Effect of three different needle holders on gastrointestinal anastomosis construction time and bursting pressure in equine jejunal segments

Background Equine small intestinal resection and anastomosis is a procedure where optimizing speed, without compromising integrity, is advantageous. There are a range of different needle holders available, but little is published on the impact surgical instrumentation has on surgical technique in veterinary medicine. The objectives of this study were to investigate if the needle holder type influences the anastomosis construction time, the anastomosis bursting pressure and whether the bursting pressure is influenced by the anastomosis construction time. Single layer end-to-end jejunojejunal anastomoses were performed on jejunal segments harvested from equine cadavers. These segments were randomly allocated to four groups. Three groups based on the needle holder type that was used: 16.5 cm Frimand (Group 1), 16 cm Mayo-Hegar (Group 2) or 20.5 cm Mayo-Hegar (Group 3) needle holders. One (Group 4) as control without anastomoses. Anastomosis construction time was recorded. Bursting pressure was determined by pumping green coloured fluid progressively into the lumen whilst recording intraluminal pressures. Maximum pressure reached prior to failure was recorded as bursting pressure. Construction times and bursting pressures were compared between needle holder, and the correlation between bursting pressure and construction time was estimated. Results Construction times were not statistically different between groups (P = 0.784). Segments from Group 2 and Group 3 burst at a statistically significantly lower pressure than those from Group 4; P = 0.031 and P = 0.001 respectively. Group 4 and Group 1 were not different (P = 0.125). The mean bursting pressure was highest in Group 4 (189 ± 61.9 mmHg), followed by Group 1 (166 ± 31 mmHg) and Group 2 (156 ± 42 mmHg), with Group 3 (139 ± 34 mmHg) having the lowest mean bursting pressure. Anastomosis construction time and bursting pressure were not correlated (P = 0.792). Conclusions The tested needle holders had a significant effect on bursting pressure, but not on anastomosis construction time. In an experimental setting, the Frimand needle holder produced anastomoses with higher bursting pressures. Further studies are required to determine clinical implications.

Ex-vivo mechanical sealing properties and toxicity of a bioadhesive patch as sealing system for fetal membrane iatrogenic defects

Preterm prelabor rupture of membranes (PPROM) is the most frequent complication of fetal surgery. Strategies to seal the membrane defect created by fetoscopy aiming to reduce the occurrence of PPROM have been attempted with little success. The objective of this study was to evaluate the ex-vivo mechanical sealing properties and toxicity of four different bioadhesives integrated in semi-rigid patches for fetal membranes. We performed and ex-vivo study using term human fetal membranes to compare the four integrated patches composed of silicone or silicone-polyurethane combined with dopaminated-hyaluronic acid or hydroxypropyl methylcellulose (HPMC). For mechanical sealing properties, membranes were mounted in a multiaxial inflation device with saline, perforated and sealed with the 4 combinations. We measured bursting pressure and maximum pressure free of leakage (n = 8). For toxicity, an organ culture of membranes sealed with the patches was used to measure pyknotic index (PI) and lactate dehydrogenase (LDH) concentration (n = 5). All bioadhesives achieved appropriate bursting pressures, but only HPMC forms achieved high maximum pressures free of leakage. Concerning toxicity, bioadhesives showed low PI and LDH levels, suggesting no cell toxicity. We conclude that a semi-rigid patch coated with HPMC achieved ex-vivo sealing of iatrogenic defects in fetal membranes with no signs of cell toxicity. These results warrant further research addressing long-term adhesiveness and feasibility as a sealing system for fetoscopy.

In Vitro Comparison of Two Single Layer Hand Sewn End-to-End Anastomosis Techniques in Normal Equine Jejunum: A Pilot study

Background: The equine small intestine can be affected by a variety of disorders, which may require some form of bypass or anastomosis procedure. Several small intestinal anastomosis techniques have been reported in scientific literature with the intention to minimize post-operative complications, however to our knowledge there are no published descriptions of the hand-sewn end-to-end single layer simple continuous Appositional technique for equine jejunojejunostomy. Objective: To compare and evaluate differences in the single layer continuous Appositional and the single layer continuous Lembert with respect to construction time, leakage pressure and bursting pressure; for the purpose of small intestinal anastomosis in the horse. Hypothesis: We hypothesized that the time spent in the execution, leakage pressure and bursting pressure will be similar between the single layer continuous Lembert and the single layer simple continuous Appositional techniques. Since this is a pilot study, it is the first step to prove the efficacy of the Appositional technique by showing its similarity with the Lembert technique, considering the latter to be the ‘gold standard’. Methodology: Thirty-Seven intestinal segments from two horses were used to compare the single layer continuous Appositional and single layer continuous Lembert techniques. The time taken to execute the anastomoses, and the number of bites taken for each pattern, were recorded. Biomechanical testing was performed to determine leakage pressure and bursting pressure. Statistical analysis was performed using GraphPad Prism 8. Result: The comparison in construction time between the Lembert group (mean, 24.23 mins, n=19) and the Appositional group (mean, 21.74 mins, n=18) were found to be statistically insignificant (P=0.3088). There was also no changes in Leakage pressure (P=0.3862) and bursting pressure (P=0.3135) between the two groups. Conclusion: This study has demonstrated that the Appositional technique is a viable alternative to the Lembert technique, with respect to construction time, leakage and bursting pressures, for the purpose of end-to-end jejunojejunal anastomosis in the horse

In Vitro Comparison of Two Single Layer Hand Sewn end‐to‐end Anastomosis Techniques in Normal Equine Jejunum: A Pilot Study

Background: The equine small intestine can be affected by a variety of disorders, which may require some form of bypass or anastomosis procedure. Several small intestinal anastomosis techniques have been reported in scientific literature with the intention to minimize post-operative complications, however to our knowledge there are no published descriptions of the hand-sewn end-to-end single layer simple continuous Appositional technique for equine jejunojejunostomy. Objective: To compare and evaluate differences in the single layer continuous Appositional and the single layer continuous Lembert with respect to construction time, leakage pressure and bursting pressure; for the purpose of small intestinal anastomosis in the horse. Hypothesis: We hypothesized that the time spent in the execution, leakage pressure and bursting pressure will be similar between the single layer continuous Lembert and the single layer simple continuous Appositional techniques. Since this is a pilot study, it is the first step to prove the efficacy of the Appositional technique by showing its similarity with the Lembert technique, considering the latter to be the ‘gold standard’. Methodology: Thirty-Seven intestinal segments from two horses were used to compare the single layer continuous Appositional and single layer continuous Lembert techniques. The time taken to execute the anastomoses, and the number of bites taken for each pattern, were recorded. Biomechanical testing was performed to determine leakage pressure and bursting pressure. Statistical analysis was performed using GraphPad Prism 8. Results: The comparison in construction time between the Lembert group (mean, 24.23 mins, n=19) and the Appositional group (mean, 21.74 mins, n=18) were found to be statistically insignificant (P=0.3088). There was also no changes in Leakage pressure (P=0.3862) and bursting pressure (P=0.3135) between the two groups. Conclusion: This study has demonstrated that the Appositional technique is a viable alternative to the Lembert technique, with respect to construction time, leakage and bursting pressures, for the purpose of end-to-end jejunojejunal anastomosis in the horse.

Comparison of bursting pressure on sleeve gastrectomy staple lines between stapling, buttressing, and oversewing

Backgrounds. One of the major complications after laparoscopic sleeve gastrectomy (LSG) is represented by leaks along the staple line. Several reinforcement techniques have been proposed, but scarce data about the real strengthening offered are present. Thus, we aimed to evaluate if different reinforcements produced different bursting pressures after LSG, and then to verify if the clinical application of the stronger reinforcement produced a reduction in leakage rate. Methods. We prospectively enrolled all consecutive obese patients that underwent LSG. We tested 3 different types of staple lines, as follows: group 1, no reinforcement; group 2, bioabsorbable buttress reinforcement; group 3, invaginating overrunning barbed suture. A burst pressure test was applied to the gastric specimen by means of high-resolution manometric catheter. After burst pressure tests, a subsequent consecutive series of patients were treated with the most effective reinforcement, and rate of leaks was recorded. Results. We enrolled in total 110 obese patients; 20 patients for each group of staple line reinforcement and then other 50 consecutive patients underwent LSG with the higher burst pressure staple line reinforcement. Median burst pressures were similar in group 1 and group 2; group 3 showed a statistically significant pressure increase ( P < .0001) than group 1 and group 2, with a 5.2-fold value. Other consecutive 50 obese patients underwent LSG with overrunning reinforcement. In none of them a leak was detected. Conclusions. Reinforcement of the SG staple line, with overrunning suture, seems to drastically increase bursting pressures in an ex vivo model and it is promising when reproduced in vivo.

INVESTIGATION OF CHARACTERISTICS OF WOVEN REINFORCING FRAMES OF PRESSURE FIRE HOSES AND THEIR INFLUENCE ON VALUES OF INTERNAL BURSTING PRESSURES

The article proposes a technique for experimental studies of contact zones between threads in woven reinforcing frames of pressure fire hoses using a JSM-6490LV scanning electron microscope and statistical methods, on the basis of which the coefficients of vertical crumpling of threads, coefficients characterizing the lengths of contact zones between threads in fractions of the diameters of the warp and weft threads, the account of which is necessary for a more accurate determination of the bursting pressures in the pressure head fire hoses. Burst pressure is regulated by GOST R 51049-97 and is an important strength parameter of a pressure head fire hose, characterizing its ability to resist destruction under the influence of the internal hydraulic pressure of a fire extinguishing fluid. The influence of such parameters of a woven reinforcing frame made of polyester threads based on polyethylene terephthalate (PET), as the breaking force of the weft threads (threads laid along the circumference of the sleeve), the radius of the sleeve, geometric densities along the warp and weft, the coefficients of vertical crumpling, has been studied. and the diameters of the warp and weft threads, the coefficients characterizing the lengths of the contact zones between the threads in fractions of the diameters of the warp and weft threads by the value of the bursting pressure in the latex pressure fire hose manufactured by BEREG, designed for a working pressure of 1.6 MPa. As a result of the study, it was established: the bursting pressure of the pressure head fire hose significantly depends on the geometric densities along the base and weft of the fabric of the reinforcing frame (with an increase (decrease) in geometric densities, the calculated bursting pressure of the hose falls (increases)); the bursting pressure of the sleeve is directly proportional to the bursting force of the weft threads and inversely proportional to the radius of the pressure head fire hose with all its other parameters constant, and the dependence of the bursting pressure on these parameters is significant; with an increase in such parameters of the woven reinforcing frame of the pressure head fire hose as the diameters of the warp and weft threads, their vertical crushing, the length of the contact zones between the threads, the bursting pressure increases, which indicates the need to take these parameters into account in the strength calculation of the woven reinforcing frames of the fire hoses . The results of the study must be taken into account when designing new types of these technical products.

Effect of Intraoperative PEEP Application on Colonic Anastomoses Healing: An Experimental Animal Study

This study aimed to assess the effect of intraoperative positive end–expiratory pressure (PEEP) intervention on the healing of colonic anastomoses in rabbits. A total of 32 New Zealand type male rabbits were divided into 2 groups of 16 animals each. Following ventilation with tracheostomy, colonic resection and anastomosis were performed in both groups. Although 10 cm of H2O PEEP level was applied in group 1 (PEEP), group 2 [zero end-expiratory pressure (ZEEP)] was ventilated without PEEP throughout the surgery. Half of both the PEEP and ZEEP group animals were killed on the third postoperative day, whereas the remaining half were killed on the seventh. Anastomotic bursting pressures, the tissue concentrations in hydroxyproline, and histologic assessments were performed. Intraoperative oxygen saturation and postoperative arterial blood gas parameters were also compared. On the first postoperative day, both arterial oxygen tension (PO2) and oxygen saturation (SO2) in the PEEP group were significantly higher than in the ZEEP group. On the seventh postoperative day, the bursting pressures of the anastomoses were significantly higher in the PEEP group; however, the hydroxyproline content was significantly lower in the PEEP group than in the ZEEP group. At day 7, the PEEP group was significantly associated with increased neoangiogenesis compared with the ZEEP group. The anastomotic healing process is positively influenced by the intraoperative PEEP application.

Double Bipolar Sealing of the Pulmonary Artery Improves the Bursting Pressures

Background In every anatomic lung resection, branches of the pulmonary artery have to be divided. In open surgery, this can be done with ligatures or staplers. In endoscopic surgery, only an endostapler can be used. By routing we ligate the vessels double. Bipolar sealing had yielded promising results, so we wanted to know if we can improve the bursting pressures especially in case of larger vessels by double sealing. Methods Experiments were performed on preparations of the left pulmonary artery extracted at the slaughterhouse. A pressure sensor was implanted at the central end to provide digital measurement of the pneumatic load on the vessel seal and thus establish bursting pressure in each case. Vessels were sealed with MARSEAL 5 (Gebrüder Martin GmbH & Co KG, Tuttlingen, Germany) and SealSafe G3 electric current. The vessels investigated were separated into three sizes: 1 to 6 mm, 7 to 12 mm, and >12 mm. The groups (n = 12 in each) were investigated for each vessel size—Group 1: ligature; Group 2: single seal; Group 3: double seals separated by gap of 0.5 cm; and Group 4: double seals separated by gap of 1.0 cm. Mean bursting pressure (mbar) was calculated for each group. Differences between groups were calculated with Mann–Whitney U test; differences with p < 0.05 were considered significant. Results The ligated vessels in the 1 to 6 mm group showed the highest bursting pressures (mean 515.7 ± 39.6 mbar). Mean bursting pressure in the single seal group was 231.6 ± 47.5 mbar. This was not significantly different from the group with double seals placed 0.5 cm apart. However, bursting pressures were significantly higher in the group with double seals placed 1 cm apart (p < 0.001). Mean value in this case was 308.5 ± 44.5 mbar. In the 7 to 12 mm vessels, mean bursting pressure was highest with ligation at 361 ± 67.1 mbar but was significantly higher in both groups with double bipolar seals (180.3 ± 52.1 mbar with 0.5-cm separation and 277.0 ± 64.5 with 1-cm separation) than in the single seal group (102.7 ± 16.1 mbar). In large vessels (>12 mm), mean bursting pressures were low (66.3 ± 12.7 mbar) with single seals but were significantly higher with double seals (162.3 ± 35.8 mbar [0.5-cm separation] and 137.3 ± 22.9 mbar [1-cm separation]). Conclusions In the ex vivo model of the pulmonary artery, double seals revealed significantly higher bursting pressures than single seals. If there is enough vessel length, the two seals should be placed 1 cm apart.

Effect of the Bioadhesive, BioGlue, on Impaired Colonic Anastomose Healing in Rats

Colonic anastomotic leakage is still a problem in general surgery practice. We sought to investigate the effect of a new tissue adhesive, BioGlue, on the healing of normal and impaired colonic anastomoses. Sixty-four rats were randomized into 4 groups. In all animals, a 1-cm segment of the left colon was resected, and an end-to-end sutured anastomosis was created. Animals were then divided into 2 groups: normal and impaired anastomosis. These 2 groups were further subdivided into 2 additional groups: animals that received BioGlue and those that did not. All rats received intraperitoneal injections of either 0.9% NaCl or 5-fluorouracil (5-FU). Anastomotic evaluation was done 7 days after surgery. Macroscopic healing, mechanical strength, and histopathologic healing parameters were evaluated. Leakage of the anastomosis was significantly higher in rats in the impaired group compared with those in the BioGlue groups (P = 0.043). The adhesion formation score was significantly higher in rats in the impaired anastomosis group compared with the other groups. Bursting pressures were significantly lower in the impaired anastomosis group than in the other ones (P = 0.001). Neoangiogenesis and fibroblast activity were different among the groups (P = 0.001). Inflammatory cell infiltration and collagen deposition did not differ among the groups (P = 0.07). Immediate postoperative intraperitoneal administration of 5-FU after colonic anastomosis inhibits intestinal wound healing. Covering colon anastomoses with BioGlue after suturing conferred beneficial effect on healing.