Use of the vascular closure staple clip applier for microvascular anastomosis in free-flap surgery

We report our initial experience using the vascular closure staple clip applier (a nonpenetrating titanium clip applied in an interrupted, everting fashion) for microvascular anastomosis in free-flap surgery. In total, 153 anastomoses were performed in 87 free flaps (174 potential anastomoses) using the vascular closure stapler between October of 1997 and June of 1999. In 66 flaps, both the arterial and venous anastomosis were performed with the clip applier, whereas in 21 flaps only the venous anastomosis was performed using the clips. A total of 146 anastomoses were performed in an end-to-end fashion, and seven were performed end-to-side. Of the 87 flaps there were 53 TRAM flaps, seven bilateral TRAM, five latissimus dorsi, four gastrocnemius, three rectus abdominis, two radial forearm fibula, and four Rubens fat-pad flaps. Seventy flaps were used for breast reconstruction, seven flaps for lower limb reconstruction, four flaps for head and neck reconstruction, and six flaps for chest wall/trunk reconstruction. There were no postoperative anastomotic complications of bleeding, thrombosis, or need for revision (100 percent patency rate), with a significantly reduced time for completion of anastomoses. The clip applier is a safe, reliable method for performing microvascular anastomoses, allowing reduced operating time and possible cost savings in free-flap surgery.     

Vascularity at sites of gastro-jejunal anastomoses.

Recent interest in vascularity in relation to peptic ulceration poses the question of relationship between three entities: (1) site of gastro-jejunal (post-anastomotic) ulcer, (2) site of the anastomotic line and (3) site of junction and possible vascular anastomosis between gastric and jejunal circulations in the region of the anastomosis. Vascular injection studies in dogs show that the main gastric and jejunal circulations run up to, but do not communicate across, the surgical anastomosis, there being a line of least vascularity at the anastomosis. Since anastomotic ulcers occur distal to the anastomotic line, this supports the view that such ulcers are situated wholly in an area of jejunal circulation.     

Sequential venous anastomosis design to enhance patency of arterio-venous grafts for hemodialysis

Arterio-venous grafts (AVGs), the second best option as long-term vascular access for hemodialysis, face major issues of stenosis mainly due to development of intimal hyperplasia at the venous anastomosis which is linked to unfavorable hemodynamic conditions. We have investigated computationally the utility of a coupled sequential venous anastomotic design to replace conventional end-to-side (ETS) venous anastomosis, in order to improve the hemodynamic environment and consequently enhance the patency of AVGs. Two complete vascular access models with the conventional and the proposed venous anastomosis configurations were constructed. Three-dimensional, pulsatile blood flow through the models was simulated, and wall shear stress (WSS)-based hemodynamic parameters were calculated and compared between the two models. Simulation results demonstrated that the proposed anastomotic design provides: (i) a more uniform and smooth flow at the ETS anastomosis, without flow impingement and stagnation point on the artery bed and vortex formation in the heel region of the ETS anastomosis; (ii) more uniform distribution of WSS and substantially lower WSS gradients on the venous wall; and (iii) a spare route for the blood flow to the vein, to avoid re-operation in case of stenosis. The distinctive hemodynamic advantages observed in the proposed anastomotic design can enhance the patency of AVGs.     

Importance of additional microvascular anastomosis in esophageal reconstruction after salvage esophagectomy

Esophageal reconstruction after salvage esophagectomy in patients who have undergone curative-intent chemoradiotherapy for esophageal cancer is associated with a significant risk of perioperative morbidity and mortality. In particular, anastomotic leakage can cause severe and potentially fatal complications, including mediastinitis and pneumonia. The authors performed esophageal reconstruction with a pedicled right colon graft after salvage esophagectomy in eight patients. To decrease the rate of anastomotic leakage, the authors performed an additional microvascular anastomosis at the distal end of the graft. The distal stumps of the ileocolic artery and vein were anastomosed to the cervical vessels. After surgery, aspiration pneumonia and localized wound infection were observed in two patients each, but slight anastomotic leakage was observed in only one patient. Postoperative swallowing function was satisfactory in all patients. Although the incidence of anastomotic leakage is reportedly high, the authors observed anastomotic leakage in only one of eight patients. The authors believe that additional microvascular anastomosis helps prevent anastomotic leakage, especially in patients who have undergone salvage esophagectomy after curative chemoradiotherapy.     

The C-seal: A Biofragmentable Drain Protecting the Stapled Colorectal Anastomosis from Leakage

Colorectal anastomotic leakage (AL) is a serious complication in colorectal surgery leading to high morbidity and mortality rates¹. The incidence of AL varies between 2.5 and 20% ^2-5. Over the years, many strategies aimed at lowering the incidence of anastomotic leakage have been examined^{6, 7}.The cause of AL is probably multifactorial. Etiological factors include insufficient arterial blood supply, tension on the anastomosis, hematoma and/or infection at the anastomotic site, and co-morbid factors of the patient as diabetes and atherosclerosis⁸. Furthermore, some anastomoses may be insufficient from the start due to technical failure.Currently a new device is developed in our institute aimed at protecting the colorectal anastomosis and lowering the incidence of AL. This so called C-seal is a biofragmentable drain, which is stapled to the anastomosis with the circular stapler. It covers the luminal side of the colorectal anastomosis thereby preventing leakage.The C-seal is a thin-walled tube-like drain, with an approximate diameter of 4 cm and an approximate length of 25 cm (figure 1). It is a tubular device composed of biodegradable polyurethane. Two flaps with adhesive tape are found at one end of the tube. These flaps are used to attach the C-seal to the anvil of the circular stapler, so that after the anastomosis is made the C-seal can be pulled through the anus. The C-seal remains in situ for at least 10 days. Thereafter it will lose strength and will degrade to be secreted from the body together with the gastrointestinal natural contents.The C-seal does not prevent the formation of dehiscences. However, it prevents extravasation of faeces into the peritoneal cavity. This means that a gap at the anastomotic site does not lead to leakage.Currently, a phase II study testing the C-seal in 35 patients undergoing (colo-)rectal resection with stapled anastomosis is recruiting. The C-seal can be used in both open procedures as well as laparoscopic procedures. The C-seal is only applied in stapled anastomoses within 15cm from the anal verge. In the video, application of the C-seal is shown in an open extended sigmoid resection in a patient suffering from diverticular disease with a stenotic colon.     

A simple method for sutureless gastrointestinal anastomosis in rat.

A simple tubing stent was attempted to test a model for sutureless gastrointestinal anastomosis in 6 male rats at the age of 15 weeks. In the 3rd and 4th weeks after the operation, X-ray examination demonstrated that the gastrointestinal passage in the anastomotic site was quite satisfactory. There was no incidence of anastomotic leakage. In the 6th week after the operation, there were no macroscopic or microscopic ruptures, nor were there any obstructions at the anastomotic site. This simple sutureless method was effective at preparing anastomosis in the gastrointestinal tract in the rat and could be applied to other small experimental animals.     

The use of mechanical suturing in colorectal anastomoses

In 16 patients affected by cancer of the mild or lower 3 of the rectum, has been performed a colorectal anastomosis by EEA Stapler, with abdomino-transanal approach. In the postoperative period no case of anastomotic bleeding or stenosis has been observed. 3 patients (18%) presented minor anastomotic dehiscence detected by radiologic examination, without clinical symptomatology. The EEA Stapler anastomosis seem sure almost as the traditional hand sutures, and allow the execution of anterior resection instead of abdominal perineal amputation of rectum.     

A new technique for microvascular anastomosis: external metallic circle

Vessel anastomosis is the most critical step in free tissue transfers and replantation surgery. We report on a new microvascular anastomosis technique that uses a metallic circle around the anastomotic circumference. Sutures are first passed inside the circle and tied outside and over the circle so as to stretch open the anastomotic site. By retraction of vessel ends, the circle is totally exteriorized and thus there is no contact with blood. In 48 rats, the external circle method was compared with the conventional technique for constructing end-to-end anastomosis between carotid arteries (1 to 1.2 mm) and femoral veins (1 to 1.5 mm). The external circle method proved to be superior to the conventional end-to-end technique in speed of execution for both arterial and venous anastomoses. Patency rates at the third week were significantly higher in the venous group using the metallic circle (100 percent versus 70.8 percent, p < 0.05). This new method may be applicable in clinical microvascular surgery.     

Rotational in vitro compliance measurement of diverse anastomotic configurations: a tool for anastomotic engineering

Anastomotic configurations with a small internal diameter are prone to intimal hyperplasia which can cause occlusion within weeks or months. A link between intimal hyperplasia and inhomogenities of the elastic profile of the anastomosis has been established, making anastomotic engineering directed towards smoothing the compliance profile at the anastomotic site essential. Methods to date restrict the anastomotic compliance measurement to one plane. We present a method by which the anastomotic configurations are rotated, thereby allowing an anastomotic elastic profile assessment in multiple planes. Eight end-to-end anastomoses (ovine common carotid artery) and three end-to-side anastomoses (e-PTFE graft to ovine common carotid artery) were prepared and mounted in an artificial circulation system. Anastomotic circumferential compliance (maximal-minimal diameter/(maximal-minimal pressure.minimal diameter)) was measured by means of a laser-scan-micrometer and a Statham pressure transducer. By rotating end-to-end anastomoses, the compliance was measured in three, and in end-to-side anastomoses in four different planes. Multiplanar compliance variability in areas remote to both end-to-end and end-to-side anastomoses was approximately 9%. At the suture line the variability was approximately 22% in end-to-end anastomoses and 78% in end-to-side anastomoses. These results show that local factors result in different compliance profiles when utilizing a multiplanar technique, particularly in end-to-side anastomoses. The rotational apparatus is a tool which can be used to more accurately engineer a homogeneously compliant anastomosis, with the ultimate goal of prolonging anastomotic patency.     

Rapid novel aortic arch replacement for thoracic aortic aneurysm using three continuous sutures and a felt cylindrical collar

This report describes the novel parachute technique of open distal anastomosis at the aortic arch replacement. Two Teflon felt cylindrical collars were initially placed on the anastomotic site of the descending aorta. All four to five outer loops of the stitches used in the parachute technique were tracked by the gathering suture. The anastomotic sutures and three gathering sutures were finally pulled simultaneously. The prosthetic graft and the aortic stump with Teflon felt were safely and completely anastomosed. Surgical or hospital death and serious complications were not found. The mean anastomotic duration (circulatory arrest duration) in 16 patients was 23 minutes. Our novel technique using a Teflon felt cylindrical collar and modified continuous suturing was not only safe but also reduced the duration of anastomosis and minimized blood loss. This technique is simple and can be applied to aortic valve replacement.     

磁压榨技术建立大鼠胃肠吻合模型的实验研究

目的:探讨采用磁压榨技术建立大鼠胃肠吻合模型的可行性。方法:设计加工适用于大鼠胃肠吻合的子、母磁体。将10只SD大鼠采用磁压榨技术进行胃肠吻合,子、母磁体分别经口置入大鼠胃和空肠内,子母磁体相吸压榨胃壁和肠壁,磁体间受压组织缺血坏死后连同磁体从吻合口脱落入肠道,胃肠吻合即建立,磁体最终经消化道自行排出体外,术后2周处死动物,获取吻合口标本,检测吻合口爆破压、肉眼和光镜下观察吻合口愈合情况。结果:10只SD大鼠中,1只因麻醉意外死亡,其余9只大鼠均顺利完成手术操作并存活至术后2周;手术平均操作时间(15.89±3.25)min,磁体排出体外时间(8.56±1.26)天(范围7-11)天;吻合口爆破压均大于200 mm Hg,吻合口组织HE染色和Masson染色可见粘膜层连续性建立,愈合良好。结论:磁压榨技术可用于大鼠胃肠吻合模型制备,具有操作简单、成功率高的优点。     

Evaluation of a Novel Laser-assisted Coronary Anastomotic Connector - the Trinity Clip - in a Porcine Off-pump Bypass Model

To simplify and facilitate beating heart (i.e., off-pump), minimally invasive coronary artery bypass surgery, a new coronary anastomotic connector, the Trinity Clip, is developed based on the excimer laser-assisted nonocclusive anastomosis technique. The Trinity Clip connector enables simplified, sutureless, and nonocclusive connection of the graft to the coronary artery, and an excimer laser catheter laser-punches the opening of the anastomosis. Consequently, owing to the complete nonocclusive anastomosis construction, coronary conditioning (i.e., occluding or shunting) is not necessary, in contrast to the conventional anastomotic technique, hence simplifying the off-pump bypass procedure. Prior to clinical application in coronary artery bypass grafting, the safety and quality of this novel connector will be evaluated in a long-term experimental porcine off-pump coronary artery bypass (OPCAB) study. In this paper, we describe how to evaluate the coronary anastomosis in the porcine OPCAB model using various techniques to assess its quality. Representative results are summarized and visually demonstrated.     

大鼠颈部自体静脉移植模型两种吻合方法的比较

目的比较间断吻合和连续吻合法建立静脉桥狭窄动物模型的优劣。方法SD大鼠20只,分成两组（间断吻合组和连续吻合组）,取颈外静脉与颈总动脉行端端吻合。术后4周取下静脉桥,观察桥管通畅性,分析新生内膜与中膜的厚度、面积比。结果连续组与间断组相比手术时间更短,出血更少,但桥管通畅率低,两组内膜增生程度没有显著差异。结论连续吻合用时短,出血少,对术者要求更高,较易形成吻合口狭窄。两者造模效果一样。     

双吻合器在全直肠系膜切除低位直肠癌保肛手术中应用的探讨

目的探讨双吻合器在全直肠系膜切除低位直肠癌保肛手术中的应用方法、并发症及临床效果。方法回顾性分析在全直肠系膜切除的基础上,应用双器械吻合技术,对48例中低位直肠癌行低位或超低位吻合的保肛手术方法,观察其术后并发症,以及术后排便功能,局部复发率。结果随访1～4年,低位吻合44例,超低位吻合4例。15例6个月内大便次数每天多于5次,6个月后大便次数均在每天3次以下,无大便失禁。吻合口漏1例,吻合口狭窄1例,吻合口出血3例,吻合口复发1例,全组无手术死亡。结论双吻合器能简化手术操作,维持正常排便功能,提高了生活质量。     

Telemanipulatory application of a magnetic coupler on the beating heart with the daVinci surgical system]

The construction of a coronary anastomosis on the beating heart under totally endoscopic conditions is technically demanding. In this study the potential benefits of an endoscopic magnetic vascular coupler (MVP, Ventrica, Inc, Fremont, CA) designed to facilitate construction of a coronary anastomosis with the help of the daVinci telemanipulator (Intuitive Surgical Inc., Sunnyvale, CA) were evaluated in a totally endoscopic coronary arterial bypass (TECAB) operation on the beating heart in eight dogs. The telemanipulated instruments were used to guide and place the endoscopic MVP-application platform (prototype). All animals underwent angiography, and gross inspection of the anastomotic site was done after excision of the hearts. The procedure was accomplished in 169 minutes (155-190). With the exception of one premature deployment, all MVP-anastomoses were accomplished in 3 minutes (1-28). The following adverse events were encountered: Bleeding from the right ventricle caused by occlusion tape (1), anastomotic leakage upon reperfusion requiring repair stitches (2), anastomotic occlusion due to a thrombus (1). All but one animal that died on reperfusion despite a patent graft and anastomosis, survived the procedure. Overall patency was 7 out of 8. The combination of telemanipulator technology allowing increased manipulation dexterity in a total endoscopic environment and the effective and time saving magnetic technique for anastomotic coupling has the potential to facilitate TECAB on the beating heart.     

胰瘘发生假说到捆绑式胰肠吻合的临床运用

为避免术后胰瘘的发生,在过去的100年间提出了多种胰肠吻合重建方式,但哪种方法最好一直备受争议.胰肠吻合后吻合针距间存在可能的间隙,这个问题或许成为胰肠吻合口瘘的爆发点,而且存在贯穿浆肌层缝合的胰腺表面外露的吻合针眼,如果缝针贯穿胰管小分支,胰液可能从针眼流出.这一假说构成了捆绑式胰肠吻合的基础.捆绑式胰肠吻合是一种安全、有效的预防术后胰瘘的吻合方式.     

The effect of established infection on microvascular surgery

The success of microvascular anastomoses in the presence of staphylococcal infection was studied using rat femoral arteries. There was a spontaneous thrombosis rate of 19 percent in normal vessels that traversed the area of infection. Vessels with an anastomosis outside the area of infection had a similar thrombosis rate, but if the anastomotic site was within the infected area itself, the thrombosis rate increased to 75 percent. Inflammatory changes with subsequent fibrosis in the media and adventitia appeared responsible for the thrombosis. The intima was unaffected by the presence of infection. This study suggests that when a microvascular anastomosis is necessary in the presence of infection, the anastomosis should be placed outside the area of infection with a pedicle to traverse the infected area.     

Long bone growth variation among Arikara skeletal populations

Long bone growth variation among skeletal samples has had limited application to ecological studies of archaeological groups, in spite of its well-known sensitivity to health and nutritional status. In this study we examine long bone growth variation among ten samples of Arikara skeletal groups, all located in the Middle Missouri subarea of South Dakota and ranging in time from A.D. 1600 to 1832. The samples are analyzed by variant, an archaeological taxonomic unit below Tradition. Children's long bones between about 0.5 and 11.9 years of age were analyzed by means of regression using the model, bone length =b₀ + b₁ (age) + b₂ (log₁₀ age). The three variants, Extended Coalescent, Postcontact Coalescent, and Disorganized Coalescent, differ from one another with regard to health and nutritional status. Extended Coalescent groups probably experienced periods of undernutrition due to unfavorable climatic conditions prevailing at the time. Postcontact Coalescent groups experienced more favorable health and nutrition due to improved climatic conditions and introduction of the horse. Disorganized Coalescent groups were exposed to undernutrition and high levels of morbidity, due to introduction of epidemic diseases, depopulation, and intertribal conflict. Analysis of slopes shows significant heterogeneity among variants for humerus, radius, and tibia, but not femur. In general, the Postcontact Coalescent is characterized by slighter greater rates of increase with age and longer bone lengths for each age than is Extended Coalescent. Disorganized Coalescent exhibits lower rates of increase, particularly in later childhood, with shorter bone lengths in late childhood. Disorganized Coalescent also presents longer radius and humerus lengths than the other two variants in early childhood, an unexpected finding. This may be partly, but not entirely, explained by differential bone response to stress along the lines of maturity gradients.     

Coronary anastomoses over intraluminal occluders

A simplified technique with the use of intraluminal vessel occluders to prevent collateral flow of blood and cardioplegic solution during saphenous vein distal coronary artery anastomosis is presented here. Additional advantages of this technique are the stenting of vessels to facilitate vessel approximation and the assurance of anastomotic patency.     

不同测压方法测试大鼠结肠破裂压

目的比较不同测压方法测试大鼠结肠破裂压的优缺点。方法45只雄性SD大鼠随机等分为手动皮球测压组（H组）、机器测压压力表头描记测试组（MP组）、“实验动物空腔脏器耐压力测试系统”测试组（ME组）。各组大鼠经尾静脉注射麻醉后,切取结肠测试结肠破裂压;大鼠结肠端-端吻合一周后切取各组大鼠结肠吻合口,同法测试吻合口破裂压。结果三种测压方法所测得正常结肠及结肠吻合口破裂压差异无统计学意义（P〉0．05）,但ME组的标准差最小,MP组次之,H组的标准差最大。结论不同测压方法均可应用于大鼠正常结肠和结肠吻合口破裂压测试,但“实验动物空腔脏器耐压力测试系统”使实验更简便、直观,实验结果更客观、精确。