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PubMed2003

A novel laparoscopic technique for stapled colon and rectal anastomosis.

BACKGROUND: We present new techniques of stapling anastomosis at laparoscopic colorectal surgery with retrospective review of data. METHODS: A triangulating stapling technique (T method) was performed in 101 laparoscopic colectomies. Adouble stapling technique (DST) with rectal division by a conventional linear stapler (Abd method) was used in 5 cases of upper/middle rectal cancers and subsequent eversion of the distal rectum from the anus (Ev method) was used for 4 low rectal cancers. Four hundred ninety-six colectomies and 280 rectal surgeries were reviewed. RESULTS: Leakage was lower in the T group (0.5%, n=196) than in the hand-sewn group (3.0%, n=233). Leakage of the DST using a laparoscopic linear stapler (12.1%, n=91) was significantly higher than with conventional DST (2.1%, n=189). There was no leakage with either Abd method or Ev method. The T-method is acceptable after laparoscopic colectomy. CONCLUSION: New methods of rectal division using conventional devices are expected to yield reliable anastomosis at laparoscopic rectal surgery.

Aged↗
PubMed2005

Prospective, randomized study: proximate PPH stapler vs. LigaSure for hemorrhoidal surgery.

PURPOSE: It has been shown that for hemorrhoidal surgery both LigaSure and stapler cause less pain than diathermy or scissor dissection. This study has attempted to establish which of the less painful alternatives proves best in an unselected series of patients with hemorrhoidal disease. METHODS: Fifty patients were randomized to undergo stapling hemorrhoidopexy or LigaSure hemorrhoidectomy. Parameters investigated were pain (primary parameter), patient satisfaction with treatment, and recovery of personal activity. Other factors investigated were operative result, ease of handling, analgesic requirements, and postoperative course. RESULTS: Both methods were found to be equivalent in all major aspects analyzed. Postoperative pain scores (P = 0.99), patient satisfaction (P = 1), and self-assessment of activity (P = 0.99) were almost identical in both groups of patients. Significant differences were found in none of the numerous factors investigated. CONCLUSION: Both methods can be used safely and without major disadvantage for the patient regardless of stage and extent of hemorrhoidal disease.

Activities of Daily Living↗
PubMed2002

End-to-end anastomosis in growing vessels using a novel suturing technique: VCS metallic staples.

For pediatric transplants, a suturing technique is needed that allows the vessel to grow along with better healing of the anastomosis, through eliminating exogenous and thrombogenic material in the intimal side, thus minimizing the risk of vascular stenosis. In this study, 12 55-day-old lambs were subjected to end-to-end anastomosis of the right carotid artery and external jugular vein using vascular closure staple (VCS) clips (the vessels from the left side served as controls). Animals were followed up with duplex ultrasound. After 6 months, angiography was performed and animals were euthanized for microscopic study of the vessels. Duplex ultrasonography and angiography showed all vessels to be patent, with no flow disturbances and no stenosis at the anastomotic site at 6 months. Stenotic segments caudal to the anastomosis site were seen in two veins. No significant changes were seen macroscopically in any of the veins, whereas one of the arteries developed a pseudoaneurysm at the anastomotic site. Histological structure was normal in all the studied veins. Arteries showed different degrees of modifications that did not affect patency or flow in any case. Measurements taken after 6 months confirm that this technique allows the vessel to grow. This technique may be useful in vascular pediatric surgery.

Anastomosis, Surgical↗
PubMed2004

Prospective comparison between endosuturing and endostapling in treating primary spontaneous pneumothorax.

OBJECTIVE: Direct management of ruptured pulmonary blebs remains the definitive treatment for spontaneous pneumothorax. We compared endosuturing and endostapling performed via thoracoscopy to determine if suture closure of the blebs without resection was sufficient to treat primary spontaneous pneumothorax. METHODS: Nine female and forty-nine male prospective patients were prospectively enrolled into two groups between July 1999 and May 2003. The patients in the suturing group were treated with an endoscopic suturing technique to close existing blebs. Patients in the stapling group underwent endoscopic stapling to excise the blebs. Only three ports were needed for each procedure. RESULTS: Neither group experienced mortality or any major morbidity. There were no significant clinical differences between the suturing and stapling groups. The intra-operative blood loss was not significantly different (32.9+/-53.9 and 13.6+/-21.8 mL, respectively, P = 0.079). The duration of pleural drainage was not statistically significant (2.7+/-1.2 and 2.3+/-2.0 days, respectively, P = 0.369). The length of postoperative hospital stay was also not statistically significant (4.2+/-1.5 and 3.8+/-2.4 days, respectively, P = 0.386). However, the operative time was significantly longer in the suturing group (135.0+/-53.8 and 89.0+/-35.6 minutes, respectively, P < 0.05). In each group, there were two cases of recurrence during the 21.5+/-12.1 month followup period, all of which recovered well after retreatment. CONCLUSIONS: We believe that this is the first prospective study on thoracoscopic suture closure of blebs. By imbricating and buttressing the blebs without resection, the endosuturing method represents an effective way to treat primary spontaneous pneumothorax.

Adolescent↗
PubMed1999

Laparoscopic low anterior resection using a triple stapling technique.

Laparoscopic low anterior resections using a triple stapling technique in five patients with rectal cancers (four Dukes A and one Dukes C) were performed. The location of the tumors was between 5 and 18 cm from the anal verge. For easy maneuverability, a 33-mm suprapubic port was used. In this technique, the Endo TA (the first stapler) is applied at the distal margin of the rectum to occlude the bowel. The bowel is irrigated with povidone-iodine solution and transected by an endolinear (the second) stapler. Anastomosis is completed by firing the circular (the third) stapler. The operative time was 177 +/- 28.0 minutes, estimated blood loss was 41.7 +/- 28.6 g, and flatus appeared 1.8 +/- 0.8 days after surgery. Follow-up studies have showed no local recurrence or distant metastasis. This procedure is safe and useful for performing laparoscopic low anterior resection.

Adenocarcinoma↗
PubMed2003

Long-term functional results after ileal pouch anal restorative proctocolectomy for ulcerative colitis: a prospective observational study.

OBJECTIVE: To document functional results in patients treated with an ileal pouch anal anastomosis (IPAA). SUMMARY BACKGROUND DATA: The restorative proctocolectomy with IPAA has become the procedure of choice for patients with ulcerative colitis, yet the long-term functional results are not well known. METHODS: We performed this prospective observational study in 391 consecutive patients (56% male; mean age, 33.7 +/- 10.8 years; range, 12-66 years) who underwent an IPAA between 1987 and 2002 (mean follow-up, 33.6 months; range, 0 to 180 months). RESULTS: The majority of patients underwent the procedure under elective circumstances with a hand-sewn ileal pouch anal anastomosis and a protective ileostomy. In 25 patients (6.4%), the procedure was performed under urgent conditions; in 137 patients (35%), the temporary ileostomy was omitted; in 117 patients (29.9%), the ileal pouch anal anastomosis was stapled. There was 1 hospital mortality (0.25%) and 1 30-day mortality. Mean length of stay was 9.2 +/- 5.6 days (3-68 days; median, 8 days) and was increased by the occurrence of septic complications (8.9 versus 13.6 days; P < 0.02) and by the omission of a temporary ileostomy (8.3 versus 10.4 days; P = 0.005). Complications included pelvic abscess (1.3%), anastomotic dehiscence (6.4%), bowel obstruction (11.7%), and anastomotic stenosis in need of mechanical dilatation (10.7%). Patients were asked to record their functional results on a questionnaire for 1 week at 3, 6, 9, 12, 18, and 24 months after the IPAA and yearly thereafter. Our data to 10 years show that median number of bowel movements (bms) was 6 bm/24 hours at all time intervals. The average number of bms increased by 0.3 bm/decade of life (P < 0.001). Throughout the entire follow-up, more than 75% of patients had at least 1 bm most nights, although fewer than 40% found it necessary to alter the time of their meals to avoid bms at inappropriate times. Depending on the time interval, between 57% and 78% of patients were always able to postpone a bm until convenient, and this ability was similar in patients with a stapled or hand-sewn ileoanal anastomosis; only up to 18% were able to always distinguish between flatus and stools, and this ability was similar in patients with a stapled or hand-sewn ileoanal anastomosis. Complete daytime and nighttime continence was achieved by 53-76% of patients depending on the time interval. The percentage of fully continent patients was higher following the stapled rather than the hand-sewn technique (P < 0.001), and this difference persisted over time. When patients experienced incontinence, its occurrence ameliorated over time (P < 0.001), and the occurrence of perianal rash and itching as well as the use of protective pads decreased over time (P < 0.008). At 5 years, patients judged quality of life as much better or better in 81.4% and overall satisfaction and overall adjustment as excellent or good in 96.3% and 97.5%, respectively. CONCLUSIONS: We conclude that the IPAA confers a good quality of life. The majority of patients are fully continent, have 6 bms/d on average, and can defer a bm until convenient. When present, incontinence improves over time.

Adult↗
PubMed2006

Experiences with PPH gun stapled ileo or coloanal anastomoses after ultralow rectal resections and proctocolectomies with J pouch reconstructions.

A new method of stapled ileo and coloanal anastomosis with PPH gun (Johnson and Johnson USA) is presented. On 47 totalcolectomised FAP and UC patients and 9 low rectal benign or clinically T1 or T2N0 rectal tumor resection there was only 5 radiologically proven anastomotic leakadge without serious septic complications. The anal sphincter function after 6 month of the ileoanal anastomosis remained good in 33/39 and acceptable in 6 cases, if the sphincter function was intact praeoperatively. There was no worthening of the moderate praeoperatively observed insufficiency. After the ultra low rectal resections all patients kept the normal anal shpincter function. The procedure seems to be as good as the double stapler method, but there remained no remnant mucosal ring between the anastomsois and the dentate line. An additional advantige of the method, that only one stapler was consumed per patient compared to the two one at the double stapler technic.

Adenomatous Polyposis Coli↗
PubMed1995

Coloanal anastomosis: are functional results better with a pouch?

PURPOSE: Different studies have shown that low colorectal and coloanal anastomosis often yield poor functional results. The aim of the present study was to investigate whether a colonic reservoir is able to improve functional results. METHODS: Thirty-eight consecutive patients subjected to low anterior resection were randomized following rectal excision in two groups. One (n = 19) had a stapled straight coloanal anastomosis, and the other (n = 19) had a 10-cm stapled colonic pouch low rectal anastomosis. Median anastomotic distance above the anal verge was 3.38 +/- 0.56 cm and 2.14 +/- 0.36 cm in both groups, respectively. Continence alterations, urgency, tenesmus, defecatory frequency, anal resting and maximum voluntary squeezing pressures, and maximum tolerable volume were evaluated one year later. RESULTS: One patient died of pulmonary embolism, and seven presented with a recurrence and were excluded from the study. Stool frequency was greater than three movements per day in 33.3 percent of cases with a reservoir and in 73.3 percent of those with a straight coloanal anastomosis (P < 0.05). Maximum tolerable volume was significantly greater in patients with a reservoir (335 +/- 195) than in those without (148 +/- 38) (P < 0.05). There were no significant differences in other variables studied. CONCLUSIONS: This study shows that some aspects of defecatory function after rectal excision could improve with a colonic reservoir.

Aged↗
PubMed2004

Early rectal stenosis following stapled rectal mucosectomy for hemorrhoids.

BACKGROUND: Within the last years, stapled rectal mucosectomy (SRM) has become a widely accepted procedure for second and third degree hemorrhoids. One of the delayed complications is a stenosis of the lower rectum. In order to evaluate the specific problem of rectal stenosis following SRM we reviewed our data with special respect to potential predictive factors or stenotic events. METHODS: A retrospective analysis of 419 consecutive patients, which underwent SRM from December 1998 to August 2003 was performed. Only patients with at least one follow-up check were evaluated, thus the analysis includes 289 patients with a mean follow-up of 281 days (+/-18 days). For statistic analysis the groups with and without stenosis were evaluated using the Chi-Square Test, using the Kaplan-Meier statistic the actuarial incidence for rectal stenosis was plotted. RESULTS: Rectal stenosis was observed in 9 patients (3.1%), eight of these stenoses were detected within the first 100 days after surgery; the median time to stenosis was 95 days. Only one patient had a rectal stenosis after more than one year. 8 of the 9 patients had no obstructive symptoms, however the remaining patients complained of obstructive defecation and underwent surgery for transanal strictureplasty with electrocautery. A statistical analysis revealed that patients with stenosis had significantly more often prior treatment for hemorrhoids (p < 0.01). According to the SRM only severe postoperative pain was significantly associated with stenoses (p < 0.01). Other factors, such as gender (p = 0.11), surgical technique (p = 0.25), revision (p = 0.79) or histological evidence of squamous skin (p = 0.69) showed no significance. CONCLUSION: Rectal stenosis is an uncommon event after SRM. Early stenosis will occur within the first three months after surgery. The majority of the stenoses are without clinical relevance. Only one of nine patients had to undergo surgery for a relevant stenosis. The predictive factor for stenosis in the patient-characteristics is previous interventions for hemorrhoids, severe postoperative pain might also predict rectal stenosis.

Chi-Square Distribution↗
PubMed2004

[Endoscopic stapling diverticulostomy for Zenker diverticulum].

INTRODUCTION: The authors have successfully applied the endoscopic stapling diverticulostomy for three patients with symptomatic Zenker diverticulum. METHOD: Under light general anesthesia the hypopharynx was explored with a rigid, double lipped laryngoscope (Weerda, Storz). The common wall between the esophagus and and diverticulum was cut across and reunited with a endosurgical stapler. RESULTS: Operating time was 25 minutes in average. There were no intraoperative or postoperative complications. The oral feeding was started on the 2. postoperative day. The patients were symptom-free and they were discharged on the fifth postoperative day. The preoperative symptoms were not reported at follow-up assessment. CONCLUSION: The endoscopic stapler diverticulostomy offers distinct advantages, including brief operative time, short hospitalization, reduced morbidity, early oral feeding and predictable resolution of symptoms. The authors proposed the technique in the treatment of the patients with Zenker's diverticulum especially for elderly cases with diverticulum larger than 3 cm.

Aged↗
PubMed2005

A simple technique for performing laparoscopic purse-string suturing during circular stapling anastomosis.

An esophagojejunostomy using a circular stapler requires the fixing of an anvil at the esophageal stump. When this placement procedure is laparoscopically performed, purse-string suturing is difficult, and there is a risk of loosening when a conventional needle driver is used. We herein present a simple but effective technique for performing laparoscopic purse-string suturing of the esophageal stump using a semiautomatic suturing device called the Endostitch. Gastrointestinal anvil placement was laparoscopically performed for 10 patients who underwent an esophagojejunostomy following a total gastrectomy. After the lumen of the esophagus was expanded using bowel forceps, the Endostitch was used to place approximately 12 encircling purse-string sutures. An anvil was positioned with support of the esophageal wall at three points with forceps. The Endostitch was used for the ligation with a sufficient degree of tension applied by extracorporeally pulling the sutures through the abdominal wall. The time for placement of the anvil averaged approximately 8 min. The ring formation following anastomosis was favorable in all patients. As a result, we consider our technique to be simple but very effective.

Anastomosis, Surgical↗
PubMedDate not supplied

Gastric emptying of liquid meals after anterior gastric stapling and posterior truncal vagotomy in beagle dogs: discrepancy with results for solid food.

BACKGROUND/AIMS: Since the development of highly selective vagotomy (HSV), simplified procedures such as posterior truncal vagotomy with anterior gastric wall stapling (PTV-AGS) became available to achieve parietal cell denervation. The purpose of this investigation was to detect possible gastric emptying disturbances due to complete vagotomy of the posterior gastric wall and to stapling of the anterior stomach wall. METHODOLOGY: Six female dogs, undergoing HSV, were compared with six others, in which PTV-AGS was performed. Radionuclide labeled liquid test meals were used to evaluate gastric emptying rate (GER) and results were compared with solid test meal emptying. RESULTS: A small, statistically insignificant fastening of liquid gastric emptying was seen early after HSV, as well as after PTV-AGS, and persisted one year after operation. There proved to be a striking lack of correlation between the GER-results after liquid versus solid meals. CONCLUSION: Just as after HSV, gastric emptying rates of liquid meals after PTV-AGS do not show a statistical difference as compared with preoperative values. Both operations therefore do not induce clinically important gastric motility changes. Separate test meals with liquid and solid food prove to be necessary in order to detect such changes.

Animals↗
PubMed2006

Laparoscopic resection of gastrointestinal stromal tumors: not all tumors are created equal.

BACKGROUND: Laparoscopic resection has become an accepted approach to gastrointestinal stromal tumors (GISTs), with acceptable early results published in the literature. Long-term recurrence rates, however, are still unclear, and the management of tumors in challenging locations requires exploration. METHODS: A retrospective analysis of all patients undergoing a laparoscopic resection of gastric GIST in our institution between November 1997 and July 2004 was performed. RESULTS: A total of 14 patients with 15 tumors were evaluated, 5 of which were located high on the lesser curve. All the patients had an attempted laparoscopic approach, with the following procedures performed: stapled wedge excision (n = 8), excision and manual sewing technique (n = 4), and distal gastrectomy (n = 1). Overall, there was a 15% (n = 2) conversion rate. Lesions found in the fundus and greater curvature areas were easily resected via simple stapled wedge excision. High lesser curve tumors were more difficult to manage and required a combination of methods for complete excision and preservation of the gastrointestinal junction including intraoperative gastroscopy, excision and manual sewing technique, and reconstruction over an esophageal bougie. There were no postoperative complications, and the length of hospital stay was 4.6 +/- 1.9 days. At a median follow-up period of 46.5 months (mean, 37.4 +/- 26 months), one patient experienced a recurrence (18 months postoperatively), with eventual disease-related death. CONCLUSION: The laparoscopic approach to gastric GIST tumors is safe and associated with acceptable short- and intermediate-term results. High lesser curve GISTs can be safely approached laparoscopically using various techniques to ensure an adequate resection margin without compromise of the GE junction.

Adult↗
PubMed2002

Repair of a diaphragmatic injury during hand assisted laparoscopic nephrectomy using an onlay patch of polypropylene and polyglactin mesh.

PURPOSE: We describe a simple and time efficient technique for repairing a diaphragmatic injury occurring during right hand assisted laparoscopic radical nephrectomy. MATERIALS AND METHODS: A dual layer polypropylene and polyglactin mesh was created extracorporeally by sewing a 2 x 2 piece of polypropylene mesh to a 2 x 2 piece of polyglactin mesh with 4, 4-zero interrupted polyglactin sutures. This dual layer was then positioned manually over the diaphragmatic rent and secured with a laparoscopic stapling device. A 16Fr chest tube was placed at the conclusion of the procedure. RESULTS: Overall operative time was 3.5 hours with an estimated blood loss of 100 cc. Repair of the diaphragmatic injury extended operative time by 25 minutes. Extubation was done at the conclusion of the case and the chest tube was removed within 36 hours of the procedure. The patient was discharged home on postoperative day 3. At 14 months of followup the patient remained disease-free on radiography and without pulmonary or gastrointestinal sequelae. CONCLUSIONS: We describe a simple and time efficient technique for repairing diaphragmatic injury occurring during right hand assisted laparoscopy. This technique takes advantage of the manual and tactile sensation provided by the hand assistance device, provides a tension-free repair and avoids laparoscopic suturing.

Chest Tubes↗
PubMedDate not supplied

New method for Billroth I reconstruction after distal gastrectomy.

Authors report a new technique for Billroth I reconstruction after distal gastrectomy using linear stapling devices, which is easier than conventional methods. The duodenum is divided 0.5 cm distal to the pyrolus ring, with a 55-mm linear stapler. The anterior wall of the duodenum is cut along the planned line of anastomosis with the gastric remnant. The anterior wall of the stomach is cut along the planned suture line having a length similar to that of the duodenum. The posterior walls of the stomach and the duodenum are placed back to back on the planned anastomotic line. End-to-end posterior anastomosis between the gastric remnant and the duodenum is simultaneously performed with gastrectomy using a 100-mm linear stapler. End-to-end anterior anastomosis is performed by hand. This technique has been used in 7 patients, and there have been no complications related to this procedure. Operative time was 152 +/- 16 min (range 130 to 180 min) on average. It is an economical and easy procedure for Billroth I reconstruction.

Anastomosis, Surgical↗
PubMed1996

Applied stapling technique in radical retropubic prostatectomy: efficient, effective and efficacious.

PURPOSE: We demonstrated the efficiency, efficacy and effectiveness of the endoscopic gastrointestinal anastomosis (GIA) stapler in radical retropubic prostatectomy. MATERIALS AND METHODS: A total of 21 patients with organ confined prostate cancer on preoperative staging underwent radical retropubic prostatectomy. During these procedures we analyzed the applicability and efficacy of the endoscopic GIA vascular stapler to effect ligation, division and stapling of the dorsal vein complex and lateral pedicles of the prostate. This group was compared to 7 controls in whom we performed surgery for organ confined disease, using the stapler solely for the lateral prostatic pedicles or not at all depending on availability. One patient with localized muscle invasive transitional cell carcinoma of the bladder underwent radical cystectomy using the endoscopic GIA stapler in a sequential fashion to ligate and divide all pedicles of the specimen. RESULTS: Mean total operative time was 2 hours (range 1 hour 40 minutes to 2 hours 50 minutes) and average estimated blood loss was 400 cc. All patients were discharged from the hospital on postoperative day 3. To date 17 of the 21 patients are continent and 6 are potent. CONCLUSIONS: Although not designed to replace the standard approach to radical retropubic prostatectomy, we believe that this technique makes the procedure easier and more approachable in the hands of the less experienced surgeon.

Humans↗
PubMed1999

Rationale and design of The National Emphysema Treatment Trial: a prospective randomized trial of lung volume reduction surgery. The National Emphysema Treatment Trial Research Group.

The National Emphysema Treatment Trial is a multicenter, randomized clinical trial of medical therapy vs medical therapy plus lung volume reduction surgery (LVRS) for the treatment of patients with severe bilateral emphysema. LVRS will be accomplished by bilateral stapled excision via median sternotomy or video-assisted thoracoscopic surgery. Every patient will complete 6 to 10 weeks of pulmonary rehabilitation prior to randomization and will participate in a maintenance program of pulmonary rehabilitation after randomization. The primary outcome to be assessed by the trial is survival. Additional outcomes to be assessed are maximum exercise capacity, pulmonary function, oxygen requirement, distance walked in 6 min, quality of life, respiratory symptoms, and health-care utilization and costs. In addition, selected clinics will evaluate lung mechanics and respiratory muscle function, partial and maximal flow-volume curves, gas exchange during maximal exercise, and right heart function. The trial is targeted to enroll patients with severe emphysema who have no significant comorbid conditions; each patient will be randomized to one of the two treatment groups. The study duration is 4.5 years with a close-out period of 6 months.

Humans↗
PubMed1994

[Comparative analysis of sutures and stapling for colorectal anastomosis in resection of the rectum in carcinoma].

In Clinic for general and vascular surgery - Military Medical Academy Belgrade since 1987 to 1993 in treatment of the rectal cancer it was done 326 low anterior resections. In 149 patients anastomosis was done with sutures and in 177 with stapler. Half of them were more then 60 years old, and in 40% of patients carcinoma was staged as Dukes C or D. In group I tumor was localised in the middle or distal third of rectum in 24.8% of patients while in group II this was in 75.7%. Anastomosis related complications where rare in stapler group, clinically evident anastomotic dehiscence was found in 11.4% patients in I group and in 99% in II group. Total mortality was 3.1%; 3.4% in the I group and 2.8% in the II group. In our comparative analysis of early complications after low anterior resection of rectum when colorectal anastomosis was done with suture or stapler technic we have found that stapler technic give opportunity for creating much more low colorectal anastomoses which are safe and with less complications and with the same oncologic control of disease.

Adult↗