Abstract
Introduction
The addition of staple-line reinforcements on circular anastomoses has not been well studied. We histologically and mechanically analyzed circular- stapled anastomoses with and without bioabsorbable staple-line reinforcement (SeamGuard®, W. L. Gore & Associates, Flagstaff, AZ) in a porcine model.
Methods
Gastrojejunal anastomoses were constructed using a #25 EEA Proximate ILS® (Ethicon Endo-Surgery, Cincinnati, OH) mechanical stapling device with and without Bioabsorbable SeamGuard® (BSG). Gastrojejunal anastomoses were resected acutely and at 1 week, and burst-pressure testing and histological analysis were performed. Standardized grading systems for inflammation, collagen deposition, vascularity, and serosal inflammation were used to compare the two anastomosis types.
Results
Acute burst pressures were significantly higher with BSG than with staples alone (1.37 versus 0.39 psi, p = 0.0075). Burst pressures at 1 week were significantly lower with BSG than with staples alone (2.24 versus 3.86 psi, p = 0.0353); however, both readings were above normal physiologic intestinal pressures. There was no statistical difference in inflammation (13.4 versus 15.6, p = 0.073), width of mucosa (3.2 mm versus 3.2 mm, p = 0.974), adhesion formation (0 versus 0.5, p = 0.575), number of blood vessels (0.5 versus 1.0, p = 0.056), or serosal inflammation (2.0 versus 1.0, p = 0.27) between the stapled anastomoses and those buttressed with BSG. Stapled-only anastomoses had statistically more collagen (2.0 versus 1.0, p = 0.005) than the anastomoses supported with BSG.
Conclusions
The addition of BSG as a staple-line reinforcement acutely improves the burst strength of a circular anastomosis but not at 1 week. At 1 week, a decrease in collagen content with the BSG-buttressed stapled anastomosis was the only difference in the histologic parameters studied with no difference in vascularity, adhesions, or inflammation. The long-term effect of BSG on anastomotic strength or scarring is yet to be determined. The clinical implications may include decreased stricture formation and also decreased strength at anastomoses.
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References
Robicsek F (1980) The birth of the surgical stapler. Surg Gynecol Obstet 150:579–583
Ravitch MM, Steichen FM (1979) A stapling instrument for end-to-end inverting anastomoses in the gastrointestinal tract. Ann Surg 189:791–797
Weiss M, Haj M (2001) Gastrointestinal anastomosis with histoacryl glue in rats. J Invest Surg 14:13–19
Malthaner RA, Hakki FZ, Saini N, Andrews BL, Harmon JW (1990) Anastomotic compression button: a new mechanical device for sutureless bowel anastomosis. Dis Colon Rectum 33:291–297
Sjolin KE, Skeie E, Naver L, Svendsen O, Jacobsen SD (1994) New technique in anastomotic surgery—experimental and preliminary clinical experience. Zentralbl Chir 119:661–666; discussion 667–670
Hardy KJ (1990) Non-suture anastomosis: the historical development. Aust NZ J Surg 60:625–633
George WD (1991) Suturing or stapling in gastrointestinal surgery: a prospective randomized study. West of Scotland and Highland Anastomosis Study Group. Br J Surg 78:337–341
Moreno-Gonzalez E, Vara-Thorbeck R (1987) Stapler versus manual anastomosis in gastrointestinal surgery. Langenbecks Arch Chir 372:99–103
Chassin JL, Rifkind KM, Sussman B, Kassel B, Fingaret A, Drager S, Chassin PS (1978) The stapled gastrointestinal tract anastomosis: incidence of postoperative complications compared with the sutured anastomosis. Ann Surg 188:689–696
Hori S, Ochiai T, Gunji Y, Hayashi H, Suzuki T (2004) A prospective randomized trial of hand-sutured versus mechanically stapled anastomoses for gastroduodenostomy after distal gastrectomy. Gastric Cancer 7:24–30
Lustosa SA, Matos D, Atallah AN, Castro AA (2001) Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev CD003144
Angrisani L, Lorenzo M, Borrelli V, Ciannella M, Bassi UA, Scarano P (2004) The use of bovine pericardial strips on linear stapler to reduce extraluminal bleeding during laparoscopic gastric bypass: prospective randomized clinical trial. Obes Surg 14:1198–1202
Arnold W, Shikora SA (2005) A comparison of burst pressure between buttressed versus non-buttressed staple-lines in an animal model. Obes Surg 15:164–171
Consten EC, Gagner M (2004) Staple-line reinforcement techniques with different buttressing materials used for laparoscopic gastrointestinal surgery: a new strategy to diminish perioperative complications. Surg Technol Int 13:59–63
de la Portilla F, Zbar AP, Rada R, Vega J, Cisneros N, Maldonado VH, Utrera A, Espinosa E (2006) Bioabsorbable staple-line reinforcement to reduce staple-line bleeding in the transection of mesenteric vessels during laparoscopic colorectal resection: a pilot study. Tech Coloproctol 10:335–338
Franklin ME Jr, Berghoff KE, Arellano PP, Trevino JM, Abrego-Medina D (2005) Safety and efficacy of the use of bioabsorbable SeamGuard in colorectal surgery at the Texas endosurgery institute. Surg Laparosc Endosc Percutan Tech 15:9–13
Nguyen NT, Longoria M, Chalifoux S, Wilson SE (2005) Bioabsorbable staple line reinforcement for laparoscopic gastrointestinal surgery. Surg Technol Int 14:107–111
Nguyen NT, Longoria M, Welbourne S, Sabio A, Wilson SE (2005) Glycolide copolymer staple-line reinforcement reduces staple site bleeding during laparoscopic gastric bypass: a prospective randomized trial. Arch Surg 140:773–778
Shikora SA (2004) The use of staple-line reinforcement during laparoscopic gastric bypass. Obes Surg 14:1313–1320
Zerey M, Peindl RD, Paton B, Hope W, Newcomb W, Schmelzer T, Cristiano J, Heath J, Lincourt AE, Kercher KW, Gersin K, Heniford BT (2007) Anastomotic leaks: a scientific perspective. J Surg Res 137:252–253
Brundage SI, Jurkovich GJ, Grossman DC, Tong WC, Mack CD, Maier RV (1999) Stapled versus sutured gastrointestinal anastomoses in the trauma patient. J Trauma 47:500–507; discussion 507–508
Brundage SI, Jurkovich GJ, Hoyt DB, Patel NY, Ross SE, Marburger R et al (2001) Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial. J Trauma 51:1054–1061
Yo LS, Consten EC, Quarles van Ufford HM, Gooszen HG, Gagner M (2006) Buttressing of the staple line in gastrointestinal anastomoses: overview of new technology designed to reduce perioperative complications. Dig Surg 23:283–291
Saito Y, Omiya H, Shomura Y, Minami K, Imamura H (2002) A new bioabsorbable sleeve for staple-line reinforcement: report of a clinical experience. Surg Today 32:297–299
Minami K, Saito Y, Shomura Y, Imamura H (2003) A device to prevent an air-leakage after a thoracoscopic surgery for spontaneous pneumothorax. Kyobu Geka 56:904–907
Miller JI Jr, Landreneau RJ, Wright CE, Santucci TS, Sammons BH (2001) A comparative study of buttressed versus nonbuttressed staple line in pulmonary resections. Ann Thorac Surg 71:319–322; discussion 323
Olmos-Zuniga JR, Jasso-Victoria R, Sotres-Vega A, Gaxiola-Gaxiola M, Cedillo-Ley I, Argote-Greene LM et al (2001) Suture-line reinforcement with glutaraldehyde-preserved bovine pericardium for nonanatomic resection of lung tissue. J Invest Surg 14:161–168
Murray KD, Ho CH, Hsia JY, Little AG (2002) The influence of pulmonary staple line reinforcement on air leaks. Chest 122:2146–2149
Vaughn CC, Vaughn PL, Vaughn CC III, Sawyer P, Manning M, Anderson D, Roseman L, Herbst TJ (1998) Tissue response to biomaterials used for staple-line reinforcement in lung resection: a comparison between expanded polytetrafluoroethylene and bovine pericardium. Eur J Cardiothorac Surg 13:259–265
Downey DM, Harre JG, Dolan JP (2005) Increased burst pressure in gastrointestinal staple-lines using reinforcement with a bioprosthetic material. Obes Surg 15:1379–1383
Downey DM, Harre JG, Pratt JW (2006) Functional comparison of staple line reinforcements in lung resection. Ann Thorac Surg 82:1880–1883
Downey DM, Michel M, Harre JG, Pratt JW (2006) Functional assessment of a new staple line reinforcement in lung resection. J Surg Res 131:49–52
Katz AR, Mukherjee DP, Kaganov AL, Gordon S (1985) A new synthetic monofilament absorbable suture made from polytrimethylene carbonate. Surg Gynecol Obstet 161:213–222
Metz SA, Chegini N, Masterson BJ (1990) In vivo and in vitro degradation of monofilament absorbable sutures, PDS and Maxon. Biomaterials 11:41–45
Farrar DF, Gillson RK (2002) Hydrolytic degradation of polyglyconate B: the relationship between degradation time, strength and molecular weight. Biomaterials 23:3905–3912
Van Winkle W Jr, Hastings JC (1972) Considerations in the choice of suture material for various tissues. Surg Gynecol Obstet 135:113–126
Kangas J, Paasimaa S, Makela P, Leppilahti J, Tormala P, Waris T et al (2001) Comparison of strength properties of poly-L/D-lactide (PLDLA) 96/4 and polyglyconate (Maxon) sutures: in vitro, in the subcutis, and in the achilles tendon of rabbits. J Biomed Mater Res 58:121–126
Shamji MF, Maziak DE, Shamji FM, Matzinger FR, Perkins DG (2002) Surgical staple metalloptysis after apical bullectomy: a reaction to bovine pericardium? Ann Thorac Surg 74:258–261
Provencher S, Deslauriers J (2003) Late complication of bovine pericardium patches used for lung volume reduction surgery. Eur J Cardiothorac Surg 23:1059–1061
Iwasaki A, Yoshinaga Y, Shirakusa T (2004) Successful removal of bovine pericardium by bronchoscope after lung volume reduction surgery. Ann Thorac Surg 78:2156–2157
Consten EC, Dakin GF, Gagner M (2004) Intraluminal migration of bovine pericardial strips used to reinforce the gastric staple-line in laparoscopic bariatric surgery. Obes Surg 14:549–554
LeVeen HH, Wapnick S, Falk G, Olivas O, Bhat D, Gaurdre M, Patel M (1976) Effects of prophylactic antibiotics on colonic healing. Am J Surg 131:47–53
Hastings JC, Winkle WV, Barker E, Hines D, Nichols W (1975) Effect of suture materials on healing wounds of the stomach and colon. Surg Gynecol Obstet 140:701–707
Zerey M, Peindl RD, Paton BL, Hope WW, Newcomb WL, Schmelzer TM, Cristiano JA, Heath JJ, Lincourt AE, Kercher KW, Gersin K, Heniford BT (2007) Anastomotic leaks: a scientific perspective. Poster Presentation, Association for Academic Surgery, Academic Surgical Congress, February 2007, Phoenix, AZ
Nelsen TS, Anders CJ (1966) Dynamic aspects of small intestinal rupture with special consideration of anastomotic strength. Arch Surg 93:309–314
Jonsson K, Jiborn H, Zederfeldt B (1983) Breaking strength of small intestinal anastomoses. Am J Surg 145:800–803
Hendriks T, Mastboom WJ (1990) Healing of experimental intestinal anastomoses. parameters for repair. Dis Colon Rectum 33:891–901
Syk I, Agren MS, Adawi D, Jeppsson B (2001) Inhibition of matrix metalloproteinases enhances breaking strength of colonic anastomoses in an experimental model. Br J Surg 88:228–234
Consten EC, Gagner M, Pomp A, Inabnet WB (2004) Decreased bleeding after laparoscopic sleeve gastrectomy with or without duodenal switch for morbid obesity using a stapled buttressed absorbable polymer membrane. Obes Surg 14:1360–1366
Pandolfino JE, Curry J, Shi G, Joehl RJ, Brasseur JG, Kahrilas PJ (2005) Restoration of normal distensive characteristics of the esophagogastric junction after fundoplication. Ann Surg 242:43–48
Peacock EE Jr, van Winkle W Jr (1976) The biochemistry and the environment of wounds and their relation to wound strength. In: Surgery and biology of wound repair. WB Saunders, Philadelphia
Halsted WS (1987) Circular suture of the intestine—an experimental study. Am J Med Sci 94:436–461
Stallmach A, Schuppan D, Riese HH, Matthes H, Riecken EO (1992) Increased collagen type III synthesis by fibroblasts isolated from strictures of patients with Crohn’s disease. Gastroenterology 102:1920–1929
Burke JP, Mulsow JJ, O’Keane C, Docherty NG, Watson RW, O’Connell PR (2006) Fibrogenesis in Crohn’s disease. Am J Gastroenterol 102:439–448
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Financial support for this project was provided by W. L. Gore & Associates, Inc.
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Hope, W.W., Zerey, M., Schmelzer, T.M. et al. A comparison of gastrojejunal anastomoses with or without buttressing in a porcine model. Surg Endosc 23, 800–807 (2009). https://doi.org/10.1007/s00464-008-0079-6
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DOI: https://doi.org/10.1007/s00464-008-0079-6