Summary Background Two commonly performed surgical interventions are available for severe (grade II–IV) haemorrhoids; traditional excisional surgery and stapled haemorrhoidopexy. Uncertainty exists ...as to which is most effective. The eTHoS trial was designed to establish the clinical effectiveness and cost-effectiveness of stapled haemorrhoidopexy compared with traditional excisional surgery. Methods The eTHoS trial was a large, open-label, multicentre, parallel-group, pragmatic randomised controlled trial done in adult participants (aged 18 years or older) referred to hospital for surgical treatment for grade II–IV haemorrhoids. Participants were randomly assigned (1:1) to receive either traditional excisional surgery or stapled haemorrhoidopexy. Randomisation was minimised according to baseline EuroQol 5 dimensions 3 level score (EQ-5D-3L), haemorrhoid grade, sex, and centre with an automated system to stapled haemorrhoidopexy or traditional excisional surgery. The primary outcome was area under the quality of life curve (AUC) measured with the EQ-5D-3L descriptive system over 24 months, assessed according to the randomised groups. The primary outcome measure was analysed using linear regression with adjustment for the minimisation variables. This trial is registered with the ISRCTN registry, number ISRCTN80061723. Findings Between Jan 13, 2011, and Aug 1, 2014, 777 patients were randomised (389 to receive stapled haemorrhoidopexy and 388 to receive traditional excisional surgery). Stapled haemorrhoidopexy was less painful than traditional excisional surgery in the short term and surgical complication rates were similar between groups. The EQ-5D-3L AUC score was higher in the traditional excisional surgery group than the stapled haemorrhoidopexy group over 24 months; mean difference −0·073 (95% CI −0·140 to −0·006; p=0·0342). EQ-5D-3L was higher for stapled haemorrhoidopexy in the first 6 weeks after surgery, the traditional excisional surgery group had significantly better quality of life scores than the stapled haemorrhoidopexy group. 24 (7%) of 338 participants who received stapled haemorrhoidopexy and 33 (9%) of 352 participants who received traditional excisional surgery had serious adverse events. Interpretation As part of a tailored management plan for haemorrhoids, traditional excisional surgery should be considered over stapled haemorrhoidopexy as the surgical treatment of choice. Funding National Institute for Health Research Health Technology Assessment programme.
Aim
Natural orifice specimen extraction (NOSE) in left‐sided colorectal surgery requires application of the circular stapler anvil to the proximal bowel without exteriorization through an additional ...abdominal incision. We describe an intracorporeal method to secure the stapler anvil, termed the intracorporeal antimesenteric ancillary trocar (IAAT) technique.
Method
The ancillary trocar is attached to the stapler anvil before introduction into the abdominal cavity through the anal or vaginal orifice. The colon is incised before the trocar spike is brought out through the antimesenteric surface 3–4 cm within the cut edge. A linear stapler is used to seal the bowel end. The ancillary trocar is detached and retrieved via the NOSE conduit. Following the NOSE procedure, a side‐to‐end colorectal anastomosis is performed with the transanal circular stapler.
Results
Ten consecutive patients underwent elective left‐sided colorectal resection with IAAT for NOSE (seven transanal, three transvaginal) from January to June 2023. Median age and body mass index were 66 (range 47–74) years and 24.3 (range 17.9–30.8) kg/m2 respectively. Two (20%) patients underwent sigmoid colectomy for sigmoid volvulus while eight (80%) underwent anterior resection for colorectal cancer. Median operating time, operative blood loss and postoperative length of hospital stay were 170 (range 140–240) min, 20 (range 10–40) mL and 1 (range 1–3) day respectively. There were no postoperative complications, readmissions or reoperations. Median follow‐up duration was 3 (range 1–6) months.
Conclusion
The IAAT double‐stapling side‐to‐end anastomotic technique is safe and feasible for patients undergoing left‐sided colorectal resection with NOSE, resulting in good outcomes.
Background
Laparoscopic rectal surgery involving rectal transection and anastomosis with stapling devices is technically difficult. The aim of this study was to evaluate the risk factors for ...anastomotic leakage (AL) after laparoscopic low anterior resection (LAR) with double-stapling technique (DST) anastomosis.
Methods
This was a retrospective single-institution study of 154 rectal cancer patients who underwent laparoscopic LAR with DST anastomosis between June 2005 and August 2013. Patient-, tumor-, and surgery-related variables were examined by univariate and multivariate analyses. The outcome of interest was clinical AL.
Results
The overall AL rate was 12.3 % (19/154). In univariate analysis, tumor size (
P
= 0.001), operative time (
P
= 0.049), intraoperative bleeding (
P
= 0.037), lateral lymph node dissection (
P
= 0.009), multiple firings of the linear stapler (
P
= 0.041), and precompression before stapler firings (
P
= 0.008) were significantly associated with AL. Multivariate analysis identified tumor size (odds ratio OR 4.01; 95 % confidence interval CI 1.25–12.89;
P
= 0.02) and precompression before stapler firings (OR 4.58; CI 1.22–17.20;
P
= 0.024) as independent risk factors for AL. In particular, precompression before stapler firing tended to reduce the AL occurring in early postoperative period.
Conclusions
Using appropriate techniques, laparoscopic LAR with DST anastomosis can be performed safely without increasing the risk of AL. Important risk factors for AL were tumor size and precompression before stapler firings.
Background
The objective of this study was to assess whether the use of staple line reinforcement (SLR) reduces staple line complications (SLC). Mechanical staple lines are essential for ...gastrointestinal surgery such as bariatric surgery. However, SLC, such as bleeding and leakage, still occur. The purposes of this study were to provide quantitative evidence on the relative efficacy of gastric SLR and to compare the rates of effectiveness of three commonly used methods.
Methods
A search of the medical literature in English language journals identified studies from Jan 1, 2000, to Dec 31, 2013, using the following reinforcement types: (1) no reinforcement, (2) oversewing, (3) a biocompatible glycolide copolymer, and (4) bovine pericardium after gastric bypasses and sleeve gastrectomies. Types of reinforcement were compared using a random-effects model.
Results
This meta-analysis reviewed 16,967 articles, extracting data on 56,309 patients concerning leak and 41,864 patients concerning bleeding. Over 40 % of patients had no reinforcement, resulting in the highest leak rate (2.75 %) and bleed rate (3.45 %). Overall, reinforcing with bovine pericardium had the lowest leak (1.28 %) and bleed (1.23 %) rates. Suture oversewing was better than no reinforcement but not as effective as bovine pericardium for leak (2.45 %) and bleed (2.69 %) rates. Buttressing with a biocompatible glycolide copolymer resulted in the second highest leak rate (2.61 %) and a bleed rate of 2.48 % but had significantly lower bleed rates than no reinforcement.
Conclusions
SLR provided superior results for patients compared to no reinforcement for reducing SLC. Buttressing with bovine pericardium resulted in the most favorable outcomes. The effectiveness of different methods used to reinforce the staple line in gastric surgery does not appear to be equal.
Available techniques for IPAA in ulcerative colitis include handsewn, double-stapled, and single-stapled anastomoses. There are controversies, indications, and different outcomes regarding these ...techniques.
To describe technical details, indications, and outcomes of 3 specific types of anastomoses in restorative proctocolectomy.
Systematic literature review for articles in the PubMed database according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses criteria.
Studies describing outcomes of the 3 different types of anastomoses, during pouch surgery, in patients undergoing restorative proctocolectomy for ulcerative colitis.
IPAA technique.
Postoperative outcomes (anastomotic leaks, overall complication rates, and pouch function).
Twenty-one studies were initially included: 6 studies exclusively on single-stapled IPAA, 2 exclusively on double-stapled IPAA, 6 studies comparing single-stapled to double-stapled techniques, 6 comparing double-stapled to handsewn IPAA, and 1 comprising single-stapled to handsewn IPAA. Thirty-seven studies were added according to authors' discretion as complementary evidence. Between 1990 and 2015, most studies were related to double-stapled IPAA, either only analyzing the results of this technique or comparing it with the handsewn technique. Studies published after 2015 were mostly related to transanal approaches to proctectomy for IPAA, in which a single-stapled anastomosis was introduced instead of the double-stapled anastomosis, with some studies comparing both techniques.
A low number of studies with handsewn IPAA technique and a large number of studies added at authors' discretion were the limitations of this strudy.
Handsewn IPAA should be considered if a mucosectomy is performed for dysplasia or cancer in the low rectum or, possibly, for re-do surgery. Double-stapled IPAA has been more widely adopted for its simplicity and for the advantage of preserving the anal transition zone, having lower complications, and having adequate pouch function. The single-stapled IPAA offers a more natural design, is feasible, and is associated with reasonable outcomes compared to double-stapled anastomosis. See video from symposium.
Linear and branched hydrocarbon chains may be appended or crosslinked at selected cysteine positions in unprotected peptides and proteins. The method involves nucleophilic substitution assisted by a ...simple zinc salt under mild conditions and can be applied at late stages of synthesis. More information can be found in the Full Paper by A. D. de Araujo, H. T. Nguyen, D. P. Fairlie.
Although smaller circular staplers are easier to insert and less likely to involve the vagina and levator ani muscles when performing double stapling technique anastomosis, surgeons often consider ...that larger circular staplers would be safer in reducing the risk of postoperative anastomotic strictures.
This study aimed to investigate the safety of using 25-mm circular staplers compared with 28/29-mm staplers in the double stapling technique anastomosis regarding the development of anastomotic strictures and other complications.
This is a retrospective observational study.
This study was conducted at a single comprehensive cancer center.
Consecutive patients undergoing curative colorectal resection with double stapling technique anastomosis for stage I to III sigmoid colon and rectal cancer between 2013 and 2016 were included.
The incidence of anastomotic complications (strictures, leakage, and bleeding) was compared between the 25- and 28/29-mm circular staplers. Predictors for anastomotic strictures were investigated with multivariable logistic regression.
Small (25-mm) staplers were used in 186 (22.8%) of 815 eligible patients. The 25-mm staplers were associated with use in female patients, splenic flexure take down, high tie of the inferior mesenteric artery, and low anastomosis. Overall anastomotic complications (11.8% vs 13.7%, p = 0.51), strictures (5.9% vs 3.3%, p = 0.11), leakage (2.7% vs 3.8%, p = 0.47), and bleeding (4.8% vs 7.6%, p = 0.19) were not different between the 25- and 28/29-mm staplers. From multivariable logistic regression, independent predictors of anastomotic strictures included diverting ostomy and anastomotic leakage, but not small circular stapler use. Most of the 32 anastomotic strictures were successfully treated without surgical intervention (finger dilation, n = 25; endoscopic intervention, n = 5).
This was a single-center retrospective study.
Use of 25-mm circular staplers for double stapling technique anastomosis is safe and does not increase the risk of anastomotic strictures and other anastomotic complications in comparison with larger staplers. See Video Abstract at http://links.lww.com/DCR/B576.
ANTECEDENTES:Aunque las engrapadoras circulares más pequeñas son más fáciles de insertar y menos probable que involucren a la vagina y los músculos elevadores del ano, cuando se realiza una anastomosis con técnica de doble engrapado, frecuentemente los cirujanos consideran que las engrapadoras circulares más grandes, serían más seguras para disminuir los riesgos de estenosis anastomóticas postoperatorias.OBJETIVO:El estudio se dirigió para investigar la seguridad en el uso de engrapadoras circulares de 25 mm, en comparación con engrapadoras de 28/29 mm, en anastomosis con técnica de doble engrapado, en relación al desarrollo de estenosis anastomóticas y otras complicaciones.DISEÑO:Estudio observacional retrospectivo.AJUSTE:Centro oncológico integral único.PACIENTES:Se incluyeron pacientes consecutivos sometidos a resección colorrectal curativa, con anastomosis y técnica de doble engrapado, para cáncer de recto y colon sigmoide en estadios I-III entre 2013 y 2016.PRINCIPALES MEDIDAS DE RESULTADO:Se compararon las incidencias de complicaciones anastomóticas (estenosis, fugas y sangrados) entre las engrapadoras circulares de 25 y 28/29 mm. Los predictores para estenosis anastomóticas se investigaron con regresión logística multivariable.RESULTADOS:Entre un total de 815 pacientes elegibles, se utilizaron engrapadoras de 25 mm en 186 (22,8%). Las engrapadoras de 25 mm se asociaron con el uso en pacientes femeninas, descenso del ángulo esplénico, ligadura alta de arteria mesentérica inferior y anastomosis baja. Complicaciones anastomóticas generales (11,8% vs. 13,7%, p = 0,51), estenosis (5,9% vs. 3,3%, p = 0,11), fugas (2,7% vs. 3,8%, p = 0,47) y sangrado (4,8% vs. 7,6%, p = 0,19). No hubo diferencia entre las engrapadoras de 25 y 28/29 mm. En la regresión logística multivariable, predictores independientes de estenosis anastomóticas incluyeron ostomía derivativa y fuga anastomótica, pero no incluyeron el uso de engrapadoras circulares pequeñas. La mayoría de las 32 estenosis anastomóticas se trataron con éxito sin intervención quirúrgica (dilatación del dedo, n = 25; intervención endoscópica, n = 5).LIMITACIONES:Fue un estudio retrospectivo de un solo centro.CONCLUSIONES:El uso de engrapadoras circulares de 25 mm para la anastomosis con técnica de doble engrapado, es seguro y no aumenta el riesgo de estenosis anastomóticas y de otras complicaciones anastomóticas, cuando son comparadas con engrapadoras más grandes. Consulte Video Resumen en http://links.lww.com/DCR/B576. (Traducción-Dr. Fidel Ruiz-Healy).
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