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Transanal local excision of posterior benign rectal tumors is usually safe. Here, we report a case of transanal excision of a posterior anastomotic recurrence of a rectal adenoma after a stapled anterior resection that resulted in perforation into the peritoneal cavity.
BACKGROUND: Although intrathoracic leakage is a major complication of oesophagectomy, precise data concerning diagnostic features and results of conservative treatment are lacking. METHODS: From 1986 to 1994, 409 oesophagectomies with stapled oesophagogastrostomy were performed, including 358 Lewis-Tanner and 51 Sweet procedures. A water-soluble contrast swallow was routinely performed on day 7 or later, before oral intake was begun. All patients except one received conservative non-surgical treatment, including nutritional support and perianastomotic drainage. RESULTS: Leaks were diagnosed in 38 patients (9.3 per cent). The leakage rate was 7.8 per cent after the Lewis-Tanner procedure and 20 per cent after the Sweet procedure (P < 0.01). Eleven patients had no symptoms. Seven of the 27 patients with symptoms had a contrast swallow that was normal, and subsequently developed a confirmed fistula after the onset of oral intake. Five patients had to undergo reoperation. All asymptomatic patients and 18 symptomatic patients recovered. Nine patients died, mainly from multiple organ failure, including three who had reoperation for resection of the gastroplasty. CONCLUSION: The potential presence of clinically silent fistula and the deleterious role of oral intake still justify routine detection of leakage after oesophageal resection. Conservative treatment results in survival with preservation of the gastroplasty in most patients, unless multiple organ failure occurs.
BACKGROUND: Mechanical stapling devices are widely used in all fields of surgery as they can cut and sew tissue in a quick and easy manner. However, complications like bleeding or leakage at the staple line are frequently encountered and can have devastating consequences. Recent developments have led to the introduction of staple line reinforcement to reduce these complications. METHODS: The literature has been reviewed to find and describe different methods to improve stapled resections and to give an extensive overview of the different staple line reinforcement materials, their properties and indications. RESULTS: Several types of staple line reinforcement are available. Reinforcement of the staple line with membranes of either non-, semi- or absorbable material seems to be effective in minimizing the risk of leakage and bleeding by providing strength to the cut tissue. CONCLUSION: Application of staple line reinforcement material seems a promising technique in preventing leakage and bleeding at the stapled suture line, thus potentially reducing complications of gastrointestinal surgery. More studies are needed to investigate the exact properties, behavior and effects of the staple line reinforcement material.
UNLABELLED: Objective of this study is to establish which kind of stapled anastomosis is the most reliable in rectal surgery. 67 patients randomly assigned to three groups underwent low anterior resection of the rectum with end-to-end, side-to-end or double stapling anastomosis. Main outcome measures were incidence of leakage at the intraoperative check of the suture, postoperative leakage, stenosis, mortality, mean post-operative stay. Side-to-end anastomosis were followed by 4 intra-operative (19%) and one post-operative (4.7%) leakages with one case of mortality (4.7%). Four intra-operative (18.2%) and 5 post-operative (22.7%) leakages, 3 stenosis (13.6%) and one case of mortality (4.5%) were observed after double-stapling procedures. No intra- or post-operative anastomotic complications were seen after end-to-end anastomosis. Mean post-operative stay was 20, 31 and 13 days for the three methods respectively. CONCLUSIONS: In this series of colo-rectal anastomoses, the end-to-end stapling technique appears to be safer and more reliable than others.
PURPOSE: Preanastomotic recurrence and stricturing after surgery for ileocolic Crohn's disease is a frequent, unexplained phenomena that may lead to prompt reoperation. The aim of this study was to determine whether a wide-lumen stapled anastomosis (side-to-side, functional end-to-end) provides better outcome than a conventional sutured end-to-end anastomosis METHOD: A case-control comparative analysis of patients with Crohn's disease from two inflammatory bowel disease centers treated with wide-lumen stapled anastomosis and a matched (age and gender) group treated with conventional sutured end-to-end anastomosis was performed. RESULTS: A total of 138 patients with Crohn's disease were treated, 69 with wide-lumen stapled anastomosis and 69 with conventional sutured end-to-end anastomosis. Preoperative therapy, number of previous resections, indication for operation, and length of bowel resected were similar in both groups. Fewer complications occurred after wide-lumen stapled anastomosis (P = 0.048). A total of 55 patients developed recurrent Crohn's disease symptoms, 39 (57 percent) in the conventional sutured end-to-end anastomosis and 16 (24 percent) in the wide-lumen stapled anastomosis group. Median follow-up was 70 and 46 months, respectively. After conventional sutured end-to-end anastomosis 18 reoperations were required, 15 for anastomotic stricture and 3 for fistulization. After wide-lumen stapled anastomosis three reoperations were necessary, two for stricture and one for fistulization. The cumulative reoperation rate for anastomotic recurrence was significantly lower (P = 0.017; log-rank test) for the wide-lumen stapled anastomosis group. CONCLUSION: Wide-lumen stapled anastomosis is as safe as conventional sutured end-to-end anastomosis and results in a lower incidence of symptomatic recurrent Crohn's disease and need for reoperation. Further prospective study of the wide-lumen stapled anastomosis technique is necessary to define the precise role of this operation in patients with Crohn's disease.
Anastomotic leakage is a major cause of mortality in colorectal surgery. Some variables associated with a high-risk level for anastomotic leakage have been identified, including denutrition, obesity, smoking, level of the anastomoses, qualification of the surgeon. Several methods have been evaluated in order to prevent anastomotic leakage. Prophylactic antibiotic therapy has been recommended, but has no effect on the rate of anastomotic leakage. Optimal preoperative colonic preparation appears to be obtained with povidone iodine enemas associated with a low residue diet. Stapling gives better results than sutures only for difficult anastomoses. Colostomy does not prevent leakage but minimizes its consequences. Omentoplasty, peritoneal drainage, gastric tube, biofragmentable anastomotic ring, and Coloshield have demonstrated their efficacy.
In suitable candidates, a reduction in gastric capacity to achieve significant weight loss is life-saving. The number and variety of procedures proposed in the last 15 years suggest that the ideal operation is still in evolution. We present a 15-year experience with a single operation designed to avoid the hazards of staple line dehiscence, achieve maximum weight loss, and maintain physiologic homeostasis. From 1979 through 1994, 212 patients, whose age, weight, and number of medical complications were consistent with the criteria for morbid obesity, underwent divided gastric bypass. All patients lost at least 70 lbs, and 95 per cent of the patients lost greater than 100 lbs in 2 years, with an average loss higher than in most comparable series. There were four post operative deaths and three late deaths. Thirteen anastomotic leaks (6%) were successfully managed. Eight patients received nutritional support and antibiotics, and five patients had operative drainage. Eighteen per cent had one or more minor complications. Divided gastric bypass avoids the problem of staple line dehiscence while providing a safe physiologic approach for maximum weight loss in the morbidly obese patient.
The circular stapling instrument has had a major impact in the practice of colorectal surgery. Stapling technology was pioneered in the early part of this century and subsequently modified. Russian initiatives led to development of the original circular stapling instrument and further progress has resulted in instruments that are widely available, reliable and totally disposable. Mechanical failure is now rare and malfunction is generally due to operator error. Complications related to the stapling technique are uncommon, although anastomotic stricture may be more frequent than when handsewn anastomosis is performed. A stapling instrument facilitates and may expedite a surgical procedure but it is an adjunct to, and not a substitute for, meticulous surgical technique.
BACKGROUND: A new penetrating stapled anastomotic system using nitinol microclips (Coalescent Surgical U-Clip) has been developed to facilitate the construction of compliant interrupted sutures for minimally invasive and robotic surgery as well as for conventional procedures. The purpose of this study was to determine the effect of nitinol U-Clips used for coronary anastomosis in the development of endothelial dysfunction, compared with conventional running sutures. METHODS: In a porcine model, both internal thoracic arteries were harvested, and the heart was removed. In a Krebs solution, 2 anastomoses were realized ex vivo between internal thoracic arteries and the left anterior descending artery. One was carried out with 12 Coalescent microclips, and the other used conventional running 7-0 polypropylene suture material (Prolene). Coronary rings on the anastomotic sites were then placed in organ chambers filled with oxygenated Krebs solution. Vascular reactivity studies were performed in standard organ chamber experiments. After the contraction of the coronary arteries in response to prostaglandin F2alpha, the endothelium-dependent relaxation response to bradykinin was studied. The other coronary arteries served as controls. RESULTS: There was no statistically significant difference among the groups (P >.05) in the amplitude of the contraction response to KCl and prostaglandin F2alpha. There were no statistically significant differences in endothelium-dependent relaxation response to bradykinin between the nitinol microclip group and controls, between the suture group and controls, and between the nitinol microclip and suture groups. CONCLUSIONS: Coalescent nitinol U-Clips used as anastomotic devices do not induce an endothelial dysfunction and allow a compliant anastomosis under satisfactory conditions.
UNLABELLED: The effects of on-table colonic irrigation followed by primary large bowel resection and anastomosis for emergency left colonic disease were prospectively studied in 54 patients. PATIENTS AND METHODS: Eighteen patients had a diverticular sigmoiditis complicated by localized (8) or generalized (4) peritonitis, 6 presented a complete sigmoid obstruction. Thirty six patients had a left colonic occlusive (33) or perforated (3) cancer. Anterograde colonic irrigation was carried out with a mean volume of 7.7 l. All patients received a double or triple antibiotic combination. The anastomosis was handsewn in 33 cases and stapled (Knight-Griffen) in 21. Seven patients with severe peritonitis had a proximal transitory stoma which was closed within 4 months. RESULTS: Two patients (3.7%) died postoperatively, one for anastomotic dehiscence and the second for evisceration. We observed 7 cases of hypothermia (< 34 degrees C) during the irrigation. Six patients developed a sepsis of the surgical wound, 2 a septicemia and l an abscess in the right iliac fossa which was percutaneously drained. All complications had a favourable outcome. CONCLUSION: This study confirms that in selected cases a single stage surgery for colonic emergencies preceded by on-table irrigation grants good results and is a safe and effective alternative to Hartmann's procedure.
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.
Anastomotic dehiscence is a serious, life-threatening complication of any rectal anastomosis and may be associated with an increased risk of local cancer recurrence. The leak rate following low anterior resection is in the region of 10% as reported in the recent randomised Dutch rectal cancer trial. Although accurate prediction of risk is impossible, certain factors are known to influence leak rates. There is an inverse relationship between the height of the anastomosis from the anal verge and the leak rate, with the lower anastomoses carrying the highest risk. Proximal defunctioning by a loop stoma mitigates the consequences of leakage and probably reduces, but does not abolish, the risk. There is little difference in rates of dehiscence between stapled and sutured colorectal anastomoses. A short colon pouch may reduce the chance of leakage. The highest risks are in unprotected anastomoses less than 5 cm from the anal verge in men who smoke and/or drink excessively, particularly if they have received pre-operative chemotherapy or chemo-radiotherapy. A high index of suspicion is required in detecting the early non-specific signs of a leak and urgent surgical intervention is usually required to avert a life-threatening situation. Faecal diversion should be regarded as the optimal safety measure to reduce the consequences of leakage and to mange leakage of an unprotected anastomosis.
Two hundred consecutive patients underwent a video-assisted thoracic surgical non-rib spreading simultaneously stapled lobectomy (VATS(n)SSL). Ninety-three were males and 107 were females, ranging in age from 20 to 92 years. Lesions consisted of 171 primary lung carcinomas, 7 metastatic tumors, and 22 benign lesions. Resections included 47 right upper lobe, 18 right middle lobe, 46 right lower lobe, 52 left upper lobe, 26 left lower lobe and 11 bilobectomies, ie, 9 right upper and middle lobes and 2 right middle and lower lobes. Operating time averaged 79.5 minutes, and no patient received a transfusion. Tumors ranged from 1 cm to 9 cm, bronchial stumps were 4 to 5 mm, and length of hospitalization averaged 3.07 days. Complications were minimal, and there was no surgical mortality. No patient developed a bronchopleural fistula or neoplastic port implant. Twenty-four patients have died of metastases. At a median follow-up of 34 months for all stages of carcinoma, there is an overall survival rate of 86%. Survival rate is 92% for stage I. VATS(n)SSL is a new technique for lobectomy that has proven to be beneficial for patients needing resection.
It is an important problem to associate bacterial infection in the process of bronchial stump healing. Wound healing processes in two types of bronchial stump closure methods, hand suturing with absorbable threads and mechanical stapling with stainless steel staples, were compared in mongrel dogs (154 dogs) which underwent right upper lobe reactions with and without infections. Half of the animals were infected with 10(9) CFU/dog of Pseudomonas aeruginosa E7 organisms. In order to understand the influence of bacterial infection on bronchial stump healing and also to evaluate the usefulness of the mechanical stapling device, we studied the number of viable bacteria, the activities of collagenase types I, II, III and IV, the amount of hydroxyproline and the histopathological finding in the bronchial stump tissue and the maximum leakage pressure. The number of viable bacteria decreased daily, but more than 10(3) CFU/g were detected even on the 21st day in infected dogs. There were no organisms detected in the stump tissues of uninfected dogs. The maximum leakage pressure levels by the 14th day after operation in the infected group were lower than in the uninfected group regardless of closure method. In the infected group of mechanical stapling the maximum leakage pressure increased daily, and on the 21st day became almost equal to that of uninfected group of mechanical stapling. The activity levels of collagenase type I in the infected group of both methods were at a maximum on the 5th day. On the same day the amount of hydroxyproline was at a minimum, and maintained a low level until the 14th day.(ABSTRACT TRUNCATED AT 250 WORDS)
BACKGROUND: The purpose of this study was to determine the frequency with which staple-line disruption occurs following vertical banded gastroplasty (VBG) in morbidly obese patients, to investigate the effect of this complication on weight loss, and to identify any clinical symptoms that might be associated with staple-line disruption. METHODS: From April of 1992 to June of 1994, 60 patients with morbid obesity underwent VBG. Double-contrast radiographic examination of the upper gastrointestinal tract was performed on all patients at 6, 12, 24, and 36 months postoperation to assess the integrity of the staple line. At these same times, the weight of each patient was measured, so that the patients found to have staple-line disruption could be compared to those without disruption in terms of weight loss. RESULTS: Over the duration of the study, staple-line disruption was found in 12 patients (20%). All of these patients demonstrated satisfactory weight loss. Between the group of patients with staple-line disruption versus the group without disruption, weight loss did not differ significantly at any time up to 3 years postoperation. In addition, in the patients with staple-line disruption, no clear symptomatology that might be associated with this complication was discovered. CONCLUSIONS: Our results lead to the conclusion that small disruptions in the staple line lack clinical importance and do not significantly affect weight loss for at least the first 3 postoperative years. Furthermore, staple-line disruption does not seem to be associated with any specific clinical symptoms. Follow-up of all patients via barium meal is the correct approach for discovering the exact incidence of this complication.
BACKGROUND: The silastic ring gastric bypass (SRGB) was introduced by Fobi in 1989, in an effort to combine the advantages of the Roux-en-Y gastric bypass with those of the vertical banded gastroplasty, while avoiding the disadvantages of each. METHODS: The results of our first 64 patients who underwent SRGB with a 5.5 cm ring have been reviewed with particular attention to weight loss, short- and medium-term morbidity and patient satisfaction. Most patients have had regular follow-up, and those not seen during the last 6 months were sent a postal questionnaire. RESULTS: The patients included 52 females and 12 males, ranging in age from 23 to 59 years (median age=39 years) at the time of surgery. Median preoperative weight, body mass index (BMI) and % excess weight were 126 kg (range 89-253 kg), 44 kg/m2 (range 36-78 kg/m2) and 113 (range 76-209) respectively. There were no serious postoperative complications and no deaths. Median hospital stay was 7 days (range 5-14 days). Eight patients (13%) are known to have had a staple-line dihiscence. Eighteen patients (28%) have had major difficulties with eating, and in nine (14%) of these the silastic ring has been removed with resolution of the eating problems, but some gain in weight. In the 54 patients with follow-up data at 2 years, median weight was 78 kg (range 55-137 kg), median BMI was 27 kg/m2 (range 20-43 kg/m2) and mean +/- SD % excess weight loss was 69+/-16. After 2 years of follow-up, eight of 54 patients (15%) were unhappy with the results of the procedure. CONCLUSION: SRGB is an effective, safe and well-tolerated procedure for achieving weight loss in the morbidly obese. The principal drawbacks relate to staple-line problems and eating difficulties related to the silastic ring. A 5.5 cm ring is probably too small to be ideal.
Recent advances in laparoscopy have renewed the interest in gastric banding techniques for the control of severe obesity. This method entails encircling the upper part of the stomach using bands made of synthetic materials, creating a small upper pouch that empties into the lower stomach through a narrow, non-stretchable stoma. The reduced capacity of the pouch and the restriction caused by the band diminish caloric intake, depending on important technical details, thus producing weight loss comparable to vertical gastroplasties, without the possibility of staple-line disruption and lesser incidence of infectious complications. However, distension of the pouch, slippage of the band and entrapment of the foreign material by the stomach have been described. To reduce the likelihood of these occurrences, reviewing the literature of the past 20 years is important to surgeons new in the bariatric field. Understanding the development of this procedure helps in avoiding mistakes made during the evolutionary process. The simplicity and non-invasiveness of the technique, low morbidity, ease of revision, and especially its complete reversibility, make gastric banding a first-line choice in bariatric surgery. However, as in other pure restrictive methods, and perhaps more important than surgical refinements, patient compliance with the behavioural changes imposed by the procedure is critical for a successful outcome.
BACKGROUND: Cervical esophagogastric anastomosis after esophagectomy is often troubled with anastomotic leak resulting in local sepsis, postoperative stricture, and prolonged hospitalization. We compared the anastomotic outcomes and clinical course of esophagectomy patients undergoing total mechanical stapled esophagogastric anastomosis versus a partial handsewn/mechanical stapled cervical anastomotic technique. METHODS: One hundred eighty-one patients underwent transhiatal (N=146) or 3-field (abdomen/chest/neck incisions) (N=35) esophagectomy. A total mechanical stapled anastomosis was accomplished in 125 patients. A handsewn/mechanical stapled anastomosis was performed in 56 patients. The total mechanical stapled anastomosis was accomplished by using the endoscopic gastrointestinal stapler to construct the posterolateral aspect and a linear stapler to close the anterior aspect of the anastomosis. Total mechanical stapled anastomosis patients had the endoscopic gastrointestinal stapler also used to divide the left gastric vessels and the short gastric mesentery for gastric mobilization. Anastomotic outcomes were analyzed by the leak rate (contrast study) and the need of serial dilations in each group. CONCLUSIONS: Total mechanical stapled technique after esophagectomy with cervical esophagogastric anastomosis appears to be effective in reducing hospitalization and anastomotic complications compared to partial or complete handsewn techniques. Liberal use of endoscopic staplers might shorten operative time. Esophageal surgeons should be aware of the advantages and become skilled with these techniques.