Laparoscopic gastrointestinal anastomoses using knotless barbed sutures are safe and reproducible: a single-center experience with 201 patients

Background

Intestinal anastomosis is a complex procedure during laparoscopy, mainly due to the difficulties knotting the sutures. Unidirectional barbed sutures have been proposed to simplify wall and mesentery closure, but the results for intestinal anastomosis are not clear. This study aimed to establish the feasibility and the safety of laparoscopic intestinal anastomosis using barbed suture.

Methods

Between June 2011 and May 2012, 15-cm-long unidirectional absorbable barbed sutures (V-Loc; Covidien, Mansfield, MA, USA) were used for all laparoscopic intestinal anastomoses: one suture for closure of intestinal openings after mechanical anastomoses and two sutures for hand-sewn anastomoses.

Results

Over a 1-year period, 201 consecutive patients required 220 laparoscopic anastomoses for gastrojejunostomy (n = 177; 172 during Roux-en-Y gastric bypass and 5 after gastrectomy), ileocolostomy (n = 15), colocolostomy (n = 1), esophagojejunostomy (n = 5), and jejunojejunostomy (n = 22; 4 after small bowel resection and 18 during gastric bypass or gastrectomy). Senior and training surgeons performed 209 closures of intestinal openings and 11 hand-sewn anastomoses. There was no conversion to usual sutures. One fistula occurred in an esophagojejunostomy and was managed conservatively. One self-limited anastomotic bleeding occurred, and no anastomotic stenosis occurred during 6 months of follow-up evaluation.

Conclusions

The use of knotless barbed suture for laparoscopic intestinal anastomosis is safe and reproducible.     

What Is the Risk of Clinical Anastomotic Leak in the Diverted Colorectal Anastomosis?

Objective

The objective of this study was to identify clinical leak in diverted colorectal anastomoses.

Design

Cohort analysis.

Setting

The study was conducted in a subspecialty practice at a tertiary care facility.

Patients

Consecutive subjects undergoing colorectal anastomosis and proximal fecal diversion between July 16, 2007 and June, 31 2012.

Interventions

No intervention was applied.

Main Outcome Measures

Clinical anastomotic leak.

Results

Two hundred forty-five patients underwent a colorectal anastomosis with proximal fecal diversion. A total of 34 (14 %) clinical leaks were identified at a median of 43 days. Clinical leaks were identified in 13 (5 %) patients within 30 days of surgery (early leaks) and in 21 (9 %) patients after 30 days of surgery (late leaks). Age, sex, use of neoadjuvant chemoradiotherapy, and method of anastomotic construction were similar in patients with clinical leaks as compared to those with no evidence of leak. However, clinical leaks were more likely to develop in patients with a diagnosis of inflammatory bowel disease or other diagnoses, i.e., radiation enteritis, ischemia, and injury/enterotomy. Patients with clinical leak were not more likely to have air leaks on intraoperative air leak testing.

Conclusions

In diverted anastomoses, most leaks become clinically apparent beyond 30 days. The standard practice of censoring outcomes that occur beyond postoperative day 30 will fail to identify a substantial fraction of leaks in diverted colorectal anastomoses.     

Gef??anschluss an die A.?carotis communis

Background

In the treatment of esophageal cancer neoadjuvant radiotherapy often leads to vascular damage of the usual recipient arteries for free jejunal transfer. End-to-side anastomosis to the carotid artery could be a potential alternative.

Patients and methods

A total of 70 patients with locally advanced carcinoma of the esophagus underwent esophagectomy after neoadjuvant radiochemotherapy. In all patients reconstruction was carried out with a free jejunal transfer. Smaller vessels could be used for anastomoses in 54 of these patients and in 16 cases the jejunal flap artery was attached to the carotid artery.

Results

Out of 54 patients 9 (17%) with microvascular anastomoses to the smaller vessels needed surgical intervention for ischemia. In 16 patients with anastomosis to the carotid artery no significant failure of perfusion occurred.

Conclusion

The carotid artery as recipient vessel in free jejunal transfer seems to be a safe therapeutic option for intestinal reconstruction of preradiated esophageal cancer with good functional results.     

End-to-End Cervical Esophagogastric Anastomoses Are Associated with a Higher Number of Strictures Compared with End-to-Side Anastomoses

Background

Leakage and benign strictures occur frequently after esophagectomy. The objective of this study was to analyze the outcome of hand-sewn end-to-end versus end-to-side cervical esophagogastric anastomoses.

Methods

A series of 390 consecutive patients who underwent esophagectomy with gastric conduit reconstruction was analyzed.

Results

The end-to-end technique was performed in 112 (29 %) patients and the end-to-side in 278 (71 %) patients. Anastomotic leakage occurred in 20 (18 %) patients with an end-to-end anastomosis versus 58 (21 %) patients with an end-to-side anastomosis (p?=?0.50). A higher incidence in anastomotic strictures was seen in end-to-end anastomoses (48 (43 %)) compared with end-to-side anastomoses (89 (32 %); p?=?0.04). Moreover, a median of 11 (7–17) dilations was necessary in patients with a benign anastomotic stricture in the end-to-end group compared with four (2–8) dilations in patients with a benign anastomotic stricture in the end-to-end group (p?<?0.036). After multivariate analysis, the difference in anastomotic leakage rates remained nonsignificant (p?=?0.74), whereas anastomotic stricture rate and number of dilations were higher in the end-to-end group (p?=?0.03 and p?=?0.01, respectively).

Conclusion

The technique of anastomosis is not significantly related to anastomotic leakage rate. However, patients with end-to-end anastomoses develop postoperative strictures more frequently, requiring a higher number of dilations compared to end-to-side anastomoses.     

A modular magnetic anastomotic device for minimally invasive digestive anastomosis: proof of concept and preliminary data in the pig model

Background

The aim of our study was to assess the feasibility of minimally invasive digestive anastomosis using a modular flexible magnetic anastomotic device made up of a set of two flexible chains of magnetic elements. The assembly possesses a non-deployed linear configuration which allows it to be introduced through a dedicated small-sized applicator into the bowel where it takes the deployed form. A centering suture allows the mating between the two parts to be controlled in order to include the viscerotomy between the two magnetic rings and the connected viscera.

Methods and procedures

Eight pigs were involved in a 2-week survival experimental study. In five colorectal anastomoses, the proximal device was inserted by a percutaneous endoscopic technique, and the colon was divided below the magnet. The distal magnet was delivered transanally to connect with the proximal magnet. In three jejunojejunostomies, the first magnetic chain was injected in its linear configuration through a small enterotomy. Once delivered, the device self-assembled into a ring shape. A second magnet was injected more distally through the same port. The centering sutures were tied together extracorporeally and, using a knot pusher, magnets were connected. Ex vivo strain testing to determine the compression force delivered by the magnetic device, burst pressure of the anastomosis, and histology were performed.

Results

Mean operative time including endoscopy was 69.2 ± 21.9 min, and average time to full patency was 5 days for colorectal anastomosis. Operative times for jejunojejunostomies were 125, 80, and 35 min, respectively. The postoperative period was uneventful. Burst pressure of all anastomoses was ≥110 mmHg. Mean strain force to detach the devices was 6.1 ± 0.98 and 12.88 ± 1.34 N in colorectal and jejunojejunal connections, respectively. Pathology showed a mild-to-moderate inflammation score.

Conclusions

The modular magnetic system showed enormous potential to create minimally invasive digestive anastomoses, and may represent an alternative to stapled anastomoses, being easy to deliver, effective, and low cost.     

Ileocolonic anastomosis: preferred techniques in 999 patients. A multicentric study

Purpose

There is no standard anastomosis technique for performing reconstruction after right hemicolectomy, and, in the literature, studies on ileocolonic anastomosis are rare. The aim of this retrospective work was to analyze the type of anastomosis techniques used and the related results in a multicentric enquiry.

Methods

A questionnaire was sent to the departments of surgery covering a 1.8 million inhabitant area to collect data concerning the anastomosis techniques used and the results related to complications.

Results

Data for 999 patients from 14 departments of surgery were collected. 95.8 % of the patients were affected by cancer and 4.2 % were affected by inflammatory bowel disease (IBD). The positioning of the anastomosing bowel was side-to-side in 60.5 % of the patients, end-to-side (E–S) in 38.1 % of the patients and end-to-end in 1.3 % of the patients. 46.4 % of the anastomoses were handsewn and 53.6 % were stapled. The complication rate in the cancer group was 5.1 % for handsewn techniques and 4.7 % for stapled techniques. The rate of anastomotic leakage was higher in the handsewn group than that in the stapled group (P < 0.05). The data for the IBD group were not statistically relevant.

Conclusions

This wide multicentric retrospective analysis showed that there remains variability in ileocolonic anastomosis techniques. Stapled anastomoses are associated with a lower incidence of leakage. In stapled anastomoses, the E–S configuration is also related to a lower incidence of leakage.     

PVA gel as a potential adhesion barrier: a safety study in a large animal model of intestinal surgery

Background

Intra-abdominal adhesions following surgery are a major source of morbidity and mortality including abdominal pain and small bowel obstruction. This study evaluated the safety of PVA gel (polyvinyl alcohol and carboxymethylated cellulose gel) on intestinal anastomoses and its potential effectiveness in preventing adhesions in a clinically relevant large animal model.

Methods

Experiments were performed in a pig model with median laparotomy and intestinal anastomosis following small bowel resection. The primary endpoint was the safety of PVA on small intestinal anastomoses. We also measured the incidence of postoperative adhesions in PVA vs. control groups: group A (eight pigs): stapled anastomosis with PVA gel compared to group B (eight pigs), which had no PVA gel; group C (eight pigs): hand-sewn anastomosis with PVA gel compared to group B (eight pigs), which had no anti-adhesive barrier. Animals were sacrificed 14 days after surgery and analyzed.

Results

All anastomoses had a patent lumen without any stenosis. No anastomoses leaked at an intraluminal pressure of 40 cmH₂O. Thus, anastomoses healed very well in both groups, regardless of whether PVA was administered. PVA-treated animals, however, had significantly fewer adhesions in the area of stapled anastomoses. The hand-sewn PVA group also had weaker adhesions and trended towards fewer adhesions to adjacent organs.

Conclusion

These results suggest that PVA gel does not jeopardize the integrity of intestinal anastomoses. However, larger trials are needed to investigate the potential of PVA gel to prevent adhesions in gastrointestinal surgery.     

A comparison of gastrojejunal anastomoses with or without buttressing in a porcine model

Introduction

The addition of staple-line reinforcements on circular anastomoses has not been well studied. We histologically and mechanically analyzed circular- stapled anastomoses with and without bioabsorbable staple-line reinforcement (SeamGuard^®, W. L. Gore &; Associates, Flagstaff, AZ) in a porcine model.

Methods

Gastrojejunal anastomoses were constructed using a #25 EEA Proximate ILS^® (Ethicon Endo-Surgery, Cincinnati, OH) mechanical stapling device with and without Bioabsorbable SeamGuard^® (BSG). Gastrojejunal anastomoses were resected acutely and at 1 week, and burst-pressure testing and histological analysis were performed. Standardized grading systems for inflammation, collagen deposition, vascularity, and serosal inflammation were used to compare the two anastomosis types.

Results

Acute burst pressures were significantly higher with BSG than with staples alone (1.37 versus 0.39 psi, p = 0.0075). Burst pressures at 1 week were significantly lower with BSG than with staples alone (2.24 versus 3.86 psi, p = 0.0353); however, both readings were above normal physiologic intestinal pressures. There was no statistical difference in inflammation (13.4 versus 15.6, p = 0.073), width of mucosa (3.2 mm versus 3.2 mm, p = 0.974), adhesion formation (0 versus 0.5, p = 0.575), number of blood vessels (0.5 versus 1.0, p = 0.056), or serosal inflammation (2.0 versus 1.0, p = 0.27) between the stapled anastomoses and those buttressed with BSG. Stapled-only anastomoses had statistically more collagen (2.0 versus 1.0, p = 0.005) than the anastomoses supported with BSG.

Conclusions

The addition of BSG as a staple-line reinforcement acutely improves the burst strength of a circular anastomosis but not at 1 week. At 1 week, a decrease in collagen content with the BSG-buttressed stapled anastomosis was the only difference in the histologic parameters studied with no difference in vascularity, adhesions, or inflammation. The long-term effect of BSG on anastomotic strength or scarring is yet to be determined. The clinical implications may include decreased stricture formation and also decreased strength at anastomoses.     

Colon anastomotic leakage: improving the mouse model

Purpose

Colon anastomotic leakage remains a serious and common surgical complication. Animal models are valuable to determine the pathophysiological mechanisms and to evaluate possible methods of prevention. The aim of this study was to develop an optimal model of clinical colon anastomotic leakage in a technically insufficient anastomosis in the mouse.

Methods

A total of 110 mice were used in three pilot studies (1–3) and two experiments (A, B). Due to the high complication rates, the analgesic regimen and surgical techniques were changed throughout the pilot studies/experiments. In the final successful experiment (B), eight and four absorbable sutures were used in the control and intervention anastomoses, respectively, and buprenorphine in chocolate spread was used for pain treatment.

Results

In the final model (experiment B), significantly more animals in the intervention group had clinical anastomotic leakage compared with controls (40 vs. 0 %, p = 0.003). The weight loss was greater and the wellness score was also lower in these animals (p < 0.001). The breaking strength of the anastomoses was not significantly different between the control group [0.55 N ± 0.09] and intervention group [0.49 N ± 0.15] (p = 0.091).

Conclusions

This mouse model closely mimics clinical colon anastomotic leakage in humans. The model is of high clinical relevance, since anastomotic leakage has a similar cause, incidence and manifestations in humans.     

Is the mid-term outcome of free right internal thoracic artery with a proximal anastomosis modification inferior to in situ right internal thoracic artery?

Background

We investigated the mid-term results of free right internal thoracic artery (RITA) grafts used in an aorto-coronary fashion with a modified proximal anastomosis.

Methods

The subjects were 214 patients who underwent coronary artery bypass grafting with anastomosis to the left circumflex arteries using the RITA as a free graft (Group A: 158 patients) or an in situ graft (Group B: 56 patients). In Group A, the proximal end of the free RITA was anastomosed onto the ascending aorta interposing free graft tissue or to part of its own tissue as a cuff.

Results

The number of RITA anastomoses was 1.38?±?0.50 in Group A and 1.04?±?0.19 in Group B (P?P?=?0.159), however, the number of cardiac events was decreased in Group A (Hazard Ratio 2.55, 95?% CI 1.03?C6.33, P?=?0.043). The graft patency was evaluated in 187 of 214 patients, and at 1, 3 and 5?years was 97.0, 97.0 and 97.0?% in Group A, and 97.9, 92.5 and 80.5?% in Group B (P?=?0.378), respectively.

Conclusion

By modifying the proximal anastomosis of the free RITA, cardiac events may be decreased, while survival and graft patency comparable with in situ RITA can be obtained, and a significantly larger number of targets can be revascularized.     

Robot-assisted renal artery aneurysm repair with a saphenous vein Y-graft interposition

Background

Renal artery aneurysms (RAA) treatment includes both surgical repair and endovascular techniques, mostly depending on the location of aneurysm [1]. For complex RAA located at renal artery bifurcation or distally, open surgical repair represents the gold standard of treatment [2]. However, the transperitoneal open access to the renal artery requires a wide laparotomy—hence the attempt to be minimally invasive with the first reports of laparoscopic approach [3, 4]. Even if it represents a possibility, laparoscopy has not yet gained widespread acceptance for the technical difficulties in performing vascular anastomosis. We herein describe the repair of a complex RAA using the Da Vinci Surgical System.

Methods

A 41-year-old woman had an accidentally discovered saccular aneurysm of the right renal artery with a maximum diameter of 20 mm, with one in and four out. A laparoscopic robot-assisted approach was planned. Intraoperatively, we confirm the strategy to group the four output branches in two different patches. Thus, a Y-shaped autologous saphenous graft was prepared and introduced through a trocar. For the three anastomoses, a polytetrafluoroethylene running suture was preferred.

Results

The total operation time was 350 min, and the estimated surgical blood loss was about 200 ml. Warm ischemia time was 58 min for the posterior branch and 24 min for the second declamping. The patient resumed a regular diet on postoperative day 2, and the hospital stay lasted 4 days. No intraoperative or postoperative morbidity was noted. A CT scan performed 2 months later revealed the patency of all the reconstructed branches.

Conclusions

The experience of our group counts five other renal aneurysm repair performed with a robot-assisted technique [5]. The presence of five different arterial branches involved in the reconstruction makes this procedure difficult. Robot-assisted laparoscopic technique represents a valid alternative to open surgery in complex cases.     

Robotic resection of choledochocele in an adult with intracorporeal hepaticojejunostomy and Roux-en-Y anastomosis: encouraging progress for robotic surgical treatment of biliary disease

Background

Robotic surgery offers three-dimensional visualization and precision of movement that could be of great value to hepatobiliary surgeons. Previous reports of robotic choledochocele resections in adults have detailed extracorporeal jejunojejunostomies. We describe a total robotic excision of a choledochal cyst with hepaticojejunostomy and intracorporeal Roux-en-Y anastomosis.

Methods

A 58-year-old woman underwent a robotic excision of a small choledochocele with hepaticojejunostomy and intracorporeal Roux-en-Y.

Result

Port placement was determined via collaborative surgical discussion and previously reported robotic right hepatectomies. Total operative time was 386 min and total robot working time was 330 min. The hepaticojejunostomy was performed using 5-0 PDS suture with parachute-style back wall and running front wall sutures. The jejunojejunostomy was a stapled anastomosis. Estimated blood loss was less than 100 mL. The patient was ambulating and tolerating oral intake on post-operative day 1, and was discharged home on post-operative day 2.

Conclusions

Robotic resection of choledochal cyst with intracorporeal Roux-en-Y anastomosis is feasible, with advantages over open surgery such as superior visualization, precision, and post-operative patient recovery.     

Orthotopic Kidney Transplantation in the Rat With the Use of a Sleeve Arterial Anastomosis Method and a Modified Stenting Technique for Renal Veins

Background

We describe a simple and reliable orthotopic kidney transplantation method in rats with the use of sleeve arterial anastomosis and a modified stenting technique for anastomosis of the renal vein (RV).

Embedded Cervical Esophagogastrostomy: A Simple and Convenient Method Using a Circular Stapler After Esophagectomy for Esophageal Carcinomas

Background

Cervical esophagogastrostomy is currently the most common method for esophageal reconstruction after esophagectomy. The advantages and disadvantages of hand-sewn, linear-stapled, or circular-stapled anastomoses have been subject to debate in recent years. We explored a new method of end-to-side anastomosis using a circular stapler that embeds the anastomosis and the remaining esophageal tissue into the gastric cavity to reduce the occurrence of anastomotic leakage and to prevent gastroesophageal reflux.

Methods

In 127 patients with esophageal carcinomas, end-to-side anastomoses with esophageal embedding were performed by connecting the anvil and body of the circular stapler inside the stomach before firing and embedding the anastomosis and remaining esophagus into the stomach after esophagectomy. Retrospective investigations on postoperative complications such as leakage, stricture, and gastroesophageal reflux were conducted.

Results

A total of 123 patients (96.9 %) had successful surgery, and 4 patients (3.3 %) developed anastomotic leakage, with the total morbidity of 20 of 123 (16.3 %) and in-hospital mortality of 1 of 123 (0.8 %). The incidence of stricture (<1 cm) affected 14 of 123 patients (11.4 %). Eight patients underwent dilatation treatment as a result of severe dysphagia (6.5 %). Half of the patients [62 of 123 (50.4 %)] experienced postoperative heartburn, 11 of 123 patients (8.9 %) experienced acid regurgitation, and 16 of 123 patients (13.0 %) experienced nocturnal cough.

Conclusions

Embedded cervical esophagogastrostomy with circular stapler is a simple and convenient method, with low incidence of anastomotic leakage and a good antireflux effect.     

Barbed Versus Usual Suture for Closure of the Gastrojejunal Anastomosis in Laparoscopic Gastric Bypass: a Comparative Trial

Background

Laparoscopic Roux-en-Y gastric bypass is one of the main bariatric procedures that require safe and reproducible anastomosis. The objective of this study is to compare the risk of leaks and stenosis of a mechanical gastric pouch jejunal anastomosis between the usual interrupted sutures and a continuous barbed suture for gastrojejunotomy, in order to reduce procedure time and costs.

Methods

A comparative trial of 100 consecutive patients undergoing laparoscopic Roux-en-Y gastric bypass was performed between October 2010 and July 2011. The population was divided into two groups of 50 consecutive patients. In the first group, gastrojejunotomy was sutured with resorbable interrupted sutures and the second with continuous barbed suture. Diabetes, body mass index and the American Society of Anaesthesiology score were compared. The time required for suturing and the incidence of anastomotic leaks and stricture were also compared after 6 months.

Results

No fistulas or anastomotic stenoses had occurred at post-operative month 6 in either group. Gastrojejunotomy suture time was significantly shorter in the barbed suture group (11 versus 8.22 min; p?<?0.01). Total costs of material to complete the reconstruction were significantly lower in the barbed suture group (€26.69 versus €18.33; p?<?0.001).

Conclusions

The use of barbed suture is as safe as usual sutures and allows easier and faster suture in the closure of gastrojejunotomy. This suture could be incorporated in the standard laparoscopic Roux-en-Y gastric bypass technique.     

Minimally invasive intrathoracic anastomosis after Ivor Lewis esophagectomy for cancer: a review of transoral or transthoracic use of staplers

Background

Minimally invasive Ivor Lewis esophagectomy is one of the approaches used worldwide for treating esophageal cancer. Optimization of this approach and especially identifying the ideal intrathoracic anastomosis technique is needed. To date, different types of anastomosis have been described. A literature search on the current techniques and approaches for intrathoracic anastomosis was held. The studies were evaluated on leakage and stenosis rate of the anastomosis.

Methods

The PubMed electronic database was used for comprehensive literature search by two independent reviewers.

Results

Twelve studies were included in this review. The most frequent applied technique was the stapled anastomosis. Stapled anastomoses can be divided into a transthoracic or a transoral introduction. This stapled approach can be performed with a circular or linear stapler. The reported anastomotic leakage rate ranges from 0 to 10%. The reported anastomotic stenosis rate ranges from 0 to 27.5%.

Conclusions

This review has found no important differences between the two most frequently used stapled anastomoses: the transoral introduction of the anvil and the transthoracic. Clinical trials are needed to compare different methods to improve the quality of the intrathoracic anastomosis after esophagectomy.     

Modified Blumgart Anastomosis for Pancreaticojejunostomy: Technical Improvement in Matched Historical Control Study

Background

Postoperative pancreatic fistula (POPF) is the main cause of fatal complications after pancreatoduodenectomy. There is still no universally accepted technique for pancreaticoenterostomy, especially in patients with soft pancreas.

Methods

Between July 2008 and June 2013, 240 patients who underwent pancreatoduodenectomy were enrolled in this single-institution matched historical control study. To approximate the pancreatic parenchyma to the jejunal seromuscular layer, 120 patients underwent anastomosis using the Kakita method (three or four interrupted penetrating sutures) and 120 underwent anastomosis using the modified Blumgart anastomosis (m-BA) method (one to three transpancreatic/jejunal seromuscular sutures to completely cover the pancreatic stump with jejunal serosa).

Results

The rate of clinically relevant POPF formation was significantly lower in the m-BA group than that in the Kakita group (2.5 vs 36 %; p?<?0.001). The duration of drain placement and the length of postoperative hospital stay were significantly shorter in the m-BA group. Multivariate analysis showed that m-BA was an independent predictor of non-formation of POPF (hazard ratio, 0.02; 95 % confidence interval, 0.01–0.08; p?<?0.001).

Conclusion

The m-BA method is safe and simple and improves postoperative outcomes. We suggest that the m-BA is suitable for use as a standard method of pancreaticojejunostomy after pancreatoduodenectomy.     

Simultane Eingriffe der offenen Herzchirurgie und Ersatz des Truncus brachiocephalicus

Objective

We investigated the feasibility of open heart surgery with combined central vascular surgery and present our results from over 9 years.

Patients and Methods

Between August 94 and June 2003, nine patients underwent open heart surgery and central vascular surgery, i.e. replacement of the brachiocephalic trunk. Eight patients received coronary artery bypass grafting and one patient aortic valve replacement. For vascular surgery, a replacement of the brachiocephalic trunk using a Dacron-prosthesis as end-to-end anastomosis or as bifurcation-prosthesis was performed.

Results

The immediate postoperative survival was 100%. The duration of the operation had a median of 318 min (range: 294–345), perfusion time 67 min (range: 62–146), myocardial ischemic time 27 min (range: 11–83).

Conclusion

The immediate perioperative course indicates no significantly increased complication rate, although the durations of the operation and anesthesia were prolonged. We conclude that concomitant open-heart surgery with central vascular surgery can be performed with low risk and should take preference over surgical therapy in different settings.     

Antimesenteric Functional End-to-End Handsewn (Kono-S) Anastomosis

Introduction

Anastomotic recurrence is a frequent event after bowel resection for Crohn??s disease. To date, no anastomotic technique has been proven to be superior in reducing surgical recurrence rates in this setting. In this article, we describe our technique in performing a new antimesenteric functional end-to-end handsewn (Kono-S) anastomosis.

Methods

The segment of bowel to be resected is identified and mobilized. The bowel is then divided transversely with a linear stapler?Ccutter device. The intervening mesentery is divided close to the bowel. The corners of the two stapled lines are sutured together, and the two stapled lines are approximated with interrupted sutures. An antimesenteric longitudinal enterotomy is performed on both sides, starting no more than 1?cm away from the staple line, to allow a transverse lumen of 7?C8?cm. The openings are closed transversely in two layers.

Results

From May 1, 2010 to July 31, 2011 we performed 46 Kono-S anastomoses. One patient had a contained anastomotic leak successfully treated conservatively. Currently, 18 patients (43?%) have undergone follow-up endoscopic surveillance with an average Rutgeert??s score of 0.7 (0?C3) at a mean of 6.8?months.

Conclusion

The Kono-S anastomosis is a safe anastomotic technique. Long-term studies are needed to confirm its efficacy in preventing surgical recurrence.     

Laparoscopic distal gastrectomy with intracorporeal handsewn Billroth-I anastomosis (ICHSA)

Background

The number of cases of laparoscopic surgery has been increasing. Lymph node dissection has been standardized, and the enlarged view provided by laparoscopes allows for the procedure to be performed successfully entirely within the abdominal cavity, but many cases of reconstruction using the Billroth-I method are performed under direct vision through a small incision. In this study, by placing an anchor thread on a suture line on the lesser curvature of the stomach, we simplified the procedure for handsewn anastomosis and safely performed gastroduodenal anastomosis at low cost to obtain good results.

Methods

From January 2009 to December 2010, we performed handsewn gastroduodenal anastomosis in 18 cases. After performing lymph node dissection, the duodenum and the stomach were separated using an automatic stapling device. Anchor sutures were placed on the suture line of the lesser curvature of the stomach. First, the seromuscular layer of the stomach and the seromuscular layer of the duodenum were sutured by performing interrupted suturing using an extracorporeal knot-tying method. With the stomach and the duodenum in a fixed state, the anastomosis area was opened. The thread of the anchor suture was pulled toward the abdominal wall, and then all layers of the stomach and the duodenum at the posterior wall were continuously sutured. Similarly, for the anterior wall, all layers were continuously sutured from the lesser curvature toward the greater curvature.

Results

We performed this anastomotic procedure in 18 patients with early gastric carcinoma. The mean time required for the anastomosis was 64.6 ± 17.1 min, and the estimated blood loss was 53.1 ± 91 g. All operations were curative, and the mean number of retrieved lymph node was 27.1 ± 10.8. A nasogastric tube was removed on the first or second day. An upper gastrointestinal series performed on postoperative days 5–6 showed no anastomotic leakage and normal transit. Oral intake was started on days 6–7. Postoperative complications included one case of a ruptured suture, but this was resolved through a conservative approach. There was no mortality. Postoperative endoscopy revealed that the anastomosis area was extremely soft, and no abnormalities were observed. Moreover, the only costs related to the anastomosis were for the thread and needles, and although more time was required compared with mechanical anastomosis, the cost was extremely low.

Conclusions

We performed gastroduodenal anastomosis under a total laparoscopic approach by handsewn. This method is economical, because it does not require the use of machinery for anastomosis, and the duodenal stump is short. We believe that this method, which can be performed in a similar manner even for obese patients, can be used as a standard method of anastomosis.