Jameson L. Chassin

The Stapled Gastrointestinal Tract Anastomosis: Incidence of Postoperative Complications Compared with the Sutured Anastomosis

Performance of gastrointestinal anastomosis by means of surgical stapling devices has achieved popularity in the last decade even though no detailed study has been reported comparing complications following the stapled anastomosis with those following hand sutured procedures performed by the same surgeons. We have reviewed 812 operative procedures on the gastrointestinal tract performed in one hospital over a four year period. Stapled anastomoses were performed in 472 with 13 (2.8%) complications related to the anastomosis; in 296 sutured anastomoses there were nine (3.0%) related complications. Comparison did not disclose any significant difference in the number of complications in these two groups. In 44 instances wherein the anastomosis contained both staples and sutures, there were no related complications. Further analysis of the patients in each group disclosed that stapling procedures were utilized in a much higher percentage of those operations which were performed under emergency conditions or in the presence of intra-abdominal sepsis, intestinal obstruction, and carcinomatosis. If the technical details of surgical stapling are mastered, this technique appears to be as safe as suturing in the performance of anastomoses in the gastrointestinal tract.

Errors and Pitfalls in Stapling Gastrointestinal Tract Anastomoses

Gastrointestinal tract anastomoses are safe to perform, provided that the surgeon has acquired the knowledge and skill to avoid certain errors and pitfalls. This paper illustrates important mistakes relative to esophageal, gastric, intestinal, and colorectal anastomoses, and includes methods for avoiding these errors.

Stapling technic for esophagogastrostomy after esophagogastric resection

A technic of esophagogastrostomy is described for constructing an end-to-side, back-to-front anastomosis using stapling devices. Twelve consecutive cases are reported with no deaths and no anastomotic leaks.

Perforated Peptic Ulcer

Perforated gastric ulcer. Not all free perforations of gastric ulcers are susceptible to simple plication techniques. Often the ulcer is large and surrounded by edema. When the perforation occurs on the posterior surface of the antrum, adequate repair by plication techniques is generally not possible. Gastric ulcers have a high rate of recurrence. For these reasons, in a good-risk patient in whom the diagnosis of perforation has been made reasonably early, gastric resection is preferred to simple plication. If for technical reasons a sound plication cannot be constructed, gastric resection is mandatory, regardless of the risk, as a recurrent gastric leak into the peritoneal cavity is almost always fatal.

Aneurysm of the hepatic artery

Summary Diagnosis of aneurysm of the hepatic artery prior to rupture requires a celiac arteriogram. A case is reported in which the only symptom was severe pain. This is the second reported case of successful resection and end to end anastomosis.

Effect of stress upon the healing of wounds in rats.

Summary 1. A variety of situations, calculated to provide a chronic “stress” stimulus, have been studied in order to determine the effect of stress upon the bursting pressure of standard laparotomy wounds in rats. 2. With the exception of mild stress (skin incisions, single turpentine injection), in each case a depression of the bursting pressure of fifth day laparotomy wounds was observed. This was accompanied by increases in the weight of the adrenal glands at autopsy. 3. The duration of this period of stress-induced depression of healing appeared to vary with the magnitude and the nature of the stress stimulus.

Effect of Adrenalectomy on Wound Healing in Normal and in Stressed Rats.

Summary 1. The bursting pressures of healing laparotomy wounds, made 15 days after bilateral adrenalectomy were equal to or superior to those of normal control rats. 2. In adrenalectomized rats, maintained on a small fixed dosage of aqueous adrenal cortex extract, skin-excision-stress did not result in depression of the bursting pressure of 5th day laparotomy wounds, as is the case with non-adrenalectomized rats subjected to the same stress.

Control of Bleeding

This chapter describes basic techniques for achieving hemostasis, including ligatures (“tying off”), suture ligature, hemostatic clips, electrocautery, and other mechanical methods. It briefly discusses topical hemostatic adjuncts. It introduces concepts essential for dealing with massive bleeding, either unexpected bleeding during an elective procedure or bleeding during laparotomy for trauma.

Roux-en-Y Biliary-Enteric Bypass

Roux-en-Y biliary bypass is performed for common duct injuries or common duct obstruction not amenable to stenting. It is also performed as part of other operations (e.g., it is part of the reconstructive phase of a Whipple resection). This chapter describes techniques and pitfalls.

Inguinal and Pelvic Lymphadenectomy

Groin lymphadenectomy is comprised of two separate lymph node groups: inguinal and pelvic. The inguinal nodes are located in the femoral triangle, based on the inguinal ligament with its apex formed by the crossing of the adductor longus and the sartorius muscles. The pelvic component of the dissection includes the lymph nodes in a triangular area whose apex is formed by the bifurcation of the common iliac artery and whose base is essentially the fascia over the obturator foramen. If the inguinal lymphadenectomy specimen is negative for metastases from the primary malignant melanoma or epidermoid carcinoma of the skin of the extremities or lower trunk, performing the pelvic dissection is probably unnecessary because the incidence of positive nodes will then be less than 5% (Holmes et al.).