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Background: We aimed to investigate the effects of nerve repair by setting a side-to-side (H-shaped) nerve graft on the most distal part of the damaged nerve to the adjacent intact nerve to accelerate its regeneration in the end organ. Methods: This pure experimental study was done on the lower extremities of two groups of rabbits in Animal Laboratory Department, 15 Khordad Hospital Tehran, Iran. In both groups, the sciatic nerve at the proximal part of the extremity below the superficial femoral branch was first cut and then repaired. In the investigation group, side-to-side H-shaped nerve grafts were applied between the sciatic and superficial femoral nerves (i.e., two branches) at the most distal to the cut site of the sciatic nerve below the superficial femoral branch at the lower extremity. The sciatic nerve was conventionally repaired in the control group. Results: None of the rabbits' feet in the control group respond to pain stimulation (were without senses) and had ulcers. They had numb legs and went lame. All had muscular atrophy and lacked nerve growth (regeneration) according to pathology. In the investigation group, 86.7% of the rabbits responded to pain stimulation and only 13.3% of them had ulcers. In addition, in pathology report, 13.3% had suffered muscular atrophy and lacked nerve regeneration. Therefore, nerve regeneration was successful in 86.7% of rabbits who underwent H-shaped nerve grafts. Conclusion: Side-to-side H-shaped nerve graft at the most distal part of an injured nerve may cause successful recovery of high (proximal) nerve injury.

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Background: Despite continuous advances in microsurgical and endovascular techniques, the treatment of complex aneurysms remains challenging. Aneurysms that are dilemmatic for conventional clipping or endovascular coiling often require bypass as part of a strategy to reduce the risk of ischemic complications. In anatomically favorable sites, the intracranial-intracranial in situ bypass may be an appealing choice. This article details the surgical strategies, operative nuances, and clinical outcomes of this technique with a consecutive series in our department. Methods: A retrospective review of a prospectively maintained neurosurgical patient database was performed to identify all patients treated with side-to-side in situ bypass from January 2016 to June 2022. In total, 12 consecutive patients, including 12 aneurysms, were identified and included in the series. The medical records, surgical videos, neuroimaging studies, and follow-up clinic notes were reviewed for every patient. Results: Of the 12 aneurysms, there were 5 middle cerebral artery aneurysms, 4 anterior cerebral artery aneurysms, and 3 posterior inferior cerebellar artery aneurysms. The morphology of the aneurysms was fusiform in 8 patients and saccular in the remaining 4 patients. There were 3 patients presented with subarachnoid hemorrhage. The treatment modality was simple in situ bypass in 8 cases and in situ bypass combined with other modalities in 4 cases. Bypass patency was confirmed in all cases by intraoperative micro-doppler probe and (or) infrared indocyanine green (ICG) video angiography intraoperatively and with digital subtraction angiography (DSA) or computed tomography angiography (CTA) postoperatively. None of the patients developed a clinically manifested stroke due to the procedure though a callosomarginal artery was intentionally removed in one patient. The median follow-up period was 16.2 months (6-36). All patients had achieved improved or unchanged modified Rankin scale scores at the final follow-ups. Conclusion: Cerebral revascularization technique remains an essential skill for the treatment of complex aneurysms. The in situ bypass is one of the most effective techniques to revascularize efferent territory when vital artery sacrifice or occlusion is unavoidable. The configuration of in situ bypass should be carefully tailored to each case, with consideration of variations in anatomy and pathology of the complex aneurysms.

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OBJECTIVES: Minimally invasive esophagectomy has improved over time becoming faster and less invasive. We have changed our technical approach from multiportal to uniportal video-assisted thoracoscopic surgery (VATS) esophagectomy over the years. In this study, we analysed our results with uniportal VATS esophagectomy technique. METHODS: This study was a retrospective analysis of 40 consecutive patients with the intent to perform uniportal VATS esophagectomy for esophageal cancer between July 2017 and August 2021. Demographic criteria, comorbidities, neoadjuvant therapy, intraoperative data, complications, length of stay, pathological data, 30- and 90-day mortality and 2-year survival data were recorded. RESULTS: Forty patients (21 female) were operated (median age 62.9 [53.5-70.25]). Eighteen patients (45%) received neoadjuvant chemoradiation. The chest part of all cases was started with uniportal VATS and 31 (77.5%) was completed uniportally (34 Ivor Lewis, 6 McKeown). The median thoracic operation time in minimally invasive Ivor Lewis esophagectomy was 90 min (77.5-100). The median time for uniportal side-to-side anastomosis was 12 min (11-16). Five (12.5%) patients had leak, and 4 were intrathoracic. Twenty-eight (70%) patients had squamous cell carcinoma, 11 adenocarcinoma and 1 squamous cell carcinoma with sarcomatoid differentiation. Thirty-seven (92.5%) patients had R0 resection. The mean number of lymph nodes dissected was 24 ± 9.5. Thirty- and ninety-day mortality was 2.5% (n = 1). The mean follow-up was 44 ± 2.8 months. Two-year survival was 80%. CONCLUSIONS: Uniportal VATS esophagectomy is a safe, fast and feasible alternative to other minimally invasive and open approaches. Comparable results to contemporary series are observed in perioperative and oncologic outcomes.

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To optimize the efficiency of ileocolic anastomosis following right hemicolectomy, several variations of the surgical technique have been tested. These include performing the anastomosis intra- or extracorporeally or performing a stapled or hand-sewn anastomosis. Among the least studied is the configuration of the two stumps (i.e., isoperistaltic or antiperistaltic) in the case of a side-to-side anastomosis. The purpose of the present study is to compare the isoperistaltic and antiperistaltic side-to-side anastomotic configuration after right hemicolectomy by reviewing the relevant literature. High-quality literature is scarce, with only three studies directly comparing the two alternatives, and no study has revealed any significant differences in the incidence of anastomosis-related complications such as leakage, stenosis, or bleeding. However, there may be a trend towards an earlier recovery of intestinal function following antiperistaltic anastomosis. Finally, existing data do not identify a certain anastomotic configuration (i.e., isoperistaltic or antiperistaltic) as superior over the other. Thus, the most appropriate approach is to master both anastomotic techniques and select between the two configurations based on each individual case scenario.

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INTRODUCTION: The distal end anastomosis is critical to the entire sequential grafts in coronary artery bypass grafting (CABG), but caliber mismatch diminishes the quality of the anastomosis. We aimed to introduce a modified distal end side-to-side (deSTS) anastomosis to handle the size mismatch and compared with classic distal end end-to-side (deETS) anastomosis. METHODS: From January 2014 to December 2018, 185 patients who underwent off-pump CABG with size mismatched sequential vein grafts (≥3.5 mm) and target coronaries (1.0-1.5 mm) at the distal end anastomoses were included. We retrospectively reviewed the data of the patients, perioperative and follow-up outcomes were analyzed. RESULTS: The deSTS group (n = 67) showed higher anastomotic flow (19.8 ± 8.0 vs 14.9±6.8 mL/min; p < 0.001) and lower pulsatility index (2.7 ± 0.8 vs 3.2 ± 1.0; p = 0.001) than the deETS group (n = 118). Higher incidence of in-hospital myocardial infarction (MI) was found in the deETS group but without significant difference (9.0% vs. 15.3%; p = 0.220). Kaplan-Meier analysis illustrated a relatively lower MI and major adverse cardiovascular and cerebrovascular events (MACCE) incidence in the deSTS group, and the deSTS group was associated with a reduction in long-term death, MI and MACCE in the adjusted Cox regression model. In addition, relatively higher graft patency was found in the deSTS group. CONCLUSIONS: The deSTS anastomosis showed superiority in solving size mismatch in sequential CABG, including better intraoperative flow dynamics, ideal long-term graft patency and reduced the incidence of perioperative and follow-up adverse events especially in MI.

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INTRODUCTION: Although stapled anastomoses have been widely evaluated in the context of the elective surgery, few reports compared manual with stapled anastomoses in patients undergoing emergency surgery. The aim of this study is to compare the outcome of hand-sewn end-to-end anastomoses with stapled side-to-side and stapled end-to-side anastomoses in patients undergoing small bowel resection for acute mesenteric ischemia secondary to intestinal obstruction. METHODS: From January 2015 to June 2021 all the hemodynamically stable patients undergoing emergency surgery with small bowel resection for intestinal obstruction were enrolled in this study. According to surgical technique in performing anastomosis, the patients were divided into three groups: group 1: hand-sewn end-to-end anastomosis, group 2: stapled end-to-side anastomosis, and group 3: stapled side-to-side anastomosis. RESULTS: Although the anastomosis failure rate was higher in group 3, it was not significantly different between the three groups (P = 0.78: chi-square test). Likewise, no significant differences in the median hospital stay were found between the patients' groups (P = 0.87: Kruskal-Wallis test). The median operating time was similar in patients undergoing stapled anastomoses and was significantly higher in patients undergoing hand-sewn anastomoses (P = 0.0009: Kruskal-Wallis test). CONCLUSIONS: In patients undergoing emergency small bowel resection for complicated intestinal obstruction, a similar outcome in terms of dehiscence rate and hospital stay can be achieved performing stapled or hand-sewn anastomoses, even if restoring the intestinal continuity with stapled technique is associated with lower operating time.

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The adoption of minimally invasive esophagectomy has been used for over a decade, and the chest part is evolving into a uniportal video-assisted thoracoscopic surgery (VATS) approach. Uniportal esophageal mobilization and anastomosis have many peculiar aspects, which include placement of the incision, alignment of instruments, and anastomosis. The incision is placed over the sixth intercostal space posterior axillary line. The esophagus is usually encircled at the level of the inferior pulmonary vein. The use of curved suction helps in the retraction of the esophagus and the exposure of the left main bronchus deep in the mediastinum. For intrathoracic anastomosis in Ivor Lewis esophagectomy, a completely side-to-side linear-stapled anastomosis is preferred. This anastomotic technique results in a long stapler line. The correct alignment of tissues and adequate anastomotic circumference are of utmost importance to prevent leaks or strictures. Perioperative and oncologic results in several series with uniportal VATS, esophageal mobilization, and anastomosis are comparable with open or other types of minimally invasive esophagectomy. Uniportal VATS for esophagectomy is feasible and fast with good results.

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Objective To study the difference in thrombus formation at distal end of the graft with two different treatments.Methods For coronary artery bypass grafting with distal-end side-to-side anastomosis (DESSA), two models with or without distal end trimming of the graft were established. Using the blood substance transport and diffusion model considering biochemical reactions, combined with hemodynamics parameters of shear rate, fluid residence time, and platelet distribution, the possibility of thrombus formation was evaluated. Numerical simulation method was used to investigate thrombus growth in coronary artery bypass grafting with DESSA.ResultsFor the model without distal end trimming of the graft, the thrombus was first formed on inner wall at distal end of the graft, and then grew inward until the thrombus occupied most of the graft region at distal end, which indicated that thrombus formation was in a stable state, and the volume of the thrombus didn’t change, the final volume of the thrombus was 15.05 mm3. For the model with distal end trimming of the graft, the final volume of the thrombus was 7.35 mm3, which was 51.2% smaller than that of the model without distal end trimming of the graft. Thrombus was formed on inner wall of the graft above the anastomosis for the model with distal end trimming of the graft, and the wall thickness was about 0.16 mm, which was 10.65% of the graft radius (1.50 mm). In the above two procedures, multiple vortices (blood flow velocity less than 10 mm/s) were formed in distal region of the graft, which further promoted thrombus formation at distal end of the graft. The area of thrombus formation obtained from numerical simulation was consistent with clinical investigation.Conclusions For clinical coronary artery bypass grafting with DESSA, the volume of the generated thrombus can be reduced for the model with distal end trimming of the graft. However, the effect of thrombus formation on inner wall of the graft above the anastomosis on coronary artery bypass grafting needs further study.

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BACKGROUND: The aim of this report is to present our experience of the last 5 years with repairs of congenital annular pancreas in neonates to determine the efficacy and outcomes of laparoscopic side-to-side duodenoduodenostomy compared to laparoscopic diamond-shaped anastomosis. METHODS: A total of 35 patients with congenital annular pancreas in neonates were operated by laparoscopic procedure at our hospital during January 2015 and September 2020. Twenty patients underwent laparoscopic side-to-side duodenoduodenostomy (group A), and 15 patients of the control group underwent laparoscopic diamond-shaped anastomosis (group B). The clinical data between the two groups were compared. RESULTS: The operative time is 77.5 ± 18.7 min in group A (range 50 ~ 125 min), and 92.5 ± 20.2 min in group B (range 75-155 min) (P = 0.029). Feedings started on postoperative day 4.5 ± 0.9 (range 3-6 days) in group A, whereas 6.5 ± 0.8 (range 4-7 days) in group B (P = 0.013). The cases in group A were discharged uneventfully in a mean of 9.2 ± 2.3 (range 7-15 days) postoperative day, and 11.4 ± 3.7 days (range 8-20 days) in group B (P = 0.041). The cases of group A have been followed up for 33.1 ± 15.4 months (range 3-60 months), group B had been followed up for 32.0 ± 14.0 months (range 6-55 months) (P > 0.05), and all the cases were doing well at the last follow-up examination. CONCLUSION: Laparoscopic side-to-side duodenoduodenostomy is beneficial to the recovery of intestinal function postoperatively in the neonate with annular pancreas.

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Totally minimally invasive Ivor-Lewis esophagectomy (TMIIL) is associated to lower rate of post-operative complication, decreases length of hospital stay and improves quality of life compared to open approach. Nevertheless, adaptation of TMIIL still proceeds at slow pace, mainly due to the difficulty to perform the intra-thoracic anastomosis and heterogeneity of surgical techniques. We present our experience with TMIIL utilizing a stapled side-to-side anastomosis. We retrospectively evaluated 36 patients who underwent a planned TMIIL from January 2017 to September 2020. Esophagogastric anastomoses were performed using a 3-cm linear-stapled side-to-side technique. General features, operative techniques, pathology data and short-term outcomes were analyzed. The median operative time was 365 min (ranging from 240 to 480 min) with a median blood loss of 100 ml (50-1000 ml). The median overall length of stay was 13 (7-64) days and in-hospital mortality rate was 2.8%. Two patients (5.6%) had an anastomotic leak, without need for operative intervention and another patient developed an anastomotic stricture, resolved with a single endoscopic dilation. Chylothorax occurred in three patients; two of these required a surgical intervention. Pulmonary complications occurred in six patients (16.7%). Based on Comprehensive Complications Index (CCI), median values of complications were 27.9 (ranging from 20.9 to 100). The results of our study suggest that TMIIL with a 3-cm linear-stapled anastomosis seems to be safe and effective, with low rates of post-operative anastomotic leak and stricture.

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BACKGROUND: Randomized controlled trials (RCTs) comparing intracorporeal anastomosis (IA) and extracorporeal anastomosis (EA) could not prove a significant reduction in postoperative stay and therefore did not provide sufficient evidence of IA. Recently, we reported a new intracorporeal anastomosis method and intracorporeal end-to-end anastomosis (IEEA). However, there have been no studies comparing intracorporeal side-to-side anastomosis (ISSA) to IEEA. PURPOSE: The main purpose of this study is to verify the superiority of IA over EA. The secondary purpose is to compare IEEA with ISSA. METHODS: Patients scheduled to undergo laparoscopic colectomy for colon cancer are recruited to the CONNECT study (multicenter, single-blind, randomized controlled study), cases in which anastomosis by the double-stapling technique is planned will be excluded. The target sample size is set at 300 cases in total, which will be randomized into 3 groups (EA, IEEA, and ISSA) in a 2:1:1 ratio. The primary endpoint is the length of postoperative hospital stay in the IA and EA groups; the secondly endpoint is the anastomotic time in IEEA and ISSA groups. We will also evaluate SF-36 ver.2, EORTC QLQ-C30 ver.3, operator stress using SURG-TLX, and the long-term outcomes, such as 5-year disease-free survival and overall survival. CONCLUSIONS: This RCT will compare the postoperative length of stay between IA and EA in twice the number of cases of previous RCTs. Concurrently, although as a secondary purpose, this will be the first study to compare IEEA and ISSA. TRIAL REGISTRATION: This trial was registered with the UMIN Clinical Trials Registry in September 2020 as UMIN000041565.

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The common limitation of surgical revascularization procedures for severe tissue ischemia due to cardiovascular diseases is the need to interrupt blood flow during the intervention. We aim to introduce a new technique that allows a sutureless, non-occlusive revascularization. A 3-step technique was developed using rabbit's aorta to simulate a side-to-side anastomosis model. It enables the creation of a bypass circuit for revascularization. The first step was the soldering of 2 vessels in a side-to-side fashion based on the laser-assisted vascular anastomosis (LAVA) principle using a diode laser emitting irradiation at 810 nm with an albumin-based solder patch between them, followed by the creation of a channel within the patch using either a holmium-doped yttrium aluminum garnet laser (Ho:YAG) at λ = 2100 nm or a xenon-chloride excimer laser (XeCl) at λ = 308 nm. Thereby, a bypass circuit was created, thus allowing a non-ischemic revascularization. The system was deemed functional when a flow was observed across the anastomosis. The highest average tensile strength recorded after side-to-side LAVA using a diode laser power of 3.2 W for 60 s was 2278.6 ± 800 mN (n = 20). The Ho:YAG laser created the channels with less tension on the anastomosis than the excimer laser. Histological analysis showed limited thermal damage and good patch-tissue adaptation. The preliminary results of this feasibility study outline the foundations for an entirely sutureless laser-assisted revascularization procedure. The next studies will evaluate the rheological parameters across the bypass circuit to optimize the post-anastomotic flow.

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Various conditions in human and veterinary medicine require intestinal resection and anastomosis, and complications from these procedures are frequent. A rapidly collapsible anastomotic guide was developed for small intestinal end-to-end anastomosis and was investigated in order to assess its utility to improve the anastomotic process and to potentially reduce complication rates. A complex manufacturing method for building a polymeric device was established utilizing biocompatible and biodegradable polyvinylpyrrolidone and polyurethane. This combination of polymers would result in rapid collapse of the material. The guide was designed as a hollow cylinder composed of overlaying shingles that separate following exposure to moisture. An in vivo study was performed using commercial pigs, with each pig receiving one standard handsewn anastomosis and one guide-facilitated anastomosis. Pigs were sacrificed after 13 days, at which time burst pressure, maximum luminal diameter, and presence of adhesions were assessed. Burst pressures were not statistically different between treatment groups, but in vivo anastomoses performed with the guide withstood 10% greater luminal burst pressure and maintained 17% larger luminal diameter than those performed using the standard handsewn technique alone. Surgeons commented that the addition of a guide eased the performance of the anastomosis. Hence, a rapidly collapsible anastomotic guide may be beneficial to the performance of intestinal anastomosis.

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BACKGROUND: Magnetic compression anastomosis (MCA) is mainly applied in the gastrointestinal and biliary tracts through a nonsurgical procedure that can create an anastomosis similar to that obtained through surgery. Magnets usually adsorb in the end-to-end direction (end-to-end anastomosis), exert a strong magnetic force and create an anastomosis according to the size of the magnets. Regular endoscopic dilation is required to prevent restenosis when the anastomotic size is small. We report a case in which MCA was successfully used to treat anastomotic stenosis of the sigmoid colon; the magnets adsorbed in the side-to-side direction rather than the end-to-end direction and generated a wide anastomosis in a short time that did not require endoscopic dilation. CASE PRESENTATION: An 81-year-old woman was admitted to our hospital to treat anastomotic stenosis of the sigmoid colon for closure of transverse colostomy. Two years prior, the Hartmann operation and drainage were performed at other hospitals due to perforated diverticulitis of the sigmoid colon. Obstruction of the sigmoid colostomy occurred, and a transverse colostomy was performed. One year after the first surgery, high anterior resection was performed, but anastomotic stenosis occurred, causing obstruction. MCA was planned because the patient had a history of multiple operations and was expected to have strong adhesions postoperatively. MCA was safely performed, but two magnets were accidently adsorbed in the side-to-side direction. The magnet position could not be changed. The two magnets were expected to move and adsorb in an end-to-end direction naturally due to bowel movements. The magnets that adsorbed in the side-to-side direction dropped from the anus 5 days after treatment, and the anastomosis was observed by colonoscopy. Three ileus tubes were placed from the transverse colostomy beyond the anastomosis to prevent restenosis. Colonoscopy showed that the anastomosis diameter was wider than expected at 14 days after treatment, and endoscopic dilation was not necessary. No complications were observed in this patient's postoperative course. Finally, closure of the patient's colostomy was successfully performed. CONCLUSIONS: MCA with side-to-side anastomosis generated a wide anastomosis in a short time.

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The purpose of this study was to compare side-to-side and functional end-to-end anastomosis techniques that are commonly used in bowel surgery. Considering the dimensions of these two different anastomosis models, SolidWorks program was used for 3 D studies. Intra-intestinal flow analyzes were performed based on the finite volume method using Ansys Fluent, a computational fluid Dynamics (CFD) program. The flow velocity, pressure, turbulent knetic energy, turbulence vortex distribution, vortex viscosity and wall shear stresses for each model were calculated in results of the analysis for the side-to-side and functional end-to-end anastomosis technique. Due to the geometrical structure of the functional end - to - end anastomosis model, turbulence and hence the vortex formation is less than the side - to - side anastomosis technique. Because intersect area of bowels has wider in functional end - to - end anastomosis model, flow become easier than other. In surgical practice, functional end-to-end anastomosis is preferred over side-to-side anastomosis because of the low probability of leakage. It can be noted that the functional end - to - end anastomosis technique will be safer because of less turbulence, based on the data of fluid flow velocities, pressure, turbulent knetic energy, turbulence vortex distribution, vortex viscosity and wall shear stresses in the anastomosis.

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Background. Anastomotic leakage (AL) remains one of the serious complications after colonic surgery. Method. A prospective interventional study to assess a modified technique of creating the ileocolic, colic-colic, and colorectal side-to-side anastomoses using a circular stapler. The primary endpoint was to evaluate the safety and efficacy of this technique in the reduction of AL. Computed tomography scan was performed when AL was clinically suspected. Result. One hundred and forty-five patients who underwent colonic resection between January 2015 and August 2018 were included. One patient underwent surgery for severe inflammatory bowel disease, and the others underwent surgery for colonic cancer. The procedures were open surgeries, including right hemicolectomy (n = 79 [54.5%]), left hemicolectomy (n = 29 [20%]), sigmoidectomy (n = 30 [20.7%]), and transverse colectomy (n = 7 [4.8%]). In 23 patients with ascending colonic obstruction, emergency right colectomy with primary anastomosis was performed. Two surgeons performed the operations (52.4% and 47.6%, respectively), and intraoperative blood loss was 50 to 100 mL. The operative time was 160 to 240 minutes. There was no mortality postoperatively, and 26 (17.9%) patients developed complications. One patient who underwent transverse colonic cancer resection developed a clinical AL (0.7%). After ileostomy, the patient was discharged with no other serious complication. The median of postoperative hospital stay was 8 days (range = 5-18 days). Conclusion. This modified technique is a safe and efficient method for anastomotic configuration in colonic surgery.

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Digestive tract reconstruction with side-to-side esophagojejunostomy is one of the most commonly used digestive tract reconstruction methods after laparoscopic total gastrectomy. It does not need an auxiliary incision. The linear stapler is used to directly enter the abdominal cavity through the Trocar to perform side-to-side anastomosis of esophagojejunostomy. The common hole can be closed by hand suture or linear stapler. 4K laparoscopy can present a clearer and more realistic view to the operators, so as to realize side-to-side esophagojejunostomy more accurately, to reduce the postoperative anastomo-tic related complications and improve the safety of the operation. This article will elaborate the technical key points and difficulties of esophagojejunostomy in 4K laparoscopic total gastrectomy, as well as the prevention and treatment of anastomotic related complications.

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OBJECTIVE: In situ side-to-side (STS) revascularization is an intracranial-intracranial bypass technique that is increasingly used to treat complex aneurysms and cerebral ischemia. This sophisticated technique involves connecting 2 proximal parallel vessels to create an artificial conduit for blood flow. This study aims to provide a detailed description of the configuration of the STS bypass technique and extensive information regarding its technical characteristics, current anastomosis approaches, and surgical significance. METHODS: A literature search was performed using the PubMed, Medline, ScienceDirect, Embase, Wiley Online Library, Cambridge Journals, SAGE Journals, Oxford Journals, Research Gate, and Google Scholar databases. The terms "intracranial-intracranial bypass," "in situ bypass," "communicating bypass," and "STS anastomosis" were searched to identify pertinent articles. Articles involving in situ STS anastomosis combined with other bypass methods were excluded. Computer tablet-drawn illustrations of this technique are provided to enhance comprehension. RESULTS: In total, 70 articles that met our search and inclusion criteria were identified. Overall, the radiographic and clinical outcomes of 132 (125 aneurysms and 7 cerebral ischemias) patients who underwent in situ STS revascularization were analyzed. CONCLUSIONS: Intracranial-intracranial bypass in the STS fashion can be a safe and effective strategy for the management of complex intracranial aneurysms and cerebral ischemia and is particularly attractive in rescue, anticipated, and troubleshooting cases. Despite its extreme rarity, a de novo aneurysm may be observed after STS anastomosis; thus, long-term follow-up is mandatory. Vascular neurosurgeons should consider including this procedure in their treatment armamentarium.

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In situ side-to-side (STS) anastomosis is a unique technique used for intracranial artery-intracranial artery revascularization. Over a 7-year period, 7 STS anastomoses were performed for anterior cerebral artery aneurysms in 6 patients and a posteroinferior cerebellar artery aneurysm in 1 patient. We provide a step-by-step guide for suturing techniques from arteriotomy to vessel wall sutures based on clinical experiences, with detailed illustrations. Technical considerations in each stage are also discussed. The current technique provides a viable option for treatment of complex aneurysms.

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BACKGROUND: Few studies have investigated the burst pressure of side-to-side anastomoses comparing different stapling devices that are commercially available. OBJECTIVES: We conducted side-to-side anastomoses with a variety of staplers and compared burst pressure in the crotch of the anastomoses. SETTING: Nagoya City East Medical Center. METHODS: We conducted side-to-side anastomoses with 9 staplers with different shapes and forms. Fresh pig small intestines were used. A side-to-side anastomosis was performed between 2 intestine specimens using a linear stapler. The burst pressure of the anastomosis was recorded. RESULTS: In total, 45 staplers were used for this experiment. The site of leakage in all cases was the crotch. Regarding the influence of the number of staple rows, the burst pressure in 3-row staplers was significantly higher than in 2-row staplers. With regard to the relationship between staple height and burst pressure, staples with a height slightly shorter than the intestinal thickness showed the highest burst pressure. In a comparison of staplers with uniform staple heights and stamplers with staples of 3 different heights, the latter had significantly lower burst pressures. Neoveil significantly increased the burst pressure in the crotch and contributed to the highest burst pressure of all the staplers used in this experiment. CONCLUSIONS: In this experiment, we defined the important factors that influence burst pressure at the crotch of a stapled, side-to-side anastomosis. These factors include the number of staple rows, the height of the staple compared with the thickness of the tissue, uniformity of staple height, and reinforcement of the staple line. In any surgical case requiring intestinal anastomosis, selection of a stapler is a critical step.

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