Influence of crotch suture augmentation on leakage pressure and leakage location during functional end‐to‐end stapled anastomoses in dogs

Abstract

Objective To determine the influence of anastomotic crotch suture augmentation on leakage pressures and leakage location following intestinal functional end‐to‐end stapled anastomosis (FEESA) in dogs. Study design Ex vivo, randomized, experimental. Sample population Chilled jejunal segments from 3 adult dogs. Methods Jejunal specimens were tested within 24 hours of collection. A FEESA was performed and randomly assigned to 1 of 4 treatment groups (n = 12/group): (1) no crotch suture (NCS); (2) simple interrupted crotch suture (SICS); (3) two simple interrupted crotch sutures (TCS) placed laterally on opposing jejunal limbs; (4) simple continuous crotch suture (SCCS) augmentation. Crotch sutures were performed using 3‐0 USP polydioxanone. Initial (ILP) and maximal (MLP) leakage pressures (Mean ± SD mm Hg) and leakage location were recorded and compared between groups. Results Initial leakage pressure was greater after placement of TCS (37.8 ± 6.4, P < .039) and SCCS (47.6 ± 11.0, P < .002) than NCS (27.1 ± 2.5) and SICS (33.0 ± 6.0). Maximal leakage pressure was greater in specimens including SICS, TCS, and SCCS than those without crotch suture augmentation (P < .043). Leakage occurred at the anastomotic crotch in 8/12 NCS, 6/12 SICS, 11/12 TCS, and 12/12 SCCS constructs (P < .001). Conclusion Augmentation of FEESA with TCS and SCCS increased ILP and decreased the occurrence of leakage from the anastomotic crotch, while all methods of anastomotic crotch augmentation increased MLP. Clinical significance Augmenting the FEESA with crotch suture(s) improved the resistance of the jejunal anastomosis to leakage in normal cadaveric segments. Placing 2 crotch sutures or use of a simple continuous pattern for anastomotic augmentation appeared to be superior to the placement of a single suture.

Gastrointestinal thickness, duration, and leak pressure of five intestinal anastomosis techniques in cats

“…Additionally, it has been established that in dogs, addition of a "crotch" suture at the junction of the antimesenteric borders where the GIA staple line ends increases resistance to leakage. 22 This was not performed in our study due to previous literature uncommonly implicating this as a site of leakage; however, the addition of a crotch suture may have increased resistance to leakage within our FEESA groups. 21 In practice, a major advantage to the use of GIA staplers is the fact that they have been demonstrated to have similar outcomes when used by novice versus experienced surgeons.…”

“…No "crotch" suture was applied as has been previously described in some reports. 21,22 2.4.4 | Functional end-to-end stapled anastomosis without oversew (FEESA)…”

Influence of barbed suture oversew of the transverse staple line during functional end‐to‐end stapled anastomosis in a canine jejunal enterectomy model

“…This was, however, purposeful to represent what is clinically available for use in our tertiary referral hospital. Our study did not evaluate additional techniques to reinforce the anastomosis such as omental wrapping, serosal patch placement or different methods of anastomotic crotch augmentation which may be used intraoperatively to augment the FEESA 35,36 . Lastly, we did not leak test the anastomosis using an infusion of saline.…”

“…Our study did not evaluate additional techniques to reinforce the anastomosis such as omental wrapping, serosal patch placement or different methods of anastomotic crotch augmentation which may be used intraoperatively to augment the FEESA. 35,36 Lastly, we did not leak test the anastomosis using an infusion of saline. This may have led to additional sutures being placed which may indirectly have led to changes in ILP, MLP or repair times.…”

Influence of staple line number and configuration on the leakage of small intestinal functional end‐to‐end stapled anastomosis: An ex vivo study

“…Although small intestinal tissues where harvested immediately after euthanasia and tested within 5 h of harvesting, these tissues likely have varying biomechanical properties compared with live dog small intestine tissues with and without disease. Additional limitations to this study include the lack of selection of closed staple height on tissue thickness, lack of histopathological evaluation of intestinal tissues, lack of additional procedures to evaluation staple line integrity (eg probing) 27 , and use of a single, simple interrupted crotch suture to augment the FEESA. 28 In summary, a FEESA constructed with a 3-row linear stapler for the vertical and transverse staple line or transverse staple line alone, using a 1.5 mm closed staple height, increased ILP compared to construct creation using 2-rows.…”