Anastomotic Outcomes in Military Exploratory Laparotomies in the Modern Combat Era

Background Intestinal anastomoses in military settings are performed in severely injured patients who often undergo damage control laparotomy in austere environments. We describe anastomotic outcomes of patients from recent wars. Methods Military personnel with combat-related intra-abdominal injuries (June 2009-December 2014) requiring laparotomy with resection and anastomosis were analyzed. Patients were evacuated from Iraq or Afghanistan to Landstuhl Regional Medical Center (Germany) before being transferred to participating U.S. military hospitals. Results Among 341 patients who underwent 1053 laparotomies, 87 (25.5%) required ≥1 anastomosis. Stapled anastomosis only was performed in 57.5% of patients, while hand-sewn only was performed in 14.9%, and 9.2% had both stapled and hand-sewn techniques (type unknown for 18.4%). Anastomotic failure occurred in 15% of patients. Those with anastomotic failure required more anastomoses (median 2 anastomoses, interquartile range [IQR] 1-3 vs. 1 anastomosis, IQR 1-2, P = .03) and more total laparotomies (median 5 laparotomies, IQR 3-12 vs. 3, IQR 2-4, P = .01). There were no leaks in patients that had only hand-sewn anastomoses, though a significant difference was not seen with those who had stapled anastomoses. While there was an increasing trend regarding surgical site infections (SSIs) with anastomotic failure after excluding superficial SSIs, it was not significant. There was no difference in mortality. Discussion Military trauma patients have a similar anastomotic failure rate to civilian trauma patients. Patients with anastomotic failure were more likely to have had more anastomoses and more total laparotomies. No definitive conclusions can be drawn about anastomotic outcome differences between hand-sewn and stapled techniques.

Development and validity evidence of an objective structured assessment of technical skills score for minimally invasive linear-stapled, hand-sewn intestinal anastomoses: the A-OSATS score

Introduction The aim of this study was to develop a reliable objective structured assessment of technical skills (OSATS) score for linear-stapled, hand-sewn closure of enterotomy intestinal anastomoses (A-OSATS). Materials and methods The Delphi methodology was used to create a traditional and weighted A-OSATS score highlighting the more important steps for patient outcomes according to an international expert consensus. Minimally invasive novices, intermediates, and experts were asked to perform a minimally invasive linear-stapled intestinal anastomosis with hand-sewn closure of the enterotomy in a live animal model either laparoscopically or robot-assisted. Video recordings were scored by two blinded raters assessing intrarater and interrater reliability and discriminative abilities between novices (n = 8), intermediates (n = 24), and experts (n = 8). Results The Delphi process included 18 international experts and was successfully completed after 4 rounds. A total of 4 relevant main steps as well as 15 substeps were identified and a definition of each substep was provided. A maximum of 75 points could be reached in the unweighted A-OSATS score and 170 points in the weighted A-OSATS score respectively. A total of 41 anastomoses were evaluated. Excellent intrarater (r = 0.807–0.988, p < 0.001) and interrater (intraclass correlation coefficient = 0.923–0.924, p < 0.001) reliability was demonstrated. Both versions of the A-OSATS correlated well with the general OSATS and discriminated between novices, intermediates, and experts defined by their OSATS global rating scale. Conclusion With the weighted and unweighted A-OSATS score, we propose a new reliable standard to assess the creation of minimally invasive linear-stapled, hand-sewn anastomoses based on an international expert consensus. Validity evidence in live animal models is provided in this study. Future research should focus on assessing whether the weighted A-OSATS exceeds the predictive capabilities of patient outcomes of the unweighted A-OSATS and provide further validity evidence on using the score on different anastomotic techniques in humans.

Study of clinical outcome of patients undergoing intestinal anastomoses with single layer extramucosal technique and double layer anastomoses

Background: Intestinal anastomosis is one of the common surgeries for cases like bowel obstruction, incarcerated hernias, benign and malignant tumours of small and large bowel. The ideal intestinal anastomosis does not leak and allow normal function of the gastrointestinal tract. This study compared single layer versus double layer intestinal anastomosis in terms of duration, postoperative complications like anastomotic leak.Methods: A total of 100 patients admitted in Hamidia hospital, based on history and clinical examinations and radiological examinations, placed in two groups, group A (single layer anastomosis) and group B (double layer anastomosis) and were operated by a qualified surgical specialist. Data analysis of anastomotic time, anastomotic leak was done and statistical tests of significance were applied. A p value less than 0.05 is considered as significant.Results: In group A (single layer) the time required to perform in 30 (60%) patients is between 16-20 minutes. In double layer, maximum were done in between 26 to 30 minutes, 32 (64%). In our study of 100 patients, there were 6 anastomotic leaks, of which four of them were in group A (single layer) and 2 of them in group B (double layer).Conclusions: In our study, the duration required to perform a single layer intestinal anastomosis is significantly lesser when compared to double layer. There is no significant difference in anastomotic leak between two groups. Less time with no difference in complications, a move towards single layer anastomosis should be preferred.

Multiple intestinal anastomosis in newborns and infants

Introduction. The present trial systematizes data, taken from one surgical center as an example, on treating patients with intestinal atresia and necrotizing enterocolitis with multiple intestinal anastomoses.Material and methods. The trial is a retrospective review on the treatment of 13 newborn infants who since 2010 have been put multiple intestinal anastomoses; the treatment was approved by the Hospital Ethics Committee. The average gestational age of patients was 31.2 weeks. The average age at the time of surgery – 7,9 days. Average weight - 2007 grams. The average number of anastomoses was 3.7 (range: 2-7). The average length of remained small intestine after the second surgery was 67.4 cm (range: 12-120 cm). No other surgical procedures, including gastrostomy or enterostomy, were performed. In all cases, surgical intervention ended with hermetic suturing of the abdominal cavity. Among them, there were 6 patients with the multifocal form of necrotizing enterocolitis; 6 patients had type IV atresia of the small intestine; 1 patient had the Ladd’s syndrome. Connection of intestinal segments was made by constructing several “end-to-end” anastomoses, double-row precision seam with PDS II 7/0 suture.Results. In the postoperative period, complications associated with anastomosis construction, such as leakage and narrowing, were not recorded. Transit function of the gastrointestinal tract restored on day 4, on average, after the surgery (range: 2-6 days). There were no early lethal outcomes within the first 28 days after the surgery which were associated with the surgery. 2 patients with short bowel syndrome (remained small intestine was 12 and 25 cm) and multivisceral disorders died on day 72 and 64 after the surgery. Survived patients were transferred to full enteral feeding in 56 days, in average, after the second surgery (range - 15-120 days).Conclusion. In our study, we have demonstrated potentials of a new surgical approach: one-stage formation of multiple intestinal anastomoses in case of multiple intestinal atresias as well as in case of multifocal forms of necrotizing enterocolitis. Maintaining the bowel length with multiple bowel anastomoses is very important factor for better survival of patients with the short bowel syndrome.

Comparison of two end-to-end continuous sutures for intestinal anastomoses in dogs.

Background: Single-layer appositional closures are preferred to inverting or everting patterns, as submucosal apposition has been shown to promote primary healing of the intestinal wall, whereas inverted or everted closures require second-intention healing and can increase the risk of luminal stenosis or anastomosis site leakage. There are different suture patterns available, but relatively few studies comparing these aspects have been published.The aim of this study was to compare two suture techniques for end-to-end anastomosis of the canine intestine (jejunum and colon): handsewn intestinal anastomosis by appositional simple continuous suture and inverting Cushing suture. The objectives of this study were to investigate 1.) whether the type of suture influences the specific effort to which the anastomosis site is submitted to, 2.) whether the anastomosis technique influences the diameter of the intestinal lumen and 3.) survival and complication rates in canine clinical cases undergoing end-to-end anastomoses. Results: The equilibrium angle for implanting the sutures in an anastomosis is 35°, aspect completely fulfilled by the simple continuous suture. The efforts to which sutures are submitted to in anastomoses are minimal for the Cushing suture. The difference in size of the anastomoses’ lumen between simple continuous suture and the Cushing suture are minimal, without being statistically relevant. The differences between the lumen of the anastomoses performed using PDS and those performed using PGA are not statistically relevant. The retrospective analysis of the outcome for 676 dogs (clinical cases) that underwent intestinal resection and anastomosis reveals that the dehiscence rate was 1.48%, out of which 1.18% following simple continuous anastomoses, and 0.3% following Cushing anastomoses. Narrowing of the intestinal lumen due to anastomotic healing was not registered.Conclusions: Use of the Cushing suture should be considered for performing an end-to-end intestinal anastomosis, although more studies are required to determine if there are any clinically significant differences between the sutures investigated in this study.

Outcomes Assessment between Hand Sewn and Stapled Intestinal Anastomosis

Objective: This study was conducted at the Department of Surgery of Liaquat University of Medical & Health Sciences, Jamshoro, Sindh, Pakistan for comparing the effectiveness of both methods: hand sewn and stapled intestinal anastomosis and to find a better comparatively to be more efficient. Methods: A total of 70 patients were encompassed who underwent intestinal anastomoses from proximal jejunum to 2/3rd of proximal distal rectum. All patients were assigned to two different groups A and B each encompassing of 35 cases. In group A, the single layer continuous and in group B single layer patients intervallic serosubmucosal anastomosis was made by implementing the stitches approximately 6 mm at a distance integrating around 5.5 mm of the gut in its stretched direction axis evading individual mucosa. The patients were observed post operatively for anastomotic fiasco such as leakage. Results: Fourteen (14) out of 35 (2.5%) patients in group A developed anastomotic leakage . In group B, the interrupted serosubmucosal anastomoses were made in 26 patients in emergency and remaining were operated schedule wise. Five (7%) patients exhibited anastomotic leakage in group B. In group A, the continuous leakage in serousubmucosal anastomosis was 2.5% while in group B interrupted serousubmucosal anastomosis was 7%. Conclusion: It has observed in past studies that single layer interrupted stitches leakage is higher as compared to continuous. It is clear that anastomotic failure in group A is greater than group B but it not considerably substantial and hence both are remarkably efficient.

Uretero-intestinal anastomoses: which method to choose? History, current state of the issue and own experience

Introduction. At the moment, after performing a cystectomy, one of the most urgent issues remains the choice of technique for performing uretero-intestinal anastomoses. Materials and methods. The search of the information was conducted in the Pubmed and Scopus databases, with a scientific electronic library Elibrary.ru and websites of professional urological and oncological associations. The search was performed for the keywords «Radical cystectomy», «uretero-intestinal anastomosis», «bladder cancer», and «neobladder». For citation in the article, 44 publications were selected. We also present our own data – long-term functional results of radical cystectomy for muscle-invasive bladder cancer for the period from 2016 to 2020. Results. The article presents a literature review on the development of modern methods for creating uretero-intestinal anastomoses in various clinical situations. The methods are presented in chronological order of their description in the literature, indicating the advantages, disadvantages and long-term results. In all 75 cases included in the analysis, a direct uretero-intestinal anastomosis was performed. In the early postoperative period, the failure of the anastomosis with the development of urinary peritonitis was detected in 2 (2.7%) patients. Six months after the operation, unilateral anastomotic stricture was detected in 2 patients (2.7%). Reflux of urine, without radiological signs of expansion of the renal cavity system and decreased renal function, was observed in 1 patient after orthoptic plastic surgery of the bladder. Conclusion. Performing urinary-intestinal anastomoses without antireflux mechanisms does not lead to deterioration of long-term functional results and is associated with a low frequency of strictures.

Choosing a method to perform an esophageal-intestinal anastomosis after complete removal of the stomach

The paper reviews various methods of performing esophageal-intestinal anastomoses with complete removal of the stomach (gastrectomy). The main methods of manual and stapler stitching of the esophagus with the jejunum are described. Special attention is paid to detailing of techniques for the most commonly performed esophageal-intestinal anastomoses, with a comparative assessment of the reliability of manual and stapler anastomoses. Given the large number of proposed methods to perform esophageal-intestinal anastomoses, it can be stated that no universal anastomosis yet exists. In laparotomy, a stapler suture is most commonly used to perform an esophageal-intestinal anastomosis with circular crosslinking devices, while the manual version implies one of the invagination techniques, or muff-like anastomosis (the Tsatsanidi K.N., Bondar G.V., Davydov M.I. procedure). With laparoscopic access, the anastomosis is performed with linear endoscopic crosslinking devices. The choice of a technique to perform an esophageal-intestinal joint remains with the operating surgeon and depends on his/hers experience, skills, individual intraoperative situation, and equipment of the operating unit.