Sutureless small bowel anastomoses: experimental study in pigs.

OBJECTIVE: To evaluate a new technique for experimental anastomosis with fibrin glue, and to compare the results with those of stapled and one-layer sutured anastomosis. DESIGN: Open laboratory study. SETTING: Teaching hospital, Sweden. ANIMALS: Ten Swedish domestic pigs. INTERVENTIONS: Each pig had three anastomoses made in the small bowel, one by each technique. The pigs were killed on the 4th postoperative day. MAIN OUTCOME MEASURES: Blood flow, collagen concentration, anastomotic index, breaking strength, thickness of bowel wall, and histological appearance. RESULTS: Two pigs died postoperatively, leaving 8 for analysis. The blood flow at each anastomotic site studied by the microsphere technique was similar irrespective of the type of anastomosis (p = 0.3), as was anastomotic collagen concentration (p = 0.09). The anastomotic index, however, was significantly higher in the stapled than in the glued or sutured ones (p = 0.03). The glued anastomosis was the weakest, being only one fifth the strength of the stapled and one third the strength of the sutured anastomosis. There was no sign of rejection of the glue (of human origin) on histological examination. Glued and stapled anastomoses showed signs of mild inflammation, which did not reach the intensity of that around the sutured anastomoses. CONCLUSION: It is possible to make a sutureless anastomosis that does not leak with a modified stapler using fibrin glue instead of staples, but the anastomosis has considerably lower breaking strength than either stapled or sutured anastomoses.

Anastomotic diameter of circular stapled oesophagojejunal anastomoses and its implication for weight development. A clinical and experimental study.

OBJECTIVE: To investigate the increase in diameter of the oesophagojejunal anastomosis after total gastrectomy with a circular stapler, and to assess experimentally the influence of oesophageal diameter on weight. DESIGN: Open prospective clinical and experimental studies. SETTING: University department of surgery, Sweden. SUBJECTS AND MATERIAL: 36 Consecutive patients who underwent total gastrectomy, and 13 domestic pigs. INTERVENTIONS: Clinical study: the end to side oesophagojejunal anastomoses were made with EEA staplers size 25 or 28, and the increase in diameter over a 12 month period was studied by by fibreoptic endoscopy. Experimental study: Each pig had 0.5 cm of the distal oesophagus resected; in 7 the oesophagus was anastomosed with one layer of continuous 3/0 polyglycolic acid, and in 6 an ILS21 stapler was used. Animals were weighed and killed at 4 1/2 months, and the width of the oesophagus at and below the anastomosis was measured. MAIN OUTCOME MEASURES: Clinical study: width of the oesophagus at 12 months. Experimental study: correlation between weight and oesophageal width at time of death. RESULTS: Clinical study: The median increase in size after 12 months with the size 25 cartridge was 8.45 mm (range 6.5-22), and for the size 28 cartridge 12 mm (2.3-30.2). The larger cartridge gave a significantly larger anastomosis (p = 0.007), but the comparative increases were similar. Experimental study: There was a significant correlation between increase in weight and anastomotic width in the 10 pigs that completed the study (r = 0.86, p < 0.001). CONCLUSION: A stapled oesophagojejunal anastomosis has the ability to dilate as necessary, and this ability is not prejudiced by the presence of the staples.

Healing of colonic anastomoses: comparative experimental study of glued, manually sutured, and stapled anastomoses.

In 10 pigs a nonsutured, glued colonic anastomosis was constructed with a modified stapling device without staples and compared with an EEA-stapled anastomosis and a one-layer-sutured anastomosis concerning radiologic appearance, breaking strength, circulation, and collagen concentration. 141Ce-labeled microspheres were used for measurements of the anastomotic blood flow before the animals were sacrificed on the 4th postoperative day. The breaking strength was recorded and an anastomotic index calculated. No leakage was found. The anastomotic width did not differ between the groups, but the interindividual variation was more prominent in the sutured group. The handsewn and stapled anastomoses were stronger than the glued anastomosis (P = 0.0009 and 0.0054, respectively). There was an increase in the anastomotic circulation in all of the anastomoses, but no differences were seen between groups. The collagen concentration was independent of the technique used.

Intersecting staple lines and blood flow in oesophagojejunal anastomoses.

Total gastrectomy and oesophagojejunostomy with linear stapling devices were performed on 22 pigs to evaluate whether intersecting staple lines reduce the blood flow with an increased risk of anastomotic leakage. The blood flow at intersecting staple lines and single row staple lines of the anastomosis was studied with the reference organ method 24 h after the first operation. The mean blood flow in intersecting staple lines was 0.305 ml min-1 g-1 tissue and 0.307 ml min-1 g-1 tissue for single row staple lines. The confidence interval for the reduction in blood flow for intersecting staple lines compared with non-crossing staple lines was from -16 to +17 per cent. In one animal the reduction in blood flow was 37 per cent; in all other animals there was no reduction in blood flow or a reduction less than 25 per cent. An equivalence test shows that if a reduction in blood flow exists it is most likely to be less than 30 per cent (P less than 0.001). Our data confirm that intersecting staple lines in oesophagojejunal anastomoses do not reduce mean anastomotic blood flow to a dangerous level.

Delay in diagnosis of gastric cancer: a prospective study evaluating doctors'- and patients' delay and its influence on five year survival.

Despite new diagnostic techniques, gastric cancer in its less aggressive stages is not diagnosed more frequently and the prognosis still remains poor. Thus, a possibility exists that there is still a delay in diagnosis. This study was therefore designed to investigate whether a delay in diagnosis of gastric cancer exists, to identify factors leading to diagnostic delay, and to settle whether the prognosis is dependent on a delay. Fifty consecutive patients with gastric carcinoma were interviewed and the diagnostic attempts prior to diagnosis were checked. It was found that thirteen patients (26%) had patients' delay (more than three months of symptoms before consulting a doctor) whereas twelve (24%) had doctors' delay (more than three months of investigations before correct diagnosis was made). Doctors' delay was more common in female (7/13) than in male patients (5/37) (p less than 0.05) and in linitis plastica (5/8) than in other types of gastric cancers (7/42), (p less than 0.05). Seven of the twelve patients with doctors' delay had been on regular check ups before diagnosis. A negative barium meal was the most common reason for doctors' delay. Survival was influenced only by tumour stage (r = -0.71, p less than 0.05). Our conclusion is that both patients' and doctors' delay are considerable in the diagnosis of gastric cancer; it is therefore suggested that improvement in five-year survival requires improved presymptomatic diagnostic methods and screening programmes.

Prediction of survival in gastric carcinoma and a new histopathologic approach.

During six years 188 consecutive patients with gastric carcinoma admitted to the Department of Surgery, University Hospital, Lund, were followed up to evaluate clinical as well as histopathologic factors which might be important to predict postoperative survival. We also introduced a new histopathologic scoring system based on nine different parameters. Radicality estimated by the surgeon, resection line margin, score at histologic grading and TNM were factors which in a multivariate analysis strongly correlated to survival.

Ischaemic pancolitis: a serious complication of chemotherapy in a previously irradiated patient. Case report.

A 47-year-old man underwent orchidectomy and radiotherapy for seminoma. Six years later he received chemotherapy for oesophageal carcinoma. After the second cycle gangrenous pancolitis developed, necessitating total colectomy. The pancolitis presumably resulted from the earlier irradiation and current chemotherapy. This complication has particularly grave implications in oesophageal malignancy, since colon is often used as oesophageal substitute.