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Intimal Surface Suture Line (End-Product) Assessment of End-to-Side Microvascular Anastomosis.

ABSTRACT: Microsurgery simulation courses increasingly use assessment methodologies to evaluate the quality of microvascular anastomosis and to provide constructive feedback in competency-based training. Assessment tools evaluating the "journey" of skill acquisition in anastomosis have evolved, including global rating scores, hand motion analysis, and evaluation of the final outcome, that is, "end-product" assessment. Anastomotic patency is the gold standard end-product in clinical microvascular surgery, and in vivo end-to-side anastomosis, which can be confirmed using the Acland-test. Microsurgery simulation training is moving to include nonliving models, where possible, according to the principles of the replacement, reduction, and refinement of the use of animals in research. While a standardized end-product assessment tool for nonliving end-to-end anastomosis exists, there is no similar tool for end-to-side anastomosis. Intimal surface suture line assessment is an error list-based tool, which involves exposing the intimal surface of a vessel and analysis of the quality of suture placement. Errors in end-to side anastomosis were classified according to the potential clinical significance (high, medium, or low) perceived by the senior authors. Intimal surface suture line assessment provides constructive feedback during microsurgery training, helping to minimize technical errors, which are likely to impact on the final outcome in a clinical environment. Intimal surface suture line assessment lends itself to nonliving simulation training courses as an end-product self-assessment tool, especially during the early learning curve, to demonstrate progression. It has intraoperative relevance by assessment of the intimal surface suture line as the final sutures are placed in an end-to-side anastomosis to provide objective feedback to trainees in relation to likely physiological anastomotic outcome.

SUBMITTER: Pafitanis G

PROVIDER: S-EPMC5548573 | biostudies-other | 2017 Jul

REPOSITORIES: biostudies-other

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Project description:BackgroundThe application of side-to-end anastomosis (SEA) in sphincter-preserving resection (SPR) is controversial. We performed a meta-analysis to compare the safety and efficacy of SEA with colonic J-pouch (CJP) anastomosis, which had been proven effective in improving postoperative bowel function.MethodsThe protocol was registered in PROSPERO under number CRD42020206764. PubMed, Embase, Web of Science, and the Cochrane Register of Controlled Trials databases were searched. The inclusion criteria were randomized controlled trials (RCTs) that evaluated the safety or efficacy of SEA in comparison with CJP anastomosis. The outcomes included the pooled risk ratio (RR) for dichotomous variables and weighted mean differences (WMDs) for continuous variables. All outcomes were calculated with 95% confidence intervals (CI) by STATA software (Stata 14, Stata Corporation, TX, USA).ResultsA total of 864 patients from 10 RCTs were included in the meta-analysis. Patients undergoing SEA had a higher defecation frequency at 12 months after SPR (WMD = 0.20; 95% CI, 0.14-0.26; P < 0.01) than those undergoing CJP anastomosis with low heterogeneity (I2 = 0%, P = 0.54) and a lower incidence of incomplete defecation at 3 months after surgery (RR = 0.28; 95% CI, 0.09-0.86; P = 0.03). A shorter operating time (WMD = - 17.65; 95% CI, - 23.28 to - 12.02; P < 0.01) was also observed in the SEA group without significant heterogeneity (I2 = 0%, P = 0.54). A higher anorectal resting pressure (WMD = 6.25; 95% CI, 0.17-12.32; P = 0.04) was found in the SEA group but the heterogeneity was high (I2 = 84.5%, P = 0.84). No significant differences were observed between the groups in terms of efficacy outcomes including defecation frequency, the incidence of urgency, incomplete defecation, the use of pads, enema, medications, anorectal squeeze pressure and maximum rectal volume, or safety outcomes including operating time, blood loss, the use of protective stoma, postoperative complications, clinical outcomes, and oncological outcomes.ConclusionsThe present evidence suggests that SEA is an effective anastomotic strategy to achieve similar postoperative bowel function without increasing the risk of complications compared with CJP anastomosis. The advantages of SEA include a shorter operating time, a lower incidence of incomplete defecation at 3 months after surgery, and better sphincter function. However, close attention should be paid to the long-term defecation frequency after SPR.

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Intimal Surface Suture Line (End-Product) Assessment of End-to-Side Microvascular Anastomosis.

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