUSIONS: This method is a promising procedure for reconstructing the anal sphincter.     

Laparoscopic very low anterior resection and coloanal anastomosis using the pull-through technique

This article describes the use of the pull-through technique, use of the stapler to facilitate the resection, removal of the specimen, and creation of the anastomosis during very low anterior resection and coloanal anastomosis done totally by laparoscopy.Read at the meeting of The Brazilian Society of Coloproctology, Sao Paulo, Brazil, July 9 to 12, 1995.     

Handsewn ileal pouch-anal anastomosis on the dentate line after total proctectomy

PURPOSE: During ileal pouch-anal anastomosis, both conservation of the anal transitional zone during the stapled technique and incomplete mucosectomy in the standard Park's procedure may expose the patient to disease recurrence. We propose here an technique whose aim is to solve both problems by performing handsewn ileal pouch-anal anastomosis on the dentate line after rectal eversion and total proctectomy. METHODS: We reviewed the records of 172 consecutive patients who had undergone ileal pouchanal anastomosis since 1984 for chronic ulcerative colitis (n=80), familial adenomatous polyposis (n=48), selected cases of Crohn's disease (n=42), or other causes (n=2). RESULTS: One patient (0.5 percent) died postoperatively. Operative morbidity was similar to that reported after the Park's and stapled procedures. Of our 128 patients with a five-year follow-up, anastomotic stricture occurred in 15 (12 percent), and 4 patients (3 percent) had to have pouch removal. Stool frequency per 24 hours was 4.8±1.6 (range, 1–11), continence was perfect in 104 patients (81 percent), and sexual activity was estimated to be unchanged in 120 (94 percent). No evidence of disease recurrence was noted in the patients with familial adenomatous polyposis or ulcerative colitis. CONCLUSIONS: During ileal pouch-anal anastomosis, Park's procedure carries the risk of incomplete mucosectomy and disease recurrence, and the stapled procedure requires a long-term follow-up of the anal transitional zone. Our alternative technique with total proctectomy avoids both problems and gives similar long-term functional results.     

Parks' coloanal pull-through anastomosis for severe,complicated radiation proctitis

A variety of operations have been proposed for the treatment of radiation injuries of the rectum. In this study, the procedure advocated by the late Sir Alan Parks—resection of the diseased segment down to its points of fixation to the vagina, bladder or prostate; with perianal mucosal stripping of the anorectal segment and primary coloanal (pull-through) anastomosis—was performed in 11 patients. In two others, an attempt at colorectal anastomosis was abandoned because of extreme scarring in the pelvis. The procedures were done following definitive treatment of carcinoma of the rectum (seven patients), carcinoma of the cervix (two patients), carcinoma of the uterus (one patient), carcinoma of the ovary (one patient), seminoma (one patient), and carcinoma of the bladder (one patient). One patient died from a pulmonary embolus on the seventh postoperative day. Of the survivors with a coloanal anastomosis, all had successful closure of their temporary colostomies with follow-up from one to six years. In eight, continence was assessed as being good or excellent. Four patients required anastomotic dilatation and another required a surgical procedure for anastomotic stricture. There was one instance each of reoperation for small bowel obstruction and ileocolic fistula. There were no instances of recurrence of hemorrhage, fistulas, perineal pain or tenesmus. The Parks procedure obviates the need for a difficult dissection of the lower rectum and separation of tissues damaged by radiation and avoids the need for eversion techniques. Its selective use is advocated for patients suffering from severe radiation injuries of the rectum. Read at the Joint Meeting of the American Society of Colon and Rectal Surgeons with the Section of Colo-Proctology, Royal Society of Medicine, and the Section of Colonic and Rectal Surgery, Royal Australasian College of Surgeons, New Orleans, Louisiana, May 6 to 11, 1984. This paper received the Harry E. Bacon Foundation Award.     

Modification of the pull-through operation

Conclusions Owing to the success that has attended my experience with this small group of patients, this new simpler technic of the pull-through operation will supplant all other methods in my practice. Read at, the meeting of the American Proctologic Society, Las Vegas, Nevada, May 10 to 13, 1971.     

Review of the pull-through operation for rectal cancer

Conclusions The pull-through operation is a good operative means of treating rectal cancer, and it will not be entirely discarded even with the development of methods of extremely low anastomoses. This has been a recital of “ancient” surgical history in some respects, because today a fair number of these patients would have had anterior resections or the Miles procedure. Furthermore, the radicality of this operation may be open to question: because the inferior mesenteric artery is not ligated at its origin, some of the sigmoidal mesentery remains. In 5 per cent of cases, however, the marginal artery of Drummond does not supply enough blood to the pulled-through segment when the inferior mesenteric artery is ligated at its origin. Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, June 11 to 15, 1978.     

Physiologic consequence of the pull-through operation

Summary Intraluminal pressures of the rectum and anal sphincter were observed in three healthy control subjects at rest and after rectal distention. Nineteen patients, who had undergone a pull-through operation, were studied under identical conditions. A zone of elevated pressure was always identified adjacent to the anal verge in the control subjects. The rectum did not respond to distention, whereas the sphincter relaxed promptly after distention. A zone of elevated pressure was detected in 18 of 19 patients by open-tip detection, and in all 19 by balloon detection. The zone of elevated pressure was adjacent to the anal orifice. Pressures within the zone were of less magnitude and width than those observed in healthy subjects. Colonic distention resulted in colonic contraction in 39% of the patients, “sphincteric” relaxation in 68% and “sphincteric” contraction in 37%. Read at the meeting of the American Proctologic Society, New Orleans, Louisiana, April 17 to 19, 1967.     

Endorectal mucosectomy, endorectal ileal pull-through and ileoanal anastomosis

Ileoanal anastomosis has evolved as a true alternative to proctocolectomy with permanent ileostomy over the past decade and has made a major impact on the operative treatment of patients with ulcerative colitis and familial polyposis. Experimental studies and clinical experience support the addition of a proximal ileal reservoir to the ileoanal anastomosis. Several types of reservoirs have been proposed of which the U-shaped reservoir has found the widest acceptance and the most frequent application. This reservoir constitutes an adequate replacement for the rectum by providing a low-pressure, compliant, peristaltically quiescent reservoir which still can be triggered to evacuate spontaneously at a reasonable threshold volume. Overall, the ileoanal anastomosis with proximal ileal reservoir fulfills the set clinical requirements: the underlying disease (polyposis, ulcerative colitis) is dealt with in a curative manner. An ileostomy is avoided. Anal continence is preserved. The operative procedure is safe and of comparable mortality and morbidity to the proctocolectomy with ileostomy. It is reasonable to expect that this procedure, i. e. ileoanal anastomosis with proximal ileal reservoir, will become the operation of choice for patients with ulcerative colitis and familial polyposis.     

A new method of colorectal anastomosis in abdominoperineal resection

Summary and Conclusions A new technic of colorectal anastomosis in abdominoperineal rectosigmoidectomy is presented. Justification of this technic is based on the principle of “adhesion by contact between the muscular surface of the everted rectum and the serosa surface of the pulled colon, and in the suture of the mucosa coat of the rectum to the mucosa coat of the colon.” The anastomosis is performed in two stages. The results obtained on 40 patients with acquired megacolon and on five with cancer of the rectum and rectosigmoid are described. There was a gratifying reduction in the incidence of disruption of the anastomosis. Read at the meeting of the American Proctologic Society, Pittsburgh, Pennsylvania, June 21 to 24, 1961. Head of the group in charge of colorectal surgery (Professor Eurico da Silva Bastos). Assistant Professor.     

A new colorectal/coloanal anastomotic technique in sphincter-preserving operation for lower rectal carcinoma using transanal pull-through combined with single stapling technique

Purpose

This study aims to introduce a new anastomotic technique-transanal pull-through combined with single stapling technique (PT-SST), and evaluate the value in the sphincter-preserving operation for lower rectal carcinoma.

Methods

Between January 2004 and September 2011, 131 consecutive patients had sphincter-preserving operations using PT-SST and double stapling technique (DST) for low colorectal anastomosis. The data was prospectively collected.

Results

There are 45 patients (male 26, median?=?55 years) in PT-SST group and 86 (male 46, median?=?55 years) in the DST group. Anastomotic leakage took place in three patients in DST group, while no anastomotic leakage happened in PT-SST group. There are recurrences in pelvic cavity for one patient (2.2 %), in anastomotic stoma for no patient, and hepatic metastasis for four patients (8.9 %) in PT-SST group; while there are recurrences in pelvic cavity for three patients (3.5 %), in anastomotic stoma for two patients (2.3 %), and hepatic metastasis for seven patients (8.1 %) in DST group. No significant difference was indicated in the terms of the recurrence and hepatic metastasis between the two groups. Patients were satisfied with functional results.

Conclusions

This new technique can solve some technique problems of DST and has at least comparable outcomes compared with DST. It is a safe and feasible procedure for performing low anastomosis with high rate of sphincter preservation. It can be used especially for patients with small pelvis.     

Esophageal anastomosis following gastrectomy for gastric cancer: comparison of hand-sewn and stapling technique

BACKGROUND/AIMS: During the past 4 years, we have experienced a marked reduction in the incidence of esophageal anastomotic leakage and/or stricture coinciding with the use of a mechanical circular stapler for gastric cancer patients. METHODOLOGY: We reviewed medical records of gastric cancer patients who underwent a total or proximal gastrectomy, and compared the leakage or stricture of stapled anastomosis with the hand-sewn anastomosis technique. A total of 390 esophageal anastomosis were performed between January 1978 and August 1997. Two types of mechanical circular staplers were used (EEA and CDH). RESULTS: Anastomotic leakage occurred in 13 (3.3%) of 390 cases; three (4.5%) of 66 cases with hand-sewn anastomosis, and 10 (3.1%) of 324 cases with stapled anastomosis (EEA: 4.5%, CDH: 0%). The anastomotic leakage rate was significantly lower in the CDH stapler group than in the EEA stapler group. Anastomotic stricture occurred in one (1.5%) of 66 cases of hand-sewn anastomosis, and 16 (4.9%) of 324 cases of stapled anastomosis (EEA: 5.9%, CDH: 2.9%). There were no significant differences in the stricture rate between the hand-sewn group and the stapler group. CONCLUSIONS: Stapling anastomosis using a CDH stapler led to a reduction in the incidence of anastomotic leakage. Surgeons must, however, continue to be aware of anastomotic stricture.     

Simple technique for pelvic drain placement in laparoscopic abdominoperineal resection

The placement of a pelvic drain after abdominoperineal resection of the rectum is a routine practice. We present a simple technique for laparoscopic placement of such a drain through the abdominal wall following laparoscopic abdominoperineal resection.     

Local recurrence following abdominoperineal excision and anterior resection for rectal carcinoma

The aim of this retrospective study is to compare the outcome of abdominoperineal excision (APE) and anterior resection (AR) for rectal cancer in terms of local tumor recurrence. A further comparison has been carried out between hand-sewn and stapled anastomosis; 147 patients have been followed for at least 2 years: 69 after APE and 78 after AR, 40 being stapled. The following variables potentially related to the risk of recurrence were evaluated: age, grading, staging, and site of the tumor. An overall 2-year local recurrence rate of 11 percent after APE and 12 percent after AR was observed, whereas it was 13 and 11 percent following stapled and hand-sewn sutures, respectively. Both differences were not statistically significant. A similar local recurrence rate was noted after APE and AR when the patients were matched for Dukes' stage and grading of the lesion. A trend toward an increased risk of recurrence following AR (P = 0.07) was shown when comparing the two procedures if mid and upper rectal cancers were grouped together. In the patients with anastomotic leaks after AR, no increase of local recurrence was observed. In conclusion, AR is unlikely to be followed by an increased risk of local recurrence and, therefore, when oncologically indicated, may be considered the operation of choice in the treatment of rectal cancer, although the possible risk of its overuse should be taken into account.