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首页> 外文期刊>Vascular and endovascular surgery >Stapled aortic anastomoses: a minimally invasive, feasible alternative to videoscopic aortic suturing?
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Stapled aortic anastomoses: a minimally invasive, feasible alternative to videoscopic aortic suturing?

机译：吻合式主动脉吻合术：一种微创，可行的替代方法，用于视频主动脉缝合？

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摘要

Widespread applications of totally laparoscopic aortic reconstructions have been limited by the long cross-clamp time required to suture the aortic anastomosis despite improvement in instrumentation. The authors' hypothesis was that a "one-step anastomosis concept" using an intraluminal stapler would allow shorter cross-clamp time but similar patency and imperviousness as videoscopic suturing techniques. An intraluminal stapler (Endopath-ILS, Ethicon) with a modified anvil was used to perform videoscopic-assisted thoracic aorta-to-iliac artery bypass with a 21 mm by 8 mm polytetrafluoroethylene (PTFE) graft in 22 sheep through a minimally invasive approach using a 5 cm thoracotomy. The graft-to-iliac artery anastomoses were hand sutured through a flank incision. Twelve sheep were used to establish the technique and 10 subsequent animals constituted the study group. Aortic cross-clamp time, imperviousness, and need for additional sutures were recorded and compared to previously reported data using videoscopic suturing in pigs. Patency was assessed by comparing lower limb arterial pressures. Macroscopic and microscopic examinations of the anastomoses were performed at different time-points within the first 3 months. Videoscopic-assisted stapled anastomoses were also performed on atherosclerotic aortas of 3 human cadavers. Stapled anastomoses between the thoracic aorta and PTFE graft were completed in 8 of 10 animals. Two animals were euthanized after stapler failure and anastomotic bleeding. Sutures to strengthen the anastomosis had to be used in 4 cases. Mean aortic cross-clamp time in 8 successful cases was 4.3 +/-2.9 minutes (range 2-11 minutes) and was significantly shorter than clamp time of videoscopic suturing technique (48.7 +/-9.4 minutes, p < 0.0001). Imperviousness was good or excellent in 4 animals and fair in 4 animals. All anastomoses were patent at the end of the procedure. Examination of the anastomosis of the 2 failed interventions showed medial aortic tear surrounding the anastomosis in 1 case and misfired staples in the other. No graft occlusion was noted during follow-up ranging from 0 to 12 weeks. At the time of harvest, no bleeding was noted after epinephrine and volume infusion to increase mean arterial pressure to 200 mm Hg for 15 minutes. Macroscopic examination of the anastomoses revealed adequate healing with circumferential stapling of the prosthesis to the aortic wall and no stenosis or thrombus except in 1 false aneurysm (1/7, 14%). Surface electron microscopy showed cells coverage of the anastomosis surface. When applied on human cadaver thoracic and abdominal aorta with atherosclerotic changes, clamping times of less than 5 minutes were achieved. However, imperviousness tested with saline was poor. An automatic stapling device allows performance of a graft-to-aorta anastomosis through a minimally invasive approach with shorter clamping time than a videoscopic suturing technique. However, the current technique of aortic stapling is unreliable and further improvements are needed.
机译：尽管仪器改进，但缝合腹主动脉吻合术所需的较长的交叉钳夹时间限制了全腹腔镜主动脉重建术的广泛应用。作者的假设是，使用腔内吻合器的“一步吻合概念”将允许更短的交叉钳夹时间，但与视频缝合技术具有相似的通畅性和不渗透性。腔内吻合器（Endopath-ILS，Ethicon）和改良的砧座通过微创方法使用22毫米羊的21毫米乘8毫米聚四氟乙烯（PTFE）移植物，通过视频辅助胸主动脉至-动脉搭桥术5厘米的开胸手术。人工缝合hand侧动脉吻合口。使用十二只绵羊来建立该技术，随后的十只动物组成了研究组。记录主动脉跨钳时间，不透性和需要额外缝合的情况，并使用视频缝合法将其与以前报道的数据进行比较。通过比较下肢动脉压评估通畅性。在头三个月内的不同时间点对吻合口进行宏观和微观检查。还对3具人体尸体的动脉粥样硬化主动脉进行了视频辅助吻合钉吻合术。 10只动物中有8只完成了胸主动脉和PTFE移植物之间的吻合吻合术。在订书机失败和吻合口出血后对两只动物实施安乐死。有4例必须使用缝合线以加强吻合。在8例成功病例中，平均主动脉交叉钳夹时间为4.3 +/- 2.9分钟（范围2-11分钟），明显短于视频缝合技术的钳夹时间（48.7 +/- 9.4分钟，p <0.0001）。不可渗透性在4只动物中是好还是极好，在4只动物中是一般的。手术结束时所有吻合口均已获得专利。对2例失败的干预措施的吻合情况进行检查后发现，其中1例在吻合处周围有内侧主动脉撕裂，而另一例则没有吻合钉书钉。在0至12周的随访期间未发现移植物阻塞。在收获时，肾上腺素和大剂量输注后15分钟未见出血，以使平均动脉压升至200 mm Hg。宏观检查吻合口发现，假体在1个假动脉瘤中（1 / 7，14％），假体周向吻合到主动脉壁并没有狭窄或血栓，可以充分治愈。表面电子显微镜显示吻合表面的细胞覆盖。当将其应用于具有动脉粥样硬化变化的人尸体胸主动脉和腹主动脉时，夹紧时间不到5分钟。但是，用盐水测试的不渗透性很差。自动缝合装置允许通过微创方法实现移植物至主动脉的吻合，其夹持时间比视频缝合技术短。然而，当前的主动脉吻合技术是不可靠的，需要进一步的改进。

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