Stapling or suturing for anastomoses of the left side of the large intestine

Two hundred and fifty patients undergoing elective surgical treatment involving anastomoses of the left side of the colon or colon and rectum have been studied in a randomized trial in which the EEA (U. S. Surgical Corp.) circular stapler has been compared with single layer sutured anastomoses. Only patients in whom either technique was feasible were included in the analysis. The operative techniques were largely standardized. Patients were studied by means of a limited barium enema on the ninth or tenth postoperative day. The data have been analyzed for leakage rate (clinical and roentgenologic), other complications and degree of experience of the surgeon. Eleven patients were excluded from the analysis because the selected technique could not be carried out; of these, eight were in the stapled group in which it was possible to perform a sutured anastomosis. There were no instances in which it was possible to staple but not possible to suture. The remaining three exclusions were patients in whom either a coloanal anastomosis or a Hartmann procedure was performed. There was no over-all difference in the leakage rate--roentgenologic, clinical or total--between the two groups. However, when analyzed by the surgeon, the clinical leakage rate for surgeons in training was greater for sutured anastomoses than for stapled anastomoses (p = 0.053). Thus, it appears that the benefits of experience are more pronounced for sutured anastomoses but that, in experienced hands, neither technique is superior.     

Treatment of rectosigmoid endometriosis by laparoscopically assisted vaginal rectosigmoidectomy.

OBJECTIVE: To describe the use of mechanical anastomoses in cases of laparoscopically assisted vaginal rectosigmoidectomy for the treatment of rectosigmoid endometriosis. METHODS: Pilot study evaluating eight patients with rectosigmoid endometriosis referred for surgical treatment. All patients were submitted to laparoscopically assisted vaginal segmental resection of the rectosigmoid with anastomoses performed using linear and circular staplers. RESULTS: The average length of the surgical procedure was 177.5 min and average duration of hospitalization was 4.13 days. There were no intra-operative complications and integrity of the anastomoses was confirmed in all patients. One patient reported partial improvement of symptoms and 7 patients presented complete clinical remission 12 months following surgery. CONCLUSION: Laparoscopically assisted vaginal segmental resection of the sigmoid infiltrated by endometriosis is a feasible surgical procedure. The technique combines transvaginal access with mechanical intestinal anastomoses performed using linear and circular staplers, and achieves good results with low morbidity.     

A comparison of the flow of iodine 125 through three different intestinal anastomoses: standard, Gambee, and stapler

Angiogenesis determines blood supply, and it is postulated that after surgery, the healing of a wound is directly related to the blood supplied to the surrounding tissues. As a first step in evaluating the process of flow through different surgical anastomoses, the flow rate of 125I through three different types of anastomoses in the intestines of dogs was determined. When the results were compared, the flow rate through the stapler anastomosis was significantly higher than the flow rate through the standard and Gambee anastomoses.     

Use of the automatic surgical stapler for intestinal anastomosis associated with gynecologic malignancy: Review of 283 procedures

Between the years 1974 and 1980, 283 intestinal stapling procedures involving the large and small bowel have been performed on the Gynecologic Oncology service. The automatic surgical staplers used in this series were: the gastrointestinal anastomosis (GIA), the thoracoabdominal (TA-55/30), and the end-to-end anastomosis (EEA) stapler (United States Surgical Corp., Stamford, Conn.). The 283 stapling operations were performed on 162 patients. Fifty-three of the patients had received pelvic irradiation prior to the intestinal operations. The complication rate was low, and compared very favorably with other techniques of gastrointestinal anastomosis which were performed by the same authors. There was one disruption of a small-bowel anastomosis, temporary stricture in three anastomoses of rectum to colon, a leak in a low colonie-rectal anastomosis which resulted in a pelvic abscess, and a rectovaginal fistula. Fifty-two patients underwent urinary diversion by bowel conduit. In all of these cases the conduit was fashioned with the aid of the automatic stapler. The low complication rate in gastrointestinal anastomoses performed with the automatic surgical staplers supports the conclusion that this is a technically superior method which provides better utilization of operating time on radical pelvic procedures.     

Pränatale Medizin – eine internationale Perspektive

Intrauterine placental and fetal surgery should be minimally invasive to keep procedure related risks for the mother and the fetus as low as possible. The EuroTwin2Twin project deals with all aspects of monochorionic twinning. Fetoscopic laser coagulation of placental anastomoses is a causal therapy and results in a significantly improved outcome as compared to repeated amniodrainages. Intrauterine surgery for diaphragmatic surgery is still experimental. Endotracheal balloon occlusion seems to improve survival rates in cases with a poor prognosis, namely with liver herniation and a lung/head ration of less than 1. Good results will only be achievable in centres with large experience with fetoscopic techniques. The Eurofoetus-Consortium comprises a group of Fetal Medicine centres to promote research and development on an international level.     

Placental types and twin-twin transfusion syndrome

OBJECTIVE: The purpose of this study was to assess the value of a proposed classification of monochorionic placenta in reference to twin-twin transfusion syndrome. STUDY DESIGN: The placentas from laser-treated patients with twin-twin transfusion syndrome and from uncomplicated monochorionic pregnancies that were delivered between January 1997 and December 2000 were included in the study. Placentas were classified as type A (no anastomoses), type B (only deep anastomoses), type C (only superficial anastomoses), and type D (deep and superficial anastomoses). The number and type of anastomoses were documented in each placental type. The severity of twin-twin transfusion syndrome was assessed in stages, as previously described. The relationship between placental types and the development and severity of twin-twin transfusion syndrome was determined. RESULTS: One hundred thirty-one placentas were examined. Twin-twin transfusion syndrome developed in 0% (0/4 placentas) of type A, in 100% (85/85 placentas) of type B, in 5.6% (1/18 placentas) of type C, and in 79.17% (19/24 placentas) of type D placentas. An average of 4.17 (range, 1-11) vascular anastomoses was found. The mean number of superficial anastomoses was not different between patients with twin-twin transfusion syndrome and patients with no twin-twin transfusion syndrome (1.6 vs 1.71, respectively; P =.69, Student t test). The presence or absence of superficial anastomoses was not associated with differences in the severity of twin-twin transfusion syndrome. CONCLUSION: This classification represents a practical approach to the surgical pathologic assessment of vascular anastomoses in monochorionic placentas, with a strong clinical correlation. It also allows for the clarification of the relationship between superficial anastomoses and twin-twin transfusion syndrome.     

Twin-twin transfusion syndrome

The understanding and management of twin-twin transfusion syndrome has evolved significantly over the past few years. Improved and standardized sonographic diagnostic criteria, understanding of the heterogeneic nature of the syndrome, development of an anatomical and reproducible surgical technique for the identification of vascular anastomoses, and technological advances and developments now allow clinicians to view the disease as a more readily understandable and treatable condition. Many tasks remain, including education of peers, better screening and diagnosis, and further development of surgical instruments. Generalization of treatment outcomes should no longer apply given the varied results with disease stage. Confirmation of our tailored approach to management of the disease according to stage should soon be corroborated with an appropriate clinical trial.     

Assessment of feto-fetal transfusion flow through placental arterio-venous anastomoses in a unique case of twin-to-twin transfusion syndrome

In vivo measurements of blood flow through arterio-venous anastomoses in monochorionic twin placentas have recently been attempted with Doppler ultrasound, but the accuracy is questionable. We present a case of twin-to-twin transfusion syndrome treated with fetoscopic laser surgery. The ex-recipient subsequently became severely anaemic and was treated with an intrauterine blood transfusion at 29 weeks' gestation. After birth, a placental injection study identified residual unidirectional arterio-venous anastomoses from the ex-recipient to the ex-donor without arterio-venous anastomoses in the opposite direction. Prospective measurements of decreasing haemoglobin levels between the intrauterine transfusion and birth allowed us to assess the net blood flow through the anastomoses as 27.9mL/24h. This finding may also explain the inaccuracy of Doppler flow measurements, as such low flow velocities cannot possibly be detected with current Doppler techniques.     

Endoscopy for contraception

Over the past 2 decades, endoscopic methods of tubal sterilization-- including laparoscopic, hysteroscopic, and transcervical techniques-- have been refined so as to be less aggressive. In developing countries, laparotomic, minilaparotomic, and chemical methods of tubal sterilization prevail. Hysteroscopic methods involving the injection of silicone plugs or inert devices and transcervical injections of adhesive and sclerosing substances remain largely experimental at this time. The failure rate of tubal sterilization has remained fairly constant at 0.5%, but there has been considerable progress in terms of safety and complications. The mortality rate has dropped from 4-110/100,000 cases in the early 1970s to 4-57/100,000 procedures. In the US, the mortality rate is 4.2 for surgical sterilization and 0.4 for chemical sterilization, while, in Bangladesh, these rates are 32.6 and 30.2, respectively. The greater safety of sterilization in developing countries is due, in part, to laparoscopy and the use of Falope rings or clips. Early complications requiring surgical intervention occur in 1.1% of laparotomic sterilization cases, 1.4% of minilaparotomies, and in 0.9-3.7% of laparoscopic sterilizations. The advent of microsurgical techniques has led to a drop in the ectopic pregnancy rate from 7-21% to 4-17%. In the US, 1.1% of women request sterilization reversal and 60% of such reversals result in an intrauterine pregnancy. Most successful are isthmo-isthmic and isthmo-ampullar anastomoses performed by skilled microsurgeons. The ultimate aim is to develop a noninvasive method of tubal sterilization that is fully reversible and can be performed in an outpatient setting.     

The role of veno-venous anastomoses in twin–twin transfusion syndrome

The aim of this study was to investigate the independent role of veno-venous (VV) anastomoses in the development of twin–twin transfusion syndrome (TTTS). Thirty TTTS placentas and 41 non-TTTS placentas, routinely injected with colored dye, were enrolled in this study. We excluded all cases with arterio-arterial (AA) anastomoses and TTTS cases treated with laser surgery. The prevalence of VV anastomoses was significantly higher in TTTS cases compared to non-TTTS cases, 37% (11/30) and 7% (3/41), respectively (P < .01; odds ratio 7.3; 95% confidence interval: 1.8–37.1). Our findings suggest that, in the absence of AA anastomoses, VV anastomoses may enhance the development of TTTS.     

Nonsurgical internal biliary drainage by endoprosthesis

Insertion of an endoprostheses for internal biliary drainage was attempted upon 150 patients with obstructive jaundice. It was successful in 123 patients, and 99 patients had permanent drainage with the endoprosthesis. The plasma bilirubin level became normal in 64 of the patients. The effect upon jaundice was equal to that in 43 patients who underwent operation with palliative surgical bypass. The median survival time was not different from that for the patients with surgical anastomoses. Twenty-eight patients died in the first month after insertion, mostly of advanced malignant disease. Fifteen of the patients in the group with surgical anastomoses died within the first month. The insertion of an endoprosthesis for bile duct obstruction is relatively easy and seems to have little risk. Most complications are caused by the transhepatic cholangiography procedure. The method may be used for temporary drainage before operation, in transient benign obstructions or as permanent drainage in unresectable lesions. In patients with dislodgement or insufficient function, additional endoprosthesis may be inserted. Thus, sufficient palliation of jaundice is achieved with a low frequency of cholangitis. Internal biliary drainage by insertion of an endoprosthesis is a valuable alternative to surgical bypass in patients with unresectable lesions.     

Management of the twin-to-twin transfusion syndrome (TTTS)

Twin-to-twin transfusion syndrome (TTTS) is a severe complication of multiple pregnancy occurring in 10-12% of monochorionic twins. This complication is mainly due to the presence of unbalanced arterio-venous anastomoses between placental branches of the umbilical circulations. The natural history of TTTS is variable. It is often difficult to predict whether a patient will show stable rather than rapidly progressive disease. A formal staging system has been suggested based on the sonographic time sequence of cases with progressive deterioration and poorer outcome. The mortality of untreated TTTS has been quoted to be more than 80% with advances in neonatal care the mortality rate may have decreased. The three most commonly used therapies for mid-trimester TTTS are amnioreduction, fetoscopic laser coagulation of the vascular anastomoses and septostomy. Outcome for fetuses with TTTS treated with amnioreduction depends on several antenatal variables which may help in counseling patients. Fetoscopic laser coagulation of vascular anastomoses represents an important evolution in the surgical treatment of TTTS. The management of the TTTS according to stage should be corroborated with an appropriate clinical trial.     

Placental Vascular Anastomoses Visualized During Fetoscopic Laser Surgery in Severe Mid-trimester Twin–twin Transfusion Syndrome

The aim of this study was to describe the type and number of placental vascular anastomoses identified during fetoscopic laser coagulation in severe mid-trimester twin–twin transfusion syndrome (TTS). In 126 patients with severe TTS, undergoing fetoscopic laser coagulation between 16 and 25 weeks of gestation, the different types of placental anastomoses [arterio-venous (AV), arterio-arterial (AA) and veno-venous (VV)] were counted. In cases of AV anastomoses their direction was identified and four groups were defined: in group 1 there were only anastomoses shunting from donor to recipient. Group 2 consisted of placentae with more anastomoses shunting from donor to recipient than in the opposite direction, group 3 showed an equal number in both directions and in group 4 there were more anastomoses shunting from recipient to donor than in the opposite direction. In 9 cases (7 per cent) the anastomoses could not be clearly identified due to impaired visualization, leaving 117 cases for analysis. The median number of anastomoses found was 5 with a range from 1–14. In all cases AV anastomoses from donor to recipient were present, 36 cases (31 per cent) had also AA anastomoses and 14 cases (12 per cent) showed VV anastomoses. Regarding the direction of AV anastomoses, the results were as follows: there were 35 cases (30 per cent) in group 1, 52 cases (44 per cent) in group 2, 14 cases (12 per cent) in group 3 and 16 cases (14 per cent) in group 4. In 54 (46 per cent) placentae there was at least one thin anastomosis whose type was unclassifiable. There were no placentae showing AV anastomoses only from the recipient to the donor fetus. This study demonstrates that AV anastomoses are the prerequisite for the development of TTS in monochorionic placentae. The majority (74 per cent) of cases showed a higher number of AV anastomoses from donor to recipient than in the opposite direction. In approximately one third of placentae there are also AA anastomoses and the overall number of anastomoses seen and coagulated during fetoscopy is higher than reported in postnatal studies.     

Placental vascular anastomoses visualized during fetoscopic laser surgery in severe mid-trimester twin-twin transfusion syndrome.

The aim of this study was to describe the type and number of placental vascular anastomoses identified during fetoscopic laser coagulation in severe mid-trimester twin-twin transfusion syndrome (TTS). In 126 patients with severe TTS, undergoing fetoscopic laser coagulation between 16 and 25 weeks of gestation, the different types of placental anastomoses [arterio-venous (AV), arterio-arterial (AA) and veno-venous (VV)] were counted. In cases of AV anastomoses their direction was identified and four groups were defined: in group 1 there were only anastomoses shunting from donor to recipient. Group 2 consisted of placentae with more anastomoses shunting from donor to recipient than in the opposite direction, group 3 showed an equal number in both directions and in group 4 there were more anastomoses shunting from recipient to donor than in the opposite direction. In 9 cases (7 per cent) the anastomoses could not be clearly identified due to impaired visualization, leaving 117 cases for analysis. The median number of anastomoses found was 5 with a range from 1-14. In all cases AV anastomoses from donor to recipient were present, 36 cases (31 per cent) had also AA anastomoses and 14 cases (12 per cent) showed VV anastomoses. Regarding the direction of AV anastomoses, the results were as follows: there were 35 cases (30 per cent) in group 1, 52 cases (44 per cent) in group 2, 14 cases (12 per cent) in group 3 and 16 cases (14 per cent) in group 4. In 54 (46 per cent) placentae there was at least one thin anastomosis whose type was unclassifiable. There were no placentae showing AV anastomoses only from the recipient to the donor fetus. This study demonstrates that AV anastomoses are the prerequisite for the development of TTS in monochorionic placentae. The majority (74 per cent) of cases showed a higher number of AV anastomoses from donor to recipient than in the opposite direction. In approximately one third of placentae there are also AA anastomoses and the overall number of anastomoses seen and coagulated during fetoscopy is higher than reported in postnatal studies.     

Transcatheter intervention in the neonate with congenital heart disease

Over the past 30 years, interventional cardiology has developed as a distinct subspecialty, playing a major role in the management of infants with CHD. In the neonatal period, a wide variety of transcatheter interventions are performed routinely, either as palliation or therapy, as adjunct to surgery, or in place of surgical intervention. Among these are creation or enlargement of ASDs to allow atrial mixing; balloon valvotomy to treat congenital valvar stenoses; balloon angioplasty or stenting of stenotic vessels (pulmonary arteries, coarctation of aorta, or systemic or pulmonary veins) or postoperative anastomoses; closure of [figure: see text] unwanted vessels (congenital fistulae or collaterals); and other miscellaneous interventions. A wide variety of patients are candidates for these procedures, including those with transposition of the great arteries or other defects with transposition physiology, left atrial outlet obstruction and hypertension, severe valvar pulmonary or aortic stenosis, hypoplastic stenotic pulmonary arteries with severe symptomatology, severe coarctation of aorta and high surgical risks, large aortopulmonary collaterals or other hemodynamically significant unwanted vessels, acute thrombosis of certain surgical anastomoses, and many more. In experienced hands, these procedures are highly successful and safe, with a low morbidity and mortality (less than 1%).     

Sequential selective laser photocoagulation of communicating vessels in twin-twin transfusion syndrome.

OBJECTIVE: We have previously described the selective laser photocoagulation of communicating vessels (SLPCV) technique for the treatment of twin-twin transfusion syndrome (TTTS). Because TTTS is thought to result from a net transfer of blood from the donor twin to the recipient twin, we hypothesized that lasering the arteriovenous anastomoses from the donor to the recipient (AVDRs) first (sequential SLPCV or SQLPCV) would result in an improved hemodynamic status and decreased likelihood of intrauterine fetal demise of the donor twin (IUFD-D). MATERIALS AND METHODS: The diagnosis of TTTS was made by ultrasound showing the combined presence of a maximum vertical pocket > or = 8 cm in one sac and < or =2 cm in the other in a monochorionic/diamniotic twin pregnancy. Triplet pregnancies and monoamniotic pregnancies were excluded. Severity of TTTS was assessed using the Quintero staging system. All vascular anastomoses were endoscopically identified and classified as AVDR (AV from donor to recipient), AVRD (AV from recipient to donor), arterio-arterial (AA), or veno-venous (VV). The surgical procedure was coded as SQLPCV if all AVDRs were lasered first. Outcome measures included intrauterine fetal demise and perinatal survival. RESULTS: One hundred and ninety-three TTTS patients (137 SQLPCV, 56 SLPCV) underwent surgery from May 2003 to August 2005. Gestational age at surgery or at delivery, Stage, patent anastomoses, or persistent/reverse TTTS were not different between the groups. IUFD-D was significantly lower in the SQLPCV than in the SLPCV group (7.3% vs 21.4%, respectively, p = 0.005). Dual perinatal survival was significantly higher in the SQLPCV than in the SLPCV group (73.7% vs 57.1%, respectively, p = 0.02), although the incidence of at least one survivor was not different between the groups (90.5% vs 87.5%, respectively). Logistic regression showed SQLPCV, but not placental location, operating time or number of anastomoses to be significantly associated with a decreased likelihood of IUFD-D (p = 0.007). CONCLUSION: SQLPCV is associated with a decreased likelihood of IUFD-D and an increased rate of dual survivors compared to SLPCV. SQLPCV represents both an anatomical and functional surgical approach to the laser treatment of twin-twin transfusion syndrome.     

双胎输血综合征的治疗进展与妊娠结局

双胎输血综合征（TTTS）是单绒毛膜双胎特有的严重并发症。相比于羊水减量术,胎儿镜激光电凝术（FLP）治疗TTTS可明显改善围产儿结局,已被公认为治疗双胎输血综合征的首选方法。文章主要对FLP的不同术式进行评价,并对接受FLP的TTTS患者的妊娠结局做一综述。     

妇科内镜手术的规范化管理

妇科腔镜技术的快速发展,导致医源性并发症增加。重视腹腔镜手术规范化培训,可以减少腔镜手术并发症。基础理论知识及临床技能的规范化培训是成为妇科腔镜医师的必需环节,加强培训对防治手术并发症,保障手术安全性具有重要意义。     

Insights into the pathophysiology of twin-twin transfusion syndrome

Twin-twin transfusion syndrome (TTTS) is attributed to trans-anastomotic transfusion between twins. Anastomoses are ubiquitous in monochorionic (MC) placentae, yet TTTS develops in only 15%. Although ex vivo and in vivo studies fail to identify a unique anastomotic signature, TTTS placentae are typically associated with an imbalance in unidirectional arteriovenous anastomoses with absent bidirectional anastomoses. Doppler detection of an artery-artery anastomosis reduces the chance of TTTS, whereas, in those that develop the disease, it improves stage-independent survival. Selective laser is often curative, but an increasingly recognized risk of persistent or reverse TTTS may be attributable to atypical arteriovenous anastomoses not identifiable from the chorionic plate. Simple dysvolaemia fails to explain several phenotypic features, including haematological concordancy, recipient hypertension, and reversibly absent end diastolic flow in the donor. The renin-angiotensin system is upregulated in the donor and downregulated in the recipient's kidneys, while paradoxically raised renin levels in the recipient may contribute to raised afterload along with endothelin. Although research is limited in humans by therapy and the lack of a suitable experimental model, further studies of placental and vascular pathophysiology may not only refine current treatment modalities but may also, in addition, suggest further avenues for downstream management such as genetic predisposition testing or pharmacological intervention.     

Studies on the healing of anastomoses of small and large intestines.

It is well known that large intestine anastomoses tend to leak much more frequently than do small intestine anastomoses. These studies were undertaken to elucidate the pathophysioplogic basis of this phenomenom. Single layer interrupted silk suture anastomoses were performed in both the distal part of the ileum and the distal part of the colon in 29 dogs. The anastomoses were resected at one through eight days and 19 to 31 days after operations. Collagen response, vascular response and bursting strength at the site of anastomoses were investigated. The results demonstrated a statistically significant decrease in the collagen and vascular response of the large versus the small intestine. This differential response may play a role in the mechanism of the relatively high incidence of suture line separations observed after colonic anastomoses.