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Comparing stapling devices

Stapling devices: better mucosal capture has higher leak pressures

Ethicon Echelon Flex GST System associated with a stronger staple line and higher leak pressures vs. Endo GIA Reload with Tri-Staple Technology

A study evaluating how the interaction between the surgical stapler and tissue may impact staple-line integrity and leak pressure, has concluded that there are differences in the degree of mucosal capture between commercial staplers and that there is a relationship between mucosal capture, leak site location and initial leak pressure.

Anastomotic leaks, although rare, are a leading cause of morbidity and mortality in gastrointestinal surgery, and staple-line integrity is an important factor in preventing the complications of these leaks. The study by Thompson et al, ‘Initial Assessment of Mucosal Capture and Leak Pressure After Gastrointestinal Stapling in a Porcine Model’, published in Obesity Surgery, sought to better understand how stapling devices may impact leaks in gastrointestinal surgery.

The mucosa layer, the inner most lining of the gastrointestinal tract, provides a barrier that prevents bacteria from entering the internal tissues, therefore helping to limit infections. The serosal aspect of staple lines is commonly observed for integrity, but the mucosal surface and state of mucosa after firing is less often inspected. As a result, Thompson and colleagues initiated a study to assess how capturing all layers of the tissue, including the mucosa, in the staple line influences staple-line and anastomotic integrity.

In the animal study, the porcine ileum was transected in vivo and staple lines were collected and rated for degree of mucosal capture on a five-point scale from one (mucosa mainly captured on both sides) to five (majority of mucosa not captured). Mucosal capture was also assessed in ex vivo staple lines, and fluid leakage pressure and location of first leak was also assessed.

The stapling devices studied were Echelon Flex GST with 60mm blue (GST60B) and green (GST60G) cartridges (Ethicon), and Endo GIA Universal with Tri-Staple Technology with 60mm medium (EGIA60AMT) reloads (purple) (Medtronic).

The results revealed that the GST60B and GST60G staple lines produced significantly better mucosal capture scores than the EGIA60AMT staple lines (p<0.001, in all tests). Compared to EGIA60AMT, leak pressures were 39% higher for GST60B (p<0.001) and 23% higher for GST60G (p=0.022). Initial staple line leak site was associated with incomplete mucosal capture 78% of the time.

It is believed this is the first study to show that the degree of mucosal capture may play a role in initial leak pressure, supported by the fact that first leak occurred predominately in the areas where mucosal capture was poor - therefore suggesting mucosal capture may be an important factor in initial staple line and anastomotic integrity. 

“There are differences in degree of mucosal capture between commercial staplers, and the devices that produce better mucosal capture had significantly higher leak pressures,” the researchers concluded. “Further research is needed to determine the significance of these findings on staple line healing throughout the postoperative period.”

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