Comparison of three purse-string suture techniques for prevention of anal leakage during surgery

OBJECTIVE To compare 3 anal purse-string suture techniques for resistance to leakage and to identify the suture technique requiring the fewest tissue bites to create a consistent leak-proof orifice closure. ANIMALS 18 large-breed canine cadavers. PROCEDURES 3 purse-string suture techniques (3 bites with 0.5 cm between bites [technique A], 5 bites with 0.5 cm between bites [technique B], and 3 bites with 1.0 cm between bites [technique C]) were evaluated. Each technique involved 2-0 monofilament nylon suture that was placed in the cutaneous tissue around the anus and knotted with 6 square throws. Standardized 2.0-cm-diameter circular templates with the designated bite number and spacing indicated were used for suture placement. Leak-pressure testing was performed, and the pressure at which saline was first observed leaking from the anus was recorded. The median and interquartile (25th to 75th percentile) range (IQR) were compared among 3 techniques. RESULTS Median leak pressure for technique A (101 mm Hg; IQR, 35 to 131.3 mm Hg) was significantly greater than that for technique C (19 mm Hg; IQR, 14.3 to 25.3 mm Hg). Median pressure did not differ between techniques A and B (50 mm Hg; IQR, 32.5 to 65 mm Hg) or between techniques B and C. CLINICAL RELEVANCE Placement of an anal purse-string suture prevented leakage at physiologic colonic and rectal pressures, regardless of technique. Placement of 3 bites 0.5 cm apart (technique A) is recommended because it used the fewest number of bites and had the highest resistance to leakage.

Repositioning of the Severe Prolapsed Silicone Tubes after Bicanalicular Nasal Intubation: A Novel Technique

Background. Bicanalicular nasal intubation is widely used in lacrimal drainage system surgery. Its common complication is lateral displacement or spontaneous prolapse. When the distal part of the silicone tubes cannot be seen in the nose endoscopically, either repositioning or removal could be a challenge. We developed a simple technique to reposition the severe prolapsed silicone tubes. Method. This retrospective study included 6 patients with severe prolapsed silicone tubes who had undergone bicanalicular nasal intubation between January 2017 and December 2019. We used a memory wire probe to pull a nylon suture through the lacrimal passage retrograde. Then, the nylon suture was cut into two lines. One line was coiled to the prolapsed tube and tied to another line. This nylon turned into a “lasso” to capture the silicone tube and then lock its knot. By pulling the nylon suture, the severe prolapsed silicone tube was repositioned to the nasal cavity. Results. Using this technique, we successfully repositioned severe prolapsed silicone tubes without any complication in 6 cases. Conclusions. Silicone tube reposition guiding by using a memory wire probe is an optional technique in the treatment of prolapse of silicone tubes, particularly if the distal part of the silicon tube was embedded in the lacrimal sac and cannot be seen in the nose by endoscopy. It is a feasible, minimally invasive, safe, and effective method, avoiding premature tube removal.

Burst Pressures in Eyes with Clear Corneal Incisions Treated with ReSure Glue

Purpose. This study aims to measure burst pressures in 3 mm clear corneal incisions sealed with ReSure, a biodegradable hydrogel sealant, and to compare it to traditional 10-0 nylon sutures and unsealed controls. Design. An ex vivo animal study. Methods. 3 mm clear corneal incisions were performed in rabbit eyes (ex vivo). The burst pressure was determined, and then, the incisions were sealed with either ReSure glue or a single 10-0 nylon suture. Burst pressure measurements were repeated. Results. Fourteen eyes were included. The median burst pressure in the suture-control group (7 eyes) prior to suture application was 7 mmHg (range: 0–45); the median burst pressure in the 7 glue-controls was 36 mmHg (range: 5–61, p = 0.08 for the comparison of the two control groups). The median burst pressure in the glue group was 93 mmHg (range: 39–129, p = 0.043 when compared to glue-control). The median burst pressure in the suture group was 158 mmHg (range: 70–180, p = 0.018 when compared to suture-control). There was no statistically significant difference in burst pressure values between the glue and suture groups ( p = 0.08). Conclusion. In this study, ReSure glue applied to 3 mm clear corneal incisions provided sufficient resistance to elevated intraocular pressure when compared to controls. The results of this study suggest that ReSure glue may be comparable to a single 10-0 nylon suture in resisting fluid egress during the early postoperative period.

Anal Atresia and Structural Malformations of the Perineum and Anus in a Mare

Background: Anal atresia is a congenital defect and is related to the flaw of an opening in the membrane that separates the endoderm of the posterior intestine from the ectodermic anal membrane. This anomaly can cause debilitating disease, death, or abnormal development of the animal. Clinical presentation of urethrorectal fistula in domestic animals differs between males and females, as in the former there is passage of the urine through the anus, whereas in females there is elimination of the feces through the vulva. The absence of description of this disease in horses stimulated describing a case of surgical resolution of anal atresia, rectal bulb agenesis, and pneumovagina of an adult mare.Case: Mare with a history of defecating through the vagina. In the anamnesis, it was determined that the owner noticed the problem after observing the animal during a walk. Clinical examination verified absence of the anus with stool evacuation through the vagina, pneumovagina, and signs of cystitis, as the animal frequently urinated small volumes. Complementary laboratory tests of blood and urine were carried out for the diagnosis of cystitis, serum biochemistry, hemogram, and urinalysis being evaluated. The operation was scheduled for eight days after clinical tests and sodium ceftiofur was prescribed, at a dose of 4.4 mg/kg, administered intramuscularly for seven days. On the date chosen for surgical intervention, the animal was fasted for the previous 12 h; procedures began with the containment of the animal in a stock, followed by pre-anesthesia with detomidine, at a dose of 20 µg/kg, administered intravenously in solution at 1%. Anesthesia was a low peridural with 2% lidocaine at a total dose of 15 mL, to be able to work in the quadruped position. After containment of the tail and taking antiseptic and aseptic care, sutures were made in the skin and vaginal mucous, as it exhibited a solution of continuity. In the mucous, suture consisted of separate simple stitches made with perforation needle and 2-0 polyglactin 910 suture, while in the skin Wolff stitches were applied using a blade needle and 2-0 nylon suture. Then, a circular incision was made in the skin in the anus region to remove local skin; this revealed the rectum which, being it far from the required location, was pulled to the new opening. The rectum was fixed to the skin by suture: four simple stiches, with a perforation needle and zero nylon suture, to serve as repairs, followed by simple stitches between the repairs, with the same type of suture. Regarding the pneumovagina, reconstruction of the perineum and application of modified Calisck surgical technique were performed to correct the vulva defect. In the post-operative phase, 4.4 mg/kg of sodium ceftiofur was administered intramuscularly for seven days, and Flunixin Meglumine, at a dose of 1.1 mg/ml for every 50 kg of body weight, was administered intravenously for four days. Furthermore, rectal enemas (3 L of warm aqueous solution associated with glycerin) were administered every eight hours for 14 consecutive days, and the wound was cleaned with 2% chlorhexidine degerming solution. The skin sutures were removed after 15 days and the animal was discharged.Discussion: Alteration of the digestive tract in horses presents nuances in genetic dependence, embryology, and congenital defects, among others. Regarding the possibility of surgical correction, it is necessary to observe the characteristics of the lesion, the handling to which the animal is subjected, care of the surgical wound, and physical conditions where surgical procedures are carried out. The results obtained with this intervention and pre-, trans-, and post-operative care were effective in reestablishing the patient.

Novel technique of fixing intracorneal rings segments after migration

A 38-year-old patient with a history of non-progressive keratoconus in the left eye presented to us with an uncorrected visual acuity of 20/400, which improved to 20/60 with pinhole. We planned for intracorneal rings segment in the left eye. Postoperatively uncorrected visual acuity improved to 20/30. The patient presented 2 weeks later with severely decreased vision to 20/100 and migration of intracorneal rings were noted with both the rings riding side by side. The patient gave history of vigorous eye rubbing. The rings were repositioned with the help of Sinskey hooks and superior ring was anchored with 10-nylon suture passed through the ring hole to the corneal stroma. Two more sutures were placed radial to the circumference of inferior ring to prevent its migration. The sutures were removed after 1 month and the patient was followed up with stable position of the rings for the next 6 months . The uncorrected visual acuity improved to 20/40.

Asymmetric 6-Strand Flexor Tendon Repair – Biomechanical Analysis Using Barbed Suture

Background: This study investigates the biomechanical performance of the Asymmetric flexor tendon repair technique using barbed suture. The Asymmetric repair technique using monofilament nylon suture was previously reported to have a higher tensile strength than the modified Lim-Tsai repair technique, but its repair stiffness and load to gap force were significantly lower. There is hence an unmet need to improve this technique and the substitution of nylon suture with barbed sutures may be the solution. Methods: Two groups consisting of 10 porcine tendons each were repaired with the six-strand Asymmetric repair technique using V-Loc® 3-0 and Supramid® 4-0 respectively. The repairs were subjected to a mechanical tester for static testing. The ultimate tensile strength, load to 2 mm gap force, repair stiffness, time taken to complete a repair and failure mechanism of the repairs were recorded and analyzed. Results: All the repairs using V-Loc® 3-0 sutures had significantly higher median values of ultimate tensile strength (64.1 N; 56.9 N), load to 2 mm gap force (39.2 N; 19.7 N), repair stiffness (6.4 N/mm; 4.7 N/mm) and time taken to complete a repair (9.4 mins; 7.7 mins). All the repairs using V-Loc® sutures failed by suture breakage while 80% of repairs using Supramid® sutures failed by suture pullout. Conclusions: The use of the barbed sutures in the Asymmetric repair technique, whilst more time consuming, has shown promising improvement to its biomechanical performance (i.e. better ultimate tensile strength, stiffness and resistance to gap formation).