Bowel anastomoses: The theory, the practice and the evidence base

Since the introduction of stapling instruments in the 1970s various studies have compared the results of sutured and stapled bowel anastomoses. A literature search was performed from 1960 to 2010 and articles relating to small bowel, colonic and colorectal anastomotic techniques were reviewed. References from these articles were also reviewed, and relevant articles obtained. Either a stapled or sutured gastrointestinal tract anastomosis is acceptable in most situations. The available evidence suggests that in the following situations, however, particular anastomotic techniques may result in fewer complications: A stapled side-to-side ileocolic anastomosis is preferable following a right hemicolectomy for cancer. A stapled side-to-side anastomosis is likely also preferable after an ileocolic resection for Crohn’s disease. Colorectal anastomoses can be sutured or stapled with similar results, although the incidence of strictures is higher following stapled anastomoses. Following reversal of loop ileostomy there is some evidence to suggest that a stapled side-to-side anastomosis or sutured enterotomy closure (rather than spout resection and sutured anastomosis) results in fewer complications. Non-randomised data has indicated that small bowel anastomoses are best sutured in the trauma patient. This article reviews the theory, practice and evidence base behind the various gastrointestinal anastomoses to help the practising general surgeon make evidence based operative decisions.

Clinical diagnostic advances in intestinal anastomotic techniques:Hand suturing,stapling,and compression devices

The development of intestinal anastomosis techniques,including hand suturing,stapling,and compression anastomoses,has been a significant advancement in surgical practice.These methods aim to prevent leakage and minimize tissue fibrosis,which can lead to stricture formation.The healing process involves various phases:hemostasis and inflammation,proliferation,and remodeling.Mechanical staplers and sutures can cause inflammation and fibrosis due to the release of profibrotic chemokines.Compression anastomosis devices,including those made of nickel-titanium alloy,offer a minimally invasive option for various surgical challenges and have shown safety and efficacy.However,despite advancements,anastomotic techniques are evaluated based on leakage risk,with complications being a primary concern.Newer devices like Magnamosis use magnetic rings for compression anastomosis,demonstrating greater strength and patency compared to stapling.Magnetic technology is also being explored for other medical treatments.While there are promising results,particularly in animal models,the realworld application in humans is limited,and further research is needed to assess their safety and practicality.

Portal vein arterialization in 25 liver transplant recipients:A Latin American single-center experience

BACKGROUND Portal vein arterialization(PVA)has been used in liver transplantation(LT)to maximize oxygen delivery when arterial circulation is compromised or has been used as an alternative reperfusion technique for complex portal vein thrombosis(PVT).The effect of PVA on portal perfusion and primary graft dysfunction(PGD)has not been assessed.All patients receiving PVA and LT at the Fundacion Santa Fe de Bogota between 2011 and 2022 were analyzed.To account for the time-sensitive effects of graft perfusion,patients were classified into two groups:prereperfusion(pre-PVA),if the arterioportal anastomosis was performed before graft revascularization,and postreperfusion(post-PVA),if PVA was performed afterward.The pre-PVA rationale contemplated poor portal hemodynamics,severe vascular steal,or PVT.Post-PVA was considered if graft hypoperfusion became evident.Conservative interventions were attempted before PVA.

Renal anastomosing hemangioma following partial nephrectomy for renal cell carcinoma:A case report

BACKGROUND Renal anastomosing hemangioma(AH)is a rare benign vascular tumor characterized by unique histopathological features.CASE SUMMARY We report a highly unusual case of renal AH.A male patient had undergone partial nephrectomy for clear cell carcinoma of the kidney four years prior.A follow-up computed tomography scan in the third postoperative year revealed a new mass near the surgical site on the same side of the kidney,raising suspicions of tumor recurrence.However,the characteristics on contrast-enhanced magnetic resonance imaging and ultrasonography were more consistent with those of a benign lesion.The patient strongly insisted on undergoing surgery due to concerns about the possibility of renal cancer recurrence.Postoperative pathology confirmed the diagnosis of renal AH.CONCLUSION This case report presents the imaging features of a patient with rare renal AH and a history of renal clear cell carcinoma,providing broader insights into the differential diagnosis of new lesions after surgery for renal cell carcinoma.

Clinical characteristics of renal anastomotic hemangioma

In this editorial,we comment on the article by Chen and Cai.We focus on renal anastomotic hemangioma,which is a rare benign hemangiomatous disease.This disease has unique clinical characteristics.Its biological behavior is benign,but its imaging results are similar to those of renal cancer.Renal anastomotic hemangioma is easy to misdiagnose and can lead to unnecessary radical nephrectomy.Therefore,urologists need a better understanding of this disease.We believe that patients with renal anastomotic hemangioma should receive individualized diagnosis and treatment to avoid overtreatment.

Endoscopic management of difficult common bile duct stones:Where are we now?A comprehensive review

Endoscopic management for difficult common bile duct(CBD)stones still presents a challenge for several reasons,including anatomic anomalies,patients’individual conditions and stone features.In recent years,variable methods have emerged that have attributed to higher stone removal success rates,reduced cost and lower adverse events.In this review,we outline a stepwise approach in CBD stone management.As first line therapy,endoscopic sphincterotomy and large balloon dilation are recommended,due to a 30%-50%reduction of the use of mechanical lithotripsy.On the other hand,cholangioscopy-assisted lithotripsy has been increasingly reported as an effective and safe alternative technique to mechanical lithotripsy but remains to be reserved in special settings due to limited large-scale evidence.As discussed,findings suggest that management needs to be tailored to the patient’s characteristics and anatomical conditions.Furthermore,we evaluate the management of CBD stones in various surgical altered anatomy(Billroth II,Roux-en-Y and Roux-en-Y gastric bypass).Moreover,we could conclude that cholangioscopy-assisted lithotripsy needs to be evaluated for primary use,rather than following a failed management option.In addition,we discuss the importance of dissecting other techniques,such as the primary use of interventional endoscopic ultrasound for the management of CBD stones when other techniques have failed.In conclusion,we recognize that endoscopic sphincterotomy and large balloon dilation,mechanical lithotripsy and intraductal lithotripsy substantiate an indication to the management of difficult CBD stones,but emerging techniques are in rapid evolution with encouraging results.

Direct Gene Transfer into Rabbit Peripheral Nerve in vivo

Exogenous gene suture was used to achieve peripheral nerve anastomoses to probe into the feasibility that the sites of anastomoses of nerves directly transfer gene and thus enable gene to be expressed at the sites of anastomoses under the condition that perfect nerve anastomoses are ensured. PCMVβ plasmid containing cytomegalovirus promoter (CMV promoter) and Escherichia coli (E.coli) β Galactosidase (β Gal) structural gene (lacZ gene) was conducted. A soaked medical 8 0nylon suture was used to perform epineurial repair of rabbit sciatic nerve. In the control group a suture soaked in sucrose PBS was used, while in the experimental group a suture soaked in PCMVβ plasmid solution was applied. The sites of anastomoses of nerves by stages were taken out, and β Gal histochemical staining was performed and β Gal enzyme activity was assayed with 5 bromo 4 chloro 3 indolyl β D galactoside. Results showed that the sites of anastomoses of nerves were taken out 2 days, 7 days, 14 days and 30 days respectively after the operation. The β Gal histochemical stains at the sites of anastomoses showed no indigo positive cells at different stages in the control group, whereas displayed indigo positive cells in the experimental group. In the control group, no β Gal enzyme activity was detected at different stages after operation, but in the experimental group, β Gal enzyme activity could be detected from the 3rd day to the 30th day after operation. It was concluded that by using exogenous gene suture, exogenous gene could be transferred to the sites of peripheral nerve and expressed the exogenous gene expression products with bioactivity, which provided the feasibility of using gene therapy to accelerate the recovery of nerve function.

TRACING COLLATERAL CIRCULATION AFTER ISCHEMIA IN RAT CORTEX BY LASER SPECKLE IMAGING

The collateral circulation is crucial for the pathophysiology and outcome of acute cortical ischemia.Current understanding of collateral circulation still remains sparse,largely due to prior limitations of spatial or/and temporal resolution in methods to evaluate these diminutive redistributive routes of cerebral blood flow(CBF)especially in leptomeningeal anastomoses that connected cortical arteries.In the study,based on a mini-stroke model,laser speckle imaging with high spatiotemporal resolution was used to assess the dynamic evolution of the collateral circulation around a mini-ischemia in the rat cortex.We found that the blood flow and diameter in the intra-arterial anastomoses were enhanced immediately after the ligation of one branch of middle cerebral artery and recovered to baseline level as arterial recirculation was performed.Whereas the communicative flow-through of the posterior cerebral artery and the middle cerebral artery anastomoses was not significant enough to be determined.This is the evidence that intra-arterial anastomoses were the primary routes to restore blood flow into the ischemic territory during the acute phase of ischemia,and laser speckle imaging method was proven as a powerful tool to be potential for subserving further investigation of the collateral circulation.

Applying refined pancreaticogastrostomy techniques in pancreatic trauma

We comment on a study titled“Feasibility and safety of"bridging"pancreaticogastrostomy for pancreatic trauma in Landrace pigs”in which ten pigs were randomized to either experimental“bridging”pancreaticogastrostomy(PG)or a control group with a routine mucosa-to-mucosa PG.At six months anastomoses had strictured and closed in both groups.The authors concluded that“bridging”PG is feasible and safe in damage control surgery during the early stage of pancreatic injury.In this letter we comment on the study design,specifically leaving a 2 cm gap between the pancreatic stump and the stomach and highlight the complexity of performing pancreatic anastomoses following trauma pancreaticoduodenectomy as to our experience in a high volume trauma centre.Our data emphasize that pancreatic anastomoses in trauma are complex procedures with significant postoperative morbidity and are best managed collaboratively by trauma and hepatopancreaticobiliary surgical teams with the required technical skills.

Surgical Coronary Revascularization Using an Off-Pump, No-Touch Technique: The Cyclone (Hexalon) Experience

The CycloneTM System (Castlewood Surgical, Inc., Concord, MA) is a novel device that facilitates the attachment of the saphenous vein onto the ascending aorta for the purpose of creating a bypass graft during a coronary artery bypass grafting (CABG) operation. It allows the surgeon to perform a hand-sewn anastomosis with no disruption of the intima of the aorta, and no need for partial clamping. During a 36-month period 109 CABG operations were performed, and the CycloneTM System (and its predecessor, the HexalonTM) was utilized to create 138 proximal anastomoses. This study demonstrates that this is a safe and effective method of creating a clampless, no-touch proximal anastomoses during off-pump CABG.

Acute Type B Dissection Complicated by Aortic Coarctation

We report a case of acute type B aortic dissection complicated by coarctation of aorta in 35-year-old women. Computed tomography angiography (CTA) showed a short segment aortic narrowing with diameter of 9.2 mm a small intimal tear, a true lumen, a false lumen, a markedly thick mural thrombus and pleural effusion. Open surgical procedure was performed and the aortic coarctation (CoA) and aortic dissection were resected and a 24-mm prosthetic graft was anastomosed. No pseudo aneurysms were present at the anastomosis sites on the follow up CTA.

Anastomosing hemangioma arising from the left renal vein:A case report

BACKGROUND Anastomosing hemangioma(AH)is a rare subtype of benign hemangioma that is most commonly found in the genitourinary tract.Due to the lack of specific clinical and radiologic manifestations,it is easily misdiagnosed preoperatively.Here,we report a case of AH arising from the left renal vein that was discovered incidentally and confirmed pathologically,and then describe its imaging characteristics from a radiologic point of view and review its clinicopathologic features and treatment.CASE SUMMARY A 74-year-old woman was admitted to our department for a left retroperitoneal neoplasm measuring 2.6 cm×2.0 cm.Her laboratory data showed no significant abnormalities.A non-contrast-enhanced computed tomography(CT)scan showed a heterogeneous density in the neoplasm.Non-contrast-enhanced magnetic resonance imaging(MRI)revealed a heterogeneous hypointensity on T1-weighed images and a heterogeneous hyperintensity on T2-weighed images.On contrastenhanced CT and MRI scans,the neoplasm presented marked septal enhancement in the arterial phase and persistent enhancement in the portal phase,and its boundary with the left renal vein was ill-defined.Based on these clinical and radiological manifestations,the neoplasm was initially considered to be a neurogenic neoplasm in the left retroperitoneum.Finally,the neoplasm was completely resected and pathologically diagnosed as AH.CONCLUSION AH is an uncommon benign hemangioma.Preoperative misdiagnoses are common not only because of a lack of specific clinical and radiologic manifestations but also because clinicians lack vigilance and diagnostic experience in identifying AH.AH is not exclusive to the urogenital parenchyma.We report the first case of this neoplasm in the left renal vein.Recognition of this entity in the left renal vein can be helpful in its diagnosis and distinction from other neoplasms.

BASIC CHARACTERISTICS AND CONTROLLING FACTORS OF ANASTOMSING FLUVIAL SYSTEMS

Although anastomosing fluvial rivers are given much attention recently by some research workers because the result channel sandstone of which is one typical primary reservoirs of petroleum and natural gas, of which the flood plains and the interchannel wetlands are pay zones where coals had formed, the comprehension of anastomosing river is some extent limited at present. Some researchers regard that the anastomosing river river and the anabranched river are the same kind of rivers. In this paper, the sedimentary, geomorphic and hydraulic characteristics and the main controlling factors of anastomosing fluvial system are summarized systematically. Some of the characteristics are compared with others fluvial rivers. Humid climate is suitable to form anastomosing channel systems, in arid semiarid regions anastomosing river maybe develop if many befitting factors combine together. The authors of the paper think that anastomosing river is one typical channel pattern and is dissimilar to anabranched channel pattern.

Wandering gravel-bed rivers and high-constructive stable channel sandy fluvial systems in the Ross River area,Yukon Territory,Canada

Mid-Cretaceous strata within the Tintina Trench, 3 km west of the community of Ross River, contain evidence of deposition in two distinct, alternating, fluvial settings. Coal-bearing, mud-dominated strata are commonly associated with high-constructive sandy channel systems, with extensive overbank, levee and splay deposits. Channels are between 3 and 30 m wide and 0.4-7 m thick. They show repetitive development of side and in-channel bar-forms, as well as up-channel widening of the rivers by selective erosion of associated overbank and levee deposits. Levees extended for several hundred metres away from the channels. In this setting low-angle inclined stratification and epsilon cross stratification may reflect lateral migration of crevasse channels or small streams. The paucity of exposure prevents recognition of the channels as products of multiple channel anastomosed systems or single channel high-constructive systems. Gravel-dominated strata, inter-bedded with, and overlying coal-bearing units, are interpreted as deposits of wandering gravel-bed rivers, with sinuosity approaching 1.4. In most exposures they appear to be dominated by massive and thin planar-bedded granule to small pebble conglomerates, which would traditionally be interpreted as sheet-flood or longitudinal bar deposits of a high-gradient braided stream or alluvial fan. Architectural analysis of exposures in an open-pit shows that the predominance of flat bedding is an artefact of the geometry of the roadside exposures. In the pit the conglomerates are dominated by large scale cross stratification on a scale of 1-5.5 m. These appear to have developed as downstream and lateral accretion elements on side-bars and on in-channel bars in water depths of 2-12 m. Stacking of strata on domed 3rd order surfaces suggests development of longitudinal in-channel bar complexes similar to those observed in parts of the modern Rhone River system. Mudstone preserved in some of the channels reflects intervals of channel abandonment or avulsion. Minimum channel width is from 70 to 450 m.

Primary vascular tumours of the kidney

Primary vascular tumours of the kidney are rare and may pose diagnostic difficulties because of their similar clinical,morphological,and immunohistochemical features.This article summarizes the clinical and pathological features of primary renal angiosarcoma and anastomosing haemangioma of the kidney including epidemiology,genetics,and prognosis.Renal anastomosing haemangiomas are benign neoplasms characterized by anastomosing capillary-sized vascular channels.These tumours are rare,with about 75 cases reported in the literature.Most anastomosing haemangiomas are found incidentally on ultrasound,computed tomography,or magnetic resonance imaging.Common symptoms include abdominal pain,haematuria,and abdominal mass.Renal anastomosing haemangiomas are characterized by recurrent mutations in GNAQ and GNA14 genes.The prognosis of anastomosing haemangioma is excellent.Primary renal angiosarcomas are malignant tumours showing endothelial differentiation.To date,76 cases have been described in the literature.Primary renal angiosarcomas are frequently symptomatic.The clinical features of renal angiosarcomas are similar to those of renal anastomosing haemangiomas,including abdominal pain,haematuria,and abdominal mass.Angiogenesis-related genes and vascular-specific receptor tyrosine kinases such as KDR,TIE1,SNRK,TEK,and FLT1 are upregulated in angiosarcomas.Primary renal angiosarcomas are highly aggressive neoplasms with a poor prognosis despite surgical treatment,chemotherapy,radiotherapy,or targeted therapy.

Topographic Map Analysis of Laramie Range Bedrock-Walled Canyon Complex and the Goshen Hole Escarpment-Surrounded Basin, Albany and Platte Counties, Southeast Wyoming, USA

The Laramie River after flowing in a north direction through southeast Wyoming’s Laramie Basin abruptly turns in an east direction to flow across the north-to-south oriented Laramie Range in a bedrock-walled canyon and eventually reaches the lower elevation Great Plains and southeast-oriented North Platte River. The North Laramie River, Bluegrass Creek, and North Sybille/Sybille Creek also flow from the Laramie Basin in separate bedrock-walled valleys into the Laramie Range before eventually joining the Laramie River. Bedrock-walled through valleys link the various Laramie Range stream and river crossing valleys and detailed topographic maps were used to determine how this anastomosing bedrock-walled canyon complex and the large escarpment-surrounded Goshen Hole basin (located just to the east of the anastomosing canyon complex) originated. Map evidence shows multiple streams of water must have diverged in the Laramie Basin from the north-oriented Laramie River to enter the Laramie Range before converging in or east of the Laramie Range and also shows how present day through valleys enabled diverging and converging streams of water to cross the Laramie Range. The anastomosing bedrock-walled valley complex studied here extends from north of the North Laramie River valley to south of the North Sybille/Sybille Creek valley. Large volumes of water flowing from the Laramie Basin to the Great Plains are interpreted to have eroded the anastomosing canyon complex and the “downstream” Goshen Hole escarpment-surrounded basin. Headward erosion of the north-oriented Sybille and Chugwater Creek valleys across large sheets of east-oriented water are interpreted to have left the Goshen Hole escarpment-surrounded basin as a large abandoned headcut. A water source was not determined, although a continental ice sheet that deeply eroded and warped the North American continent is considered to be a possible source.

Analysis of Mountains Passes along the East-West Continental Divide and Other Drainage Divides Surrounding the Boulder River Drainage Basin, Jefferson County, Montana, USA

Detailed topographic maps of drainage divides surrounding the Jefferson County, Montana, Boulder River drainage basin were analyzed to determine the nature of drainage systems that preceded today’s Boulder River drainage system and how the Boulder River drainage system evolved from those earlier drainage systems. The Boulder River studied here drains in a north, east, and south direction to the Jefferson River, which at Three Forks, Montana joins the north-oriented Madison and Gallatin Rivers to form the north-oriented Missouri River. The North American east-west Continental Divide surrounds the Boulder River drainage basin western half and mountainous drainage divides with the Jefferson and Missouri Rivers surround the drainage basin’s eastern half. More than 25 deep mountain passes are notched into these drainage divides and provide evidence of the regional drainage system that preceded the present day Boulder River drainage system. Analysis of pass elevations and of orientations of valleys leading in opposite directions from those mountain passes shows that prior to Boulder River drainage system development immense volumes of south-oriented water moving in anastomosing complexes of diverging and converging channels flowed across the Boulder River drainage basin area and that the Boulder River drainage system evolved as deeper channels progressively captured flow from shallower channels. While not documented in detail crustal warping probably raised Boulder River drainage basin areas relative to adjacent valleys and basins as capture events took place. A water source was not determined, but may have been from a large North American continental ice sheet, although Boulder River drainage basin evolution probably occurred while mid Tertiary sediments were filling adjacent valleys and basins.

Use of Detailed Topographic Map Evidence of the Southeast Wyoming Gangplank Area to Compare Two Fundamentally Different Geomorphology Paradigms, USA

Drainage divides along a southern Laramie Range crest area and in the nearby southeast Wyoming Gangplank area (as observed on detailed topographic maps) suggest present-day drainage routes in the Cheyenne Tablelands region originated as headward erosion of south-oriented valleys (now the downstream Lodgepole, Crow, and Lone Tree Creek valleys) from an actively eroding northeast-oriented South Platte River valley captured flood flow in the south half of a large east-oriented anastomosing channel complex while headward erosion of a north-oriented valley (now the downstream Horse Creek valley) from the southeast-oriented North Platte River valley captured the north half of the same large anastomosing channel complex. The Gangplank, which today serves as a low gradient ramp of Tertiary Ogallala Formation sediments leading from the Great Plains to the Laramie Range erosion surface, is located along the Crow Creek-Lone Tree Creek drainage divide and low points along that divide (referred to here as divide crossings) suggest, prior to headward erosion of what is now its south-oriented downstream Lone Tree Creek valley, upstream east-oriented Lone Tree Creek drainage routes were intertwined with east-oriented Crow Creek drainage routes, which today flow much further in an east direction (than east-oriented upstream Lone Tree Creek drainage routes) before also turning in a south direction to reach the South Platte River. The ability of the commonly accepted regional geomorphology paradigm to explain this topographic map evidence is then compared with a fundamentally different and new regional geomorphology paradigm’s ability to explain the same evidence. While both paradigms offer possible explanations the new paradigm, which requires headward erosion of the valleys to have occurred as massive continental ice sheet melt water floods crossed the region, explains much more of the drainage system evidence and also permits much more detailed explanations.

Single-port laparoscopic surgery for sigmoid volvulus

AIM:To report our experience with single-port laparoscopic surgery(SPLS)for sigmoid volvulus(SV).METHODS:Between October 2009 and April 2013,10patients underwent SPLS for SV.SPLS was performed transumbilically or through a predetermined stoma site.Conventional straight and rigid-type laparoscopic instruments were used.After intracorporeal,segmental resection of the affected sigmoid colon,the specimen was extracted through the single-incision site.Patientdemographics and perioperative data were analyzed.RESULTS:SPLS for SV was successful in all 10 patients(4,resection and primary anastomosis;6,Hartmann’s procedure).The median operative time and postoperative hospitalization period were 168(range,85-315)min and 6.5(range,4-29)d,respectively.No intraoperative complications were noted;there were 2 postoperative complications,including 1 anastomotic leak.CONCLUSION:SPLS was a safe and feasible therapeutic approach for SV,when performed by a surgeon experienced in conventional laparoscopic surgery.

Renal Anastomosing Hemangioma Simulating Angiosarcoma as a Second Primary in a Patient with Breast Cancer

Anastomosing hemangioma is a type of tumor lesion of benign behavior scarcely documented, it has been observed in renal parenchyma, testicles, ovaries and adrenal glands, it is usually prone to perirenal and renal medullary adipose tissue. In this case report, we present an anastomosed hemangioma in the right kidney of a 33-year-old woman, with previous coexistence of breast cancer, in which an unusual behavior was detected, with characteristics of vascular lesion, in this case we report: The classic conditions, its heterogeneous nature and the vascular alterations that presents in different imaging modalities.