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Comment on: improving the side-to-side stapled anastomosis: comparison of staplers for robust crotch formation
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Surgery for Obesity and Related Diseases ] (2017) 00–00
Editorial
Comment on: improving the side-to-side stapled anastomosis: comparison of staplers for robust crotch formation We read with great interest the article by Kimura et al. [1] evaluating the effect of different stapler configurations on ex vivo burst pressure of side-to-side intestinal anastomosis. They have found that staplers with 3-row staples, uniform height, and a height slightly shorter than the intestinal thickness were associated with the highest burst pressure. The authors should be applauded for an elegant study providing evidence in support of the importance of choosing the correct stapler configuration in constructing a mechanically strong anastomosis. However, several aspects of the study design merits further discussion to evaluate the significance of its finding with the proper perspective. More than a century ago, Chlumsky [2] first described the use of bursting pressure for assessment of anastomotic strength. Due to the variability in factors, including experimental animal species, rate of bowel inflation, and radius of the intestine, it is difficult to perform valid comparisons of absolute data across studies [3]. An in vivo animal study found that regardless of the anastomotic method, the burst pressures at the anastomotic sites were uniformly higher than the physiologic intraluminal pressure [4]. A separate study attempted to quantify intraluminal pressure adjacent to a colorectal anastomosis in the first few days after a lowanterior resection in human patients. The researchers found that two thirds of the recorded pressures were between 10 and 20 mm Hg while o2% exceeded 50 mm Hg [5], meaning that most of the established burst pressures described in the study by Kimura et al. [1] will never be reached under physiologic conditions. In view of the ex vivo setting of the present study, it is not feasible to compare bursting pressure of anastomoses with physiologic intraluminal pressure obtained from unoperated control animals or adjacent bowel segments. In the absence of control intraluminal pressure, it is difficult to assess whether the burst pressure differences found among the various stapler configurations is of clinical importance, because they may well be above physiologic intraluminal pressures observed in the early postoperative phase.
The second point to bear in mind while interpreting the present study’s result pertains to the role mechanical strength plays in preventing anastomotic leakage. Studies have found that bursting pressure of anastomoses usually remained low during the first 3- to 4-postoperative days and increased rapidly to exceed those of the uninjured intestine afterward as wound healing took place [6,7]. Ultimately, the strength of an anastomosis depends on the collagen content deposited by the healing process within the intestinal submucosa rather than the mechanical strength of the surgical material [8]. In routine clinical practice, surgeons are constantly striving to find the balance between constructing an anastomosis that is tight enough to prevent dehiscence in the early postoperative period and loose enough to allow maximal perfusion of the cut edges for improved healing afterward. While no systematic investigation exists regarding the optimal anastomotic tension for human patients, animal studies evaluating suture tensions in colonic anastomoses have demonstrated that exceedingly high tensions lead to elevated leakage rate just as too little tension [9]. In the absence of evidence suggesting that physiologic intraluminal pressure will ever reach or exceed measured burst pressure at the anastomosis, the reader should bear in mind the possibility that a tighter stapled anastomosis with a higher burst pressure may actually lead to increased leak rate due to the tissue ischemia at the edge of the resection. The present study highlights the critical role stapler configuration plays in determining the mechanical strength of intestinal anastomosis and surgeons should take an individualized approach to pick the optimal staple height, staple row number, and configuration according to the intestinal tissue characteristics encountered. In the future, experiments should be designed bearing in mind that the ultimate goal is not to fashion an airtight anastomosis, but to reduce postoperative leak rate. This requires careful consideration of not only the mechanical strength, but also interaction between the surgical material and the intestinal perfusion, tissue tension, and intestinal microbiome [10].
http://dx.doi.org/10.1016/j.soard.2017.10.016 1550-7289/r 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.
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Y-Y Juo and E. Dutson / Surgery for Obesity and Related Diseases ] (2017) 00–00
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Yen-Yi Juo, M.D., M.P.H. Erik Dutson, M.D., F.A.C.S. Center for Advanced Surgical and Interventional Technology (CASIT), Los Angeles, California Department of Surgery, University of California Los Angeles, Los Angeles, California References [1] Kimura M. Improving the side-to-side stapled anastomosis: comparison of staplers for robust crotch formation In press. Surg Obes Relat Dis 2018. In press. [2] Chlumsky V. Experimentelle untersuchungen ueber die verschiedenen methode der darmvereinigung [in German]. Bruns Beitr Klin Chir 1899;25:539–600. [3] Hendriks T, Mastboom WJ. Healing of experimental intestinal anastomoses. Parameters for repair. Dis Colon Rectum 1990;33 (10):891–901.
[4] Paral J, Lochman P, Blazej S, Pavlik M. Glued versus stapled anastomosis of the colon: an experimental study to determine comparative resistance to intraluminal pressure. Asian J Surg 2014;37(3):154–61. [5] Burkitt DS, Donovan IA. Intraluminal pressure adjacent to left colonic anastomoses. Br J Surg 1990;77(11):1288–90. (1990). [6] Wise L, McAlister W, Stein T, Schuck P. Studies on the healing of anastomoses of small and large intestines. Surg Gynecol Obstet 1975;141(2):190–4. [7] Hesp FL, Hendriks T, Lubbers EJ, deBoer HH. Wound healing in the intestinal wall. A comparison between experimental ileal and colonic anastomoses. Dis Colon Rectum 1984;27(2):99–104. [8] Halsted WS. Classic articles in colonic and rectal surgery. William Stewart Halsted 1852-1922. Circular suture of the intestine–an experimental study. Dis Colon Rectum 1984;27(9):838–41. [9] Waninger J, Kauffmann GW, Shah IA, Farthmann EH. Influence of the distance between interrupted sutures and the tension of sutures on the healing of experimental colonic anastomoses. Am J Surg 1992;163(3):319–23. [10] Shogan BD, Carlisle EM, Alverdy JC, Umanskiy K. Do we really know why colorectal anastomoses leak? J Gastrointest Surg 2013;17 (9):1698–707.
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Surgery for Obesity and Related Diseases ] (2017) 00–00
Editorial
Comment on: improving the side-to-side stapled anastomosis: comparison of staplers for robust crotch formation We read with great interest the article by Kimura et al. [1] evaluating the effect of different stapler configurations on ex vivo burst pressure of side-to-side intestinal anastomosis. They have found that staplers with 3-row staples, uniform height, and a height slightly shorter than the intestinal thickness were associated with the highest burst pressure. The authors should be applauded for an elegant study providing evidence in support of the importance of choosing the correct stapler configuration in constructing a mechanically strong anastomosis. However, several aspects of the study design merits further discussion to evaluate the significance of its finding with the proper perspective. More than a century ago, Chlumsky [2] first described the use of bursting pressure for assessment of anastomotic strength. Due to the variability in factors, including experimental animal species, rate of bowel inflation, and radius of the intestine, it is difficult to perform valid comparisons of absolute data across studies [3]. An in vivo animal study found that regardless of the anastomotic method, the burst pressures at the anastomotic sites were uniformly higher than the physiologic intraluminal pressure [4]. A separate study attempted to quantify intraluminal pressure adjacent to a colorectal anastomosis in the first few days after a lowanterior resection in human patients. The researchers found that two thirds of the recorded pressures were between 10 and 20 mm Hg while o2% exceeded 50 mm Hg [5], meaning that most of the established burst pressures described in the study by Kimura et al. [1] will never be reached under physiologic conditions. In view of the ex vivo setting of the present study, it is not feasible to compare bursting pressure of anastomoses with physiologic intraluminal pressure obtained from unoperated control animals or adjacent bowel segments. In the absence of control intraluminal pressure, it is difficult to assess whether the burst pressure differences found among the various stapler configurations is of clinical importance, because they may well be above physiologic intraluminal pressures observed in the early postoperative phase.
The second point to bear in mind while interpreting the present study’s result pertains to the role mechanical strength plays in preventing anastomotic leakage. Studies have found that bursting pressure of anastomoses usually remained low during the first 3- to 4-postoperative days and increased rapidly to exceed those of the uninjured intestine afterward as wound healing took place [6,7]. Ultimately, the strength of an anastomosis depends on the collagen content deposited by the healing process within the intestinal submucosa rather than the mechanical strength of the surgical material [8]. In routine clinical practice, surgeons are constantly striving to find the balance between constructing an anastomosis that is tight enough to prevent dehiscence in the early postoperative period and loose enough to allow maximal perfusion of the cut edges for improved healing afterward. While no systematic investigation exists regarding the optimal anastomotic tension for human patients, animal studies evaluating suture tensions in colonic anastomoses have demonstrated that exceedingly high tensions lead to elevated leakage rate just as too little tension [9]. In the absence of evidence suggesting that physiologic intraluminal pressure will ever reach or exceed measured burst pressure at the anastomosis, the reader should bear in mind the possibility that a tighter stapled anastomosis with a higher burst pressure may actually lead to increased leak rate due to the tissue ischemia at the edge of the resection. The present study highlights the critical role stapler configuration plays in determining the mechanical strength of intestinal anastomosis and surgeons should take an individualized approach to pick the optimal staple height, staple row number, and configuration according to the intestinal tissue characteristics encountered. In the future, experiments should be designed bearing in mind that the ultimate goal is not to fashion an airtight anastomosis, but to reduce postoperative leak rate. This requires careful consideration of not only the mechanical strength, but also interaction between the surgical material and the intestinal perfusion, tissue tension, and intestinal microbiome [10].
http://dx.doi.org/10.1016/j.soard.2017.10.016 1550-7289/r 2017 American Society for Metabolic and Bariatric Surgery. All rights reserved.
56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100 101 102 103 104 105 106 107 108 109 110
Y-Y Juo and E. Dutson / Surgery for Obesity and Related Diseases ] (2017) 00–00
2
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Yen-Yi Juo, M.D., M.P.H. Erik Dutson, M.D., F.A.C.S. Center for Advanced Surgical and Interventional Technology (CASIT), Los Angeles, California Department of Surgery, University of California Los Angeles, Los Angeles, California References [1] Kimura M. Improving the side-to-side stapled anastomosis: comparison of staplers for robust crotch formation In press. Surg Obes Relat Dis 2018. In press. [2] Chlumsky V. Experimentelle untersuchungen ueber die verschiedenen methode der darmvereinigung [in German]. Bruns Beitr Klin Chir 1899;25:539–600. [3] Hendriks T, Mastboom WJ. Healing of experimental intestinal anastomoses. Parameters for repair. Dis Colon Rectum 1990;33 (10):891–901.
[4] Paral J, Lochman P, Blazej S, Pavlik M. Glued versus stapled anastomosis of the colon: an experimental study to determine comparative resistance to intraluminal pressure. Asian J Surg 2014;37(3):154–61. [5] Burkitt DS, Donovan IA. Intraluminal pressure adjacent to left colonic anastomoses. Br J Surg 1990;77(11):1288–90. (1990). [6] Wise L, McAlister W, Stein T, Schuck P. Studies on the healing of anastomoses of small and large intestines. Surg Gynecol Obstet 1975;141(2):190–4. [7] Hesp FL, Hendriks T, Lubbers EJ, deBoer HH. Wound healing in the intestinal wall. A comparison between experimental ileal and colonic anastomoses. Dis Colon Rectum 1984;27(2):99–104. [8] Halsted WS. Classic articles in colonic and rectal surgery. William Stewart Halsted 1852-1922. Circular suture of the intestine–an experimental study. Dis Colon Rectum 1984;27(9):838–41. [9] Waninger J, Kauffmann GW, Shah IA, Farthmann EH. Influence of the distance between interrupted sutures and the tension of sutures on the healing of experimental colonic anastomoses. Am J Surg 1992;163(3):319–23. [10] Shogan BD, Carlisle EM, Alverdy JC, Umanskiy K. Do we really know why colorectal anastomoses leak? J Gastrointest Surg 2013;17 (9):1698–707.
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