Ann Surg Treat Res.  2020 Aug;99(2):72-81. 10.4174/astr.2020.99.2.72.

Compression injury of the circular stapler for gastrointestinal end-to-end anastomosis: preliminary in-vitro study

Affiliations
  • 1Department of Surgery, Pusan National University School of Medicine, Yangsan, Korea
  • 2Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Korea
  • 3Department of Food and Nutrition, College of Medical and Life Science, Silla University, Busan, Korea
  • 4Department of Biomedical Engineering, Pusan National University School of Medicine, Yangsan, Korea
  • 5Biomedical Materials Science, School of Dentistry, University of Birmingham, Birmingham, United Kingdom

Abstract

Purpose
This preliminary in-vitro study was designed to evaluate the risk factors of compression injury from use of a circular stapler for end-to-end anastomosis.
Methods
Transparent collagen plates were prepared in dry and wet conditions. Physical properties of collagen plates and porcine colon tissue were examined using a rheometer. Adjustable and fixed-type circular staplers were applied on the collagen plates and the gap distance and compressive pressure were measured during anvil approximation. Tissue injury was evaluated using a compression injury scale. Compression properties were accessed to optimal or overcompression based on gap distance.
Results
Unacceptable injuries were rarely observed on the dry collagens, regardless of compression device. In the adjustable compression, the compressibility ratio was similar between dry and wet collagen. Overcompression and unacceptable injury increased on the wet collagens. In the fixed compression, the compressibility ratio increased significantly and unacceptable injuries were observed in more than 50% of wet collagens. Peak pressure was significantly higher in the fixed-compression types than those of adjustable type. On bivariate correlation analysis, fixed-compression type and wet collagens were respectively associated with overcompression. On multivariate analysis, edematous collagen condition was the most important risk factor and proximal anvil side, fixed compression type, and overcompression were also independent risk factors for unacceptable compression injury.
Conclusion
In the edematous tissue condition, unintentional overcompression could be increased and result in tissue injury on the compression line of the circular stapler.

Keyword

Anastomotic leak; Colorectal surgery; Soft tissue injuries; Surgical anastomosis; Surgical staplers

Figure

  • Fig. 1 Structure of 2 commercial circular stapler devices. (A) Anvil connecting unit of adjustable-compression type stapler showed round anvil edge and small staple driver on the staple cartridge when firing trigger was fully closed. (B) Fixed-compression type stapler had sharp lip on anvil edge and pusher bar protruding from the staple cartridge. (C) The cross-sectional view of collagen plates on the circular stapler with compressive pressure sensor placed between proximal and distal collagen plates. (D) Controlled tissue compression (CTC) scale and (E) indicator window with green bar on the stapler shafts using indicators for proper compression. (F) Optimal and overcompression depending on the gap distance between anvil and staple cartridge.

  • Fig. 2 Compression injury scale. Acceptable injury was defined as cases in which the depth of tissue injury extended to less than half of collagen thickness (score 1–3); unacceptable injury was defined as cases where the depth of damage exceeded the half of collagen thickness (score 4–5).

  • Fig. 3 The gap distance and unacceptable injury of the adjustable type stapler according to compression propriety on the wet collagen plates. (A) Comparing with optimal compression, the overcompression cases had significantly lower gap distance. (B) The incidence of unacceptable injuries was higher in the overcompression cases than optimal compression cases. *P < 0.05.

  • Fig. 4 Real-time compressive pressure measurements. Compressive pressure curves according to compression type of AC (A), MC (B), and FC (C) on the both dry and wet collagen plates. Peak compressive pressure levels showed significant increment in FC on the dry (D) and wet (E) collagen plates. (F) The upward curve patterns of compressive pressure were different on the collagen conditions. In contrary to steep pressure rising on the dry collagen plates, gradual plateau was showed even after optimal compression point on the wet collagen. AC, adjustable compression; MC, maximal compression; FC, fixed compression; CTC scale, controlled tissue compression scale. *P < 0.05, *P < 0.001.

  • Fig. 5 The bivariate correlation analysis of the risk factors relating unacceptable injury.


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