Precision Medicine in Aortic Anastomosis: A Numerical and Experimental Study of a Novel Double-Sided Needle

Background: Hand-sewn anastomosis is a crucial part of aortic reconstruction surgery and significantly affects its outcome. The present study presents a novel, bidirectional surgical needle aimed to improve aortic anastomosis in terms of speed and ease of use. Our objective was to assess the efficacy of the new design in comparison with the conventional needle. Methods: A series of simulations were conducted with COMSOL software in order to perform a fatigue comparative analysis between the new and the conventional needle design. Ease of penetration into a piece of polydimethylsiloxane was evaluated. Lastly, the prototype was tested under in-vitro conditions in comparison with the conventional needle. Results: Based on fatigue analysis, the new needle design improves durability, provided the two tips are equally used. The polytetrafluoroethylene coating improves penetration into the tissue by 7% to 17%, while electropolishing improves penetration up to 19%. When using the novel needle design, the average anastomotic task completion time was significantly reduced by 22% and the overall distance of hand movements was significantly reduced by 20%. Conclusions: The proposed design exhibited a shorter anastomotic time and seems promising in relation to ease of use and simplicity of the anastomotic technique it introduces.

O-OGC08 The Impact of Anastomotic Techniques on Post-operative Anastomotic Complications: Results of the Oesophago-Gastric Anastomosis Audit (OGAA)

Background The optimal anastomotic techniques in esophagectomy to minimize rates of anastomotic leakage (AL) and conduit necrosis (CN) are not known. The aim of this study was to assess whether anastomotic technique is associated with anastomotic failure after esophagectomy in the international Oesophago-Gastric Anastomosis Audit (OGAA) cohort. Methods This prospective observational multicenter cohort study included patients undergoing esophagectomy for esophageal cancer over nine months in 2018. The primary exposure was the anastomotic technique, classified as handsewn, linear stapled or circular stapled. The primary outcome was a composite of AL and CN, as defined by the Esophageal Complications Consensus Group. Multivariable logistic regression modelling was used to identify the strength of association between anastomotic techniques and anastomotic failure. Results Of the 2238 esophagectomies, the anastomosis was handsewn in 27.1%, linear stapled in 21.0% and circular stapled in 51.9%. Anastomotic techniques differed significantly between the anastomosis site (p < 0.001), with the majority of neck anastomoses being handsewn (69.9%), whilst most chest anastomoses were stapled (66.3% circular stapled, 19.3% linear stapled). Rates of AL/CN differed significantly between the anastomotic techniques (p < 0.001), from 19.3% in handsewn anastomoses, to 14.0% in linear stapled, and 12.1% in circular stapled. This was confirmed by multivariable analysis (Odds ratio (OR): 0.63, 95% CI: 0.46 - 0.86) for circular stapled vs. handsewn anastomosis. However, subgroup analysis by anastomosis site suggested that this effect was predominantly present in neck anastomoses, with AL/CN rates of 23.2% vs. 14.6% vs 5.9% for handsewn vs. linear stapled anastomoses vs circular stapled, compared to 13.7% vs. 13.8% vs 12.2% in chest anastomoses. Conclusions Handsewn anastomoses appear to be associated with higher rates of anastomotic failure for anastomoses in the neck. However, anastomotic failure rates in the chest were similar across techniques and there was no significant difference on multivariable analysis. Further research into standardization of approach and techniques may further improve outcomes.

Anastomotic Technique—How to Optimize Success and Minimize Leak Rates

Determining when to perform a bowel anastomosis and whether to divert can be difficult, as an anastomosis made in a high-risk patient or setting has potential for disastrous consequences. While the surgeon has limited control over patient-specific characteristics, the surgeon can control the technique used for creating anastomoses. Protecting and ensuring a vigorous blood supply is fundamental, as is mobilizing bowel completely, and employing adjunctive techniques to attain reach without tension. There are numerous ways to create anastomoses, with variations on the segment and configuration of bowel used, as well as the materials used and surgical approach. Despite numerous studies on the optimal techniques for anastomoses, no one method has prevailed. Without clear evidence on the best anastomotic technique, surgeons should focus on adhering to good technique and being comfortable with several configurations for a variety of conditions.

A Modified Adventitial Inversion With Graft Insertion Technique in Acute Type A Aortic Dissection

Acute type A aortic dissection may originate from a primary intimal tear located in the ascending aorta and often extends retrogradely into the aortic root. How to prevent bleeding in the aortic root and eliminate false lumen is very important in aortic dissection. We have developed a modified anastomotic technique that involves inverting adventitial and graft into aorta and reinforcing with a felt strip on the external border of the aortic wall. 45 consecutive patients had undergone this surgical procedure for aortic root reconstruction in aortic dissection, there had been no reoperations either for bleeding or remnant dissection so far.

Optimization of anastomotic technique and gastric conduit perfusion with hyperspectral imaging in an experimental model for minimally invasive esophagectomy

ObjectiveTo optimize anastomotic technique and gastric conduit perfusion with hyperspectral imaging (HSI) for total minimally invasive esophagectomy (MIE) with linear stapled anastomosis.Summary Background DataEsophagectomy is the mainstay of esophageal cancer treatment but anastomotic insufficiency related morbidity and mortality remain challenging for patient outcome.MethodsA live porcine model (n=50) for MIE was used with gastric conduit formation and linear stapled side-to-side esophagogastrostomy. Four main experimental groups differed in stapling length (3 vs. 6 cm) and anastomotic position on the conduit (cranial vs. caudal). Tissue oxygenation around the anastomotic site was evaluated using HSI and was validated with histopathology.ResultsThe tissue oxygenation (ΔStO2) after the anastomosis remained constant only for the short stapler in caudal position (−0.4± 4.4%, n.s.) while it dropped markedly in the other groups (short-cranial: -15.6± 11.5%, p=0.0002; long-cranial: -20.4± 7.6%, p=0.0126; long-caudal: -16.1± 9.4%, p<0.0001) Tissue samples from deoxygenated stomach as measured by HSI showed correspondent eosinophilic pre-necrotic changes in 35.7± 9.7% of the surface area.ConclusionsTissue oxygenation at the anastomotic site of the gastric conduit during MIE is influenced by stapling technique. Optimal oxygenation was achieved with a short stapler (3 cm) and sufficient distance of the anastomosis to the cranial end of the gastric conduit. HSI tissue deoxygenation corresponded to histopathologic necrotic tissue changes. These findings allow for optimization of gastric conduit perfusion and anastomotic technique in MIE.Level of EvidenceNot applicable. Translational animal science. Original article.