Use of a linear stapling device to construct an inverted, triangulated, end-to-end anastomosis of the equine jejunum

An inverting, triangulated, stapled, end-to-end anastomosis technique was evaluated in the jejunum of four horses. None of the horses showed evidence of gastrointestinal disturbance after surgery; however, stricture and adhesion formation were pronounced in three animals examined 10 days, one month, and two months after surgery. The animal examined four months after surgery had no adhesions present at the anastomosis, and only mild narrowing of the intestinal lumen. Histologic examination of the anastomoses showed lack of a normal mucosal lining in some examined sections up to two months postsurgery. While mucosal and serosal continuity were eventually reestablished, this was not true of the muscularis, the ends of which were joined by fibrous tissue. Gaps in the staple line and malalignment of staples were present in the animal examined four months after surgery, indicating migration and/or loss of the staples from the anastomosis. The inverting, triangulated staple technique had little or no apparent advantages over previously reported results with similar everting techniques. The severity of adhesions observed with the inverting technique suggests that the adhesions observed with the similar everting technique may not be due solely to the everted nature of the anastomosis.     

Comparison of three suture techniques for anastomosis of the small intestine in the horse

Seven horses were used to compare the Gambee, the crushing, and a 2-layer inverting suture pattern composed of a simple continuous layer in the mucosa oversewn with a continuous Lembert pattern in the seromuscular layer. Horses were evaluated at 30 days for adhesion formation, lumen diameter, and quality of healing at the anastomotic sites. One horse was euthanatized 9 days after surgery after 24 hours of ileus and colic; necropsy revealed septic peritonitis and widespread adhesions. One horse had no adhesions. The remaining horses had adhesions associated with 50% of the Gambee and 50% of the crushing anastomoses. There were no adhesions related to the 2-layer inverting techniques in these 6 horses. There was no significant difference in percentage reduction of lumen diameters between the 3 techniques, and there was no evidence of chronic obstruction resulting from any of the anastomotic techniques. Histologically, the inflammatory response and fibrosis were minimal in the single layer patterns, but there was increased fibrosis and suture tract inflammation in the 2-layer inverting technique.     

Comparison of staple and suture techniques for end-to-end anastomosis of the small colon in horses

Two techniques for end-to-end anastomosis of the small colon were evaluated in each of 6 horses. A simple interrupted suture pattern that excluded the mucosa and was oversewn with an inverting suture was compared with a triangulated double-row pattern of stainless steel staples. Anastomotic sites were evaluated at 2 weeks, 2 months, and 6 months for extent of abdominal adhesions, lumen diameter at anastomotic sites, bursting pressures, and healing response. Clinical postoperative complications were not associated with either technique. At postmortem examination, there was extensive adhesion formation from the mesocolon to the stapled anastomotic site. The suture technique resulted in greater luminal diameters (P less than or equal to 0.05), with good apposition of the tissue layers. Staples were missing as early as 2 weeks after surgery, and their loss was associated with separation of the muscularis at later evaluation periods. Regardless of technique, all but one anastomotic segment burst away from the anastomotic site along the mesenteric taenial band. For the 12 anastomoses performed in normal horses, the suturing technique was better than the stapling technique because of significantly larger lumen diameters, better anastomotic healing, and minimal intra-abdominal adhesion formation.     

ANGIOGRAPHIC EVALUATION OF BOVINE INTESTINAL HEALING FOLLOWING INVERTING, EVERTING, AND END-ON ANASTOMOSIS

Angiography during intestinal healing following single-layer inverting, everting, and end-on anastomoses was carried out in 18 calves. Six anastomoses using the same technique were performed in each animal. Six anastomoses, along with one main artery supplying the anastomotic site, were removed from each calf on the first, third, seventh, 15th, 21st, and 28th postoperative days. Angiograms of tubular intestinal segments were obtained after intraarterial infusion of 2–3 ml of sodium iothalamate and lead suspension. Lead-infused intestinal segments were cut open through the mesenteric border to obtain additional angiograms of flat bowel. Angiograms in the early stage of intestinal healing revealed hypervascularity at the cut edges and an avascular zone at the suture line. These changes were more intense with the everting than with the inverting and end-on techniques. The sprouting of vessels at the anastomotic junction and their crossing over started on third postoperative day but were clearly visualized only after the seventh postoperative day. By 15–21 days after operation, anastomotic sites were almost completely revascularized for all techniques. Everted anastomosis elicited more intense vascular response and resulted in earlier vascularization than the other two techniques. No appreciable differences in the pattern of revascularization were observed with inverting and end-on anastomoses. Lead suspension proved to be better than sodium iothalamate for such studies. Angiograms of the open bowel provided more realistic and confirmatory information regarding the sequence of vascular-changes at the suture line.     

Intestinal surgery in small animals: historical foundations,current thinking,and future horizons

Intestinal wounds require precise closure after intestinal biopsy, enterotomy, or enterectomy in small animals. Preexisting factors such as intra‐abdominal sepsis and hypoalbuminemia as well as poor surgical technique increase the risk of intestinal dehiscence, with considerable negative impact on patient morbidity and mortality. Live dog studies have demonstrated the dangers of mucosal eversion especially in the septic abdomen. Approximating patterns preserve luminal diameter, heal optimally, and have equal bursting strength compared with inverting patterns after 24 hours. Simple interrupted and simple continuous suture patterns and disposable skin staples are established alternatives for manual wound closure. Knotless quilled suture currently used in laparoscopic gastropexy techniques shows bursting strength equal to monofilament sutures in dog cadaveric intestine. Dehiscence rates with hand sewn vs titanium automated stapling anastomosis are similar in uncomplicated cases; however, auto stapling devices may be the preferred method of anastomosis when preexisting abdominal sepsis is present and when patient size allows it. Regardless of the technique, current standard of care involves leak testing and omental wrapping, followed by early postoperative feeding. The past decade has ushered in an exciting new era of laparoscopic assisted techniques that have the potential to reduce postoperative pain and patient morbidity. An understanding of these applications will establish the future of minimally invasive small animal intestinal surgery for veterinary specialists. In summary, surgeons have a variety of methods at their disposal for optimal clinical outcome in small animal intestinal surgery.     

In vitro evaluation of a closed-bowel technique for one-layer hand-sewn inverting end-to-end jejunojejunosotomy in the horse

OBJECTIVE: To report a technique for closed-bowel 1-layer inverting end-to-end jejunojejunal anastomosis in horses. STUDY DESIGN: Experimental study. SAMPLE POPULATION: Fresh cadaveric jejunal segments from 12 horses. METHODS: For each bowel segment a 1-layer closed and a 2-layer inverting end-to-end jejunojejunosotomy was created. Anastomosis construction time and anastomotic bursting pressure were measured and compared. RESULTS: Closed-bowel anastomosis was significantly faster to create than a 2-layer technique. Luminal narrowing (<30%) was similar with both techniques and comparable with other inverting techniques. Bursting pressure was significantly higher for the 2-layer technique, although all anastomoses resisted pressures higher than those reported for other jejunojejunal anastomosis techniques. CONCLUSIONS: A 1-layer hand-sewn, closed, inverting jejunojejunosotomy using a modified Doyen clamp was easy and faster to perform, and resulted in functional characteristics similar to, a 2-layer hand-sewn inverting technique. CLINICAL RELEVANCE: A closed, 1-layer inverting technique could be considered for equine jejunal anastomosis but requires in vivo evaluation before recommendation for clinical use.     

Experimental Large Colon Resection at the Cecocolic Ligament in the Horse

Ten normal horses had approximately 95% of the length of the large colon resected with a side-to-side anastomosis between right ventral and right dorsal colon performed with surgical stapling equipment. Four horses died shortly after surgery of colitis (1 horse) or failure of the TA 90 transection staple line (3 horses). Another horse died 4 months after surgery from disseminated streptococcal infection but had recovered well from the colon resection. Five horses survived long term (18 months) with no clinical evidence of adverse effects of the resection. Surviving horses had weight loss and soft fecal consistency for 3 to 12 weeks after surgery but returned to preoperative values within 12 months. At a second surgery 1 year later (5 horses) or at necropsy 4 months later (1 horse), fibrous omental adhesions were present over the transection staple line in four horses and over the anastomotic staple line in two horses. Omental adhesions to the everted staple line were moderate but not associated with any clinical sequellae. An incisional hernia was present in one horse. The anastomotic stomata measured between 8 and 9 cm, which was 60% of the size of the original surgically created stomata. Failure of the transection staple line occurred in the first three of five horses in which the procedure was attempted due to improper configuration of the staples or crushing of the tissue between the staples. Experience corrected this complication.     

Cystotomy Closure: A Comparison of the Strength of Appositional and Inverting Suture Patterns

Dorsal cystotomies were performed in 60 healthy dogs. Twenty bladders were closed with a single-layer interrupted appositional suture pattern, 20 with a two-layer interrupted appositional suture pattern, and 20 with a two-layer continuous inverting suture pattern. Four dogs from each group were euthanatized at hours 0, 3, 12, 18, and 24. Mechanical strength of the cystotomy closures was evaluated by calculating the circular bursting wall tension. The single-layer interrupted appositional suture pattern was as strong as both two-layer suture patterns at hours 3, 12, 18, and 24. The two-layer interrupted appositional suture pattern was as strong as the two-layer continuous inverting suture pattern during the first 24 hours.     

Evaluation of three techniques for end-to end anastomosis of the small colon in horses

In an attempt to determine the best method for surgical removal of devitalized small colon lesions, 12 horses underwent a double small colon resection and end-to-end anastomosis. In 4 horses (study 1), an appositional single-layer (APP-1) suture pattern was compared with an inverting 2-layer (INV-2) suture pattern. In 8 horses (study 2), an appositional 2-layer (APP-2) suture pattern was compared with the INV-2 suture technique. Polydioxanone suture (size 1-0), was used. Horses were evaluated at necropsy 3, 10, 14, 28, or 56 days after surgery. Postoperative complications (peritonitis, impaction, or excessive adhesions) were encountered in 100, 42, and 13% of the APP-1, INV-2, and APP-2 anastomoses, respectively. Postmortem evaluation of the small colon revealed dehiscence of the anastomotic site, diffuse peritonitis, and adhesion formation in 3 of the 4 horses in which the resection line was closed with the APP-1 pattern. With the INV-2 and APP-2 techniques, more intestinal inversion was present in the nontaenial than in the taenial portion of the small colon. More postoperative impactions were found with the INV-2 (n = 5) anastomoses than with the APP-2 (n = 1) technique; this appeared to be the result of excessive tissue inversion. There was no difference in lumen diameter between the INV-2 and the APP-2 techniques (P greater than or equal to 0.05).(ABSTRACT TRUNCATED AT 250 WORDS)     

In vitro evaluation of an inverted end-to-end equine jejunojejunal anastomosis using skin staples

OBJECTIVE: To compare functional indices of end-to-end (EEA) jejunojejunal anastomosis using skin staples in horses with a 2-layer inverting hand-sewn technique. STUDY DESIGN: Experimental study. SAMPLE POPULATION: Jejunal segments from 8 fresh equine cadavers. METHODS: For each bowel segment, 2 EEA anastomoses were created: one 2-layer hand-sewn and one 1-layer using skin staples. Time for anastomosis creation was recorded and compared. Lumen diameter of each anastomosis was measured on digital radiographs after intraluminal instillation of contrast medium and inflation of the jejunal segments to 14 mm Hg. Anastomotic indices (a compensated measure of stoma diameter) and bursting pressure were determined. RESULTS: EEA jejunal anastomosis using skin staples was significantly faster than use of a 2-layer hand-sewn technique. Anastomotic index, a measure of lumen size, was significantly larger with the skin-staple technique; however, the bursting pressure of stapled anastomoses was significantly less than for the hand-sewn technique, but the values were well above those reported for other anastomotic techniques. CONCLUSIONS: An anastomotic technique using skin staples was easy to learn and perform, effective and faster, and mechanically comparable with a hand-sewn 2-layer technique. CLINICAL RELEVANCE: The staple technique could be beneficial in equine gastrointestinal surgery by reducing anastomosis time, although further in vivo studies are needed to establish clinical safety.     

Pullout strength for three suture patterns used for canine tracheal anastomosis

OBJECTIVE: To compare pullout strength of 3 suture patterns used for canine tracheal anastomosis. STUDY DESIGN: Experimental study. SAMPLE POPULATION: Cadaveric canine tracheae (n = 20). METHOD: Tracheal segments were anastomosed with 1 of 3 suture patterns: simple continuous, simple interrupted, and simple interrupted reinforced with horizontal mattress, each encircling annular cartilage rings adjacent to the transection site. Horizontal mattress sutures encircled the annular rings proximal and distal to the rings closest to the anastomosis. Each construct was distracted (0.5 mm/s) in a materials testing machine to failure. Load-displacement curves were generated and failure load (pullout strength) determined and mode of failure recorded. RESULTS: Tracheal anastomosis with a simple interrupted pattern was significantly weaker (mean+/-SD pullout strength, 102.55+/-30.14 N) than simple continuous (135.53+/-15.47 N) or simple interrupted plus horizontal mattress (132.39+/-21.46 N), which were not different from each other. Mode of failure was consistently by suture tear out. CONCLUSIONS: Both simple continuous and simple interrupted reinforced with horizontal mattress suture patterns have significant biomechanical advantage over a simple interrupted pattern alone in canine cadaveric tracheal anastomosis. The simple continuous pattern had the least variability in pullout strength. CLINICAL RELEVANCE: A simple continuous technique should be considered when selecting a tension-relieving pattern for canine tracheal anastomosis. It offers the same biomechanical advantage as a simple interrupted pattern reinforced with a horizontal mattress pattern and its strength appears to be reliably maintained when tested in canine cadaver tracheae.     

Comparison of three closure methods and two absorbable suture materials for closure of jejunal enterotomy incisions in healthy dogs

The macroscopic and histological appearance of jejunal antimesenteric incisions approximated with two different absorbable suture materials (monofilament versus multifilament) and three closure techniques (appositional single layer, crushing single layer, and double layer) were compared in healthy dogs at 14 or 28 days, postoperatively. No significant differences between the two suture materials were observed for most of the macroscopic or histological variables. However, the monofilament suture material caused significantly more fibrous tissue reaction in the muscular layer of the jejunum than did the multifilament suture material. Of the three enterotomy closure techniques used in this study, the appositional single-layer method proved to be the best. The double-layer closure method caused a significant decrease in the incisional circumference, the relative circumference, and volume of the jejunum, and a significant increase in jejunal wall thickness. Our findings suggest that canine jejunal enterotomy incisions can be closed using an appositional suture pattern with relatively rapidly absorbable monofilament suture material. The use of double-layer suture patterns for closure of jejunal enterotomy incisions should be avoided because the size of the intestinal lumen may be reduced.     

Surgery: Comparison of three closure methods and two absorbable suture materials for closure of jejunal enterotomy incisions in healthy dogs

Summary

The macroscopic and histological appearance of jejunal antimesenteric incisions approximated with two different absorbable suture materials (monofilament versus multifilament) and three closure techniques (appositional single layer, crushing single layer, and double layer) were compared in healthy dogs at 14 or 28 days, postoperatively. No significant differences between the two suture materials were observed for most of the macroscopic or histological variables. However, the monofilament suture material caused significantly more fibrous tissue reaction in the muscular layer of the jejunum than did the multifilament suture material. Of the three enterotomy closure techniques used in this study, the appositional single‐layer method proved to be the best. The double‐layer closure method caused a significant decrease in the incisional circumference, the relative circumference, and volume of the jejunum, and a significant increase in jejunal wall thickness. Our findings suggest that canine jejunal enterotomy incisions can be closed using an appositional suture pattern with relatively rapidly absorbable monofilament suture material. The use of double‐layer suture patterns for closure of jejunal enterotomy incisions should be avoided because the size of the intestinal lumen may be reduced.     

Jejunal Intussusception: A Complication of Functional End-to-End Stapled Anastomoses in Two Ponies

Jejunojejunal intussusception occurred after jejunal resection and stapled functional end-to-end anastomosis in two pony mares. In both mares, the lead point of the intussusception was the stapled functional end-to-end (FEE) anastomosis. The stapled free ends of jejunum were oversewn with an inverting suture pattern. A possible explanation for development of the intussusception was the acute angle created in the intestine by the FEE anastomsis. This angulation may have impaired flow of ingesta causing motility changes that predisposed the site to intussusception. Because the oversewn blind intestinal ends acted as the lead point for formation of the intussusception, it may be inadvisable to oversew the stapled anastomotic ends.     

One stage functional end-to-end stapled intestinal anastomosis and resection performed by nonexpert surgeons for the treatment of small intestinal obstruction in 30 dogs

Objectives: To describe stapled 1‐stage functional end‐to‐end intestinal anastomosis for treatment of small intestinal obstruction in dogs and evaluate outcome when the technique is performed by nonexpert surgeons after limited training in the technique. Study Design: Case series. Animals: Dogs (n=30) with intestinal lesions requiring an enterectomy. Methods: Stapled 1‐stage functional end‐to‐end anastomosis and resection using a GIA‐60 and a TA‐55 stapling devices were performed under supervision of senior residents and faculty surgeons by junior surgeons previously trained in the technique on pigs. Procedure duration and technical problems were recorded. Short‐term results were collected during hospitalization and at suture removal. Long‐term outcome was established by clinical and ultrasonographic examinations at least 2 months after surgery and from written questionnaires, completed by owners. Results: Mean±SD procedure duration was 15±12 minutes. Postoperative recovery was uneventful in 25 dogs. One dog had anastomotic leakage, 1 had a localized abscess at the transverse staple line, and 3 dogs developed an incisional abdominal wall abscess. No long‐term complications occurred (follow‐up, 2–32 months). Conclusion: Stapled 1‐stage functional end‐to‐end anastomosis and resection is a fast and safe procedure in the hand of nonexpert but trained surgeons.     

Experimental Use of Fluoroalkyl Cyanoacrylate in Canine Urethral Anastomosis

The results of a study designed to evaluate a fluoroalkyl cyanoacrylate tissue adhesive as an adjunct to suture anastomosis of the severed canine pelvic urethra are presented. The urethral anastomotic sites were evaluated by contrast radiography, gross pathology, and histopathology. Urethral anastomosis resulted in a clinically functional urethra in all 6 control dogs (suture anastomosis) and 5 of the 6 test dogs (suture anastomosis plus adhesive). A severe stricture at the anastomotic site developed in 1 dog in the test group. Evidence of leakage was detected by contrast radiography in 1 dog of each group. Microscopic evidence of incomplete closure was detected in 4 control dogs and 2 test dogs. An extensive granulomatous inflammatory reaction was associated with use of the adhesive. The lower incidence of microscopic leakage observed in the test dogs was attributed to fibroplasia induced by the cyanoacrylate and not to the adhesive properties of the cyanoacrylate.     

Response of Canine Synovial Membrane to Three Different Types of Suture Material

The synovial tissue response to three different suture materials was assessed in nine dogs. Stifle joint arthrotomies were sutured with either chromic gut, teflon coated polyester suture, or polypropylene suture; all joint capsule layers were penetrated, exposing the suture material to the joint cavity. The synoviocytic and subsynviocytic layers at the arthrotomy site were examined histologically one, two, and three weeks following surgery. Chromic gut caused the greatest cellular inflammatory response and polypropylene the least. Teflon coated polyester and chromic gut were associated with nearly the same degree of tissue fibrosis. Polypropylene was associated with much less fibrosis than the other suture materials.     

Initial evaluation of a technique for complete cecal bypass in the horse

OBJECTIVE: To describe a novel stapling technique for creation of a complete cecal bypass, without ileal transection in horses. STUDY DESIGN: Experimental study. ANIMALS: Four adult horses. METHODS: Through a ventral median celiotomy, jejunocolostomy was made with an intraluminal anastomosis device (ILA-100) and oversewn with a Cushing pattern to reinforce the staple line. Immediately distal to the anastomosis, 4 rows of staples were applied using a thoracoabdominal stapling device (TA-90) to occlude the lumen of the distal jejunum and proximal ileum. Necropsy exams were performed at least 60 days after surgery. RESULTS: No intraoperative complications occurred. Cecal bypass was functional in all horses at necropsy. The most oral staple line across the ileum partially failed in 1 horse; however cecal bypass was functional. CONCLUSIONS: Complete cecal bypass without ileal transection is a viable alternative to traditional methods of complete cecal bypass. Two sets of staple lines across the ileum are recommended. Longer term follow-up is warranted before clinical use of this technique. CLINICAL RELEVANCE: Cecal bypass without ileal transection is technically simple and effectively bypasses the cecum. It also should intuitively require less time and have a reduced risk of contamination compared with complete cecal bypass with ileal transection.     

Cholecystoduodenostomy in the Dog Comparison of Two Techniques

A mucosal apposition technique for cholecystoduodenostomy was compared to the cutting suture technique. The mucosal apposition technique was easier to perform, less traumatic, and produced a significantly larger anastomotic opening than the cutting suture technique. Eleven of 12 dogs returned to normal activity within 5 days after the mucosal apposition technique. Six of 12 dogs required 10 to 21 days after the cutting suture technique before regaining normal activity. Healing was similar for both techniques. Aerobic and anaerobic bacteria were cultured from the gallbladders of both groups postoperatively.
Cholecystograms demonstrated rapid drainage of the biliary system following mucosal apposition. Drainage of the biliary system following the cutting suture technique was slower; gallbladders tended to be irregularly shaped and distended.
Gallbladders rapidly filled with contrast material during upper gastrointestinal barium studies following cholecystoduodenostomy by mucosal apposition. Gallbladders filled more slowly and less completely following the cutting suture technique: drainage of refluxed contrast material was delayed in some dogs.
Serum enzyme elevations (SGPT, SAP) and subclinical periportal inflammation and fibrosis were found following both techniques. Peripheral circulating eosinophil counts were significantly higher in dogs following the cutting suture technique.     

Pylorectomy and gastroduodenostomy in the dog: technique and clinical results in 28 cases

Pylorectomy and end-to-end gastroduodenostomy are surgical procedures that allow excision of abnormal pyloric tissue and provide improved gastric outflow. These techniques were used for the treatment of benign, malignant, and ulcerative conditions that were judged to be not adequately treatable with pyloromyotomies or pyloroplasties. End-to-end gastroduodenostomy was not much more difficult than a standard intestinal anastomosis; however, a thorough knowledge of the pyloric area anatomy was required to avoid serious surgical errors. In addition, gentle tissue manipulation and precise suture placement reduced the chance of iatrogenic pancreatitis, biliary obstruction, tissue ischemia, and/or suture line leakage. The results of surgery depended on the underlying disease process. Dogs with benign lesions such as chronic hypertrophic pyloric gastropathy responded favorably to treatment. Dogs with malignant disease and perforated ulcers had low long-term survival rate. Pyloric adenocarcinoma was not adequately treated with this method alone.