Background: The biofragmentable anastomotic ring has been used to this day for various types of anastomosis in the gastrointestinal tract, but it has not yet achieved widespread acceptance among surgeons. The purpose of this retrospective study is to compare surgical outcomes of sutureless with suture method of Roux-and-Y jejunojejunostomy in patients with gastric cancer.Methods: Two groups of patients were obtained based on anastomosis technique (sutureless group versus hand sewn group): perioperative outcomes were recorded for every patient.Results: The mean time spent to complete a sutureless anastomosis was 11 +/- 4 min, whereas the time spent to perform hand sewn anastomosis was 23 +/- 7 min. Estimated intraoperative blood loss was 178 +/- 32ml in the sutureless group and 182 +/- 23ml in the suture-method group with no significant differences. No complications were registered related to enteroanastomosis. Intraoperative mortality was none for both groups.Conclusions: The Biofragmentable Anastomotic Ring offers a safe and time-saving method for the jejuno-jejunal anastomosis in gastric cancer surgery, and for this purpose the ring has been approved as a standard method in our clinic. Nevertheless currently there are few studies on upper gastrointestinal sutureless anastomoses and this could be the reason for the low uptake of this device

Braccio, Bartolomeo

Cosenza, Angelo

Di Martino, Natale

Esposito, Giuseppe

Grassia, Michele

Izzo, Giuseppe

Marano, Luigi

Petrillo, Marianna

Porfidia, Raffaele

Reda, Gianmarco

Schettino, Michele

BMC Surgery

PubMed

Luigi Marano

Bartolomeo Braccio

Michele Schettino

Giuseppe Izzo

Angelo Cosenza

Michele Grassia

Raffaele Porfidia

Gianmarco Reda

Marianna Petrillo

Giuseppe Esposito

Natale Di Martino

Springer - Publisher Connector

RESEARCH ARTICLE Open Access
Sutureless jejuno-jejunal anastomosis in gastric
cancer patients: a comparison with handsewn
procedure in a single institute
Luigi Marano*, Bartolomeo Braccio, Michele Schettino, Giuseppe Izzo, Angelo Cosenza, Michele Grassia,
Raffaele Porfidia, Gianmarco Reda, Marianna Petrillo, Giuseppe Esposito, Natale Di Martino
From XXV National Congress of the Italian Society of Geriatric Surgery
Padova, Italy. 10-11 May 2012
Abstract
Background: The biofragmentable anastomotic ring has been used to this day for various types of anastomosis in
the gastrointestinal tract, but it has not yet achieved widespread acceptance among surgeons. The purpose of this
retrospective study is to compare surgical outcomes of sutureless with suture method of Roux-and-Y
jejunojejunostomy in patients with gastric cancer.
Methods: Two groups of patients were obtained based on anastomosis technique (sutureless group versus hand
sewn group): perioperative outcomes were recorded for every patient.
Results: The mean time spent to complete a sutureless anastomosis was 11±4 min, whereas the time spent to
perform hand sewn anastomosis was 23±7 min. Estimated intraoperative blood loss was 178±32ml in the
sutureless group and 182±23ml in the suture-method group with no significant differences. No complications were
registered related to enteroanastomosis. Intraoperative mortality was none for both groups.
Conclusions: The Biofragmentable Anastomotic Ring offers a safe and time-saving method for the jejuno-jejunal
anastomosis in gastric cancer surgery, and for this purpose the ring has been approved as a standard method in
our clinic. Nevertheless currently there are few studies on upper gastrointestinal sutureless anastomoses and this
could be the reason for the low uptake of this device.
Background
The concept of compression anastomosis was intro-
duced for the first time in February 1826 at the meeting
of the Societe Royale de Medicine de Marseilles by
Felix-Nicholas Denans who performed an end-to-end
anastomosis using a metallic (silver or zinc) ring in a
canine model [1]. At that time, this technique was still
evolving, and in 1892 Murphy developed a new device
of compression anastomosis in humans [2-6], which has
been called “Murphy’s button”, that was extensively
used. However, its clinical success was limited for rela-
tively common anastomotic stenosis [7]. Approximately
one century after Murphy, in 1985, Hardy et al [8]
described the biofragmentable anastomotic ring (BAR).
This device has been used so far for various types of ana-
stomosis in the upper and lower gastrointestinal tract
[6-14], for elective and emergency surgery [8,10-18], but
it has not yet achieved widespread acceptance among
surgeons [19]. The purpose of this retrospective study is
to compare surgical outcomes of BAR with suture
method of Roux-and-Y jejunojejunostomy in patients
with gastric cancer who have undergone to total or
partial gastrectomy.
Material and methods
From April 2002 to June 2010, 131 patients with a mean
age of 64 years (range 37-89), 87 males and 44 females
with a diagnosis of gastric cancer referred to the 8th
* Correspondence: marano.luigi@email.it
Institution: VIII General and Gastrointestinal Surgery (Chief Prof. N. Di
Martino) - School of Medicine - Second University of Naples - Piazza Miraglia
2, 80138 Naples, Italy
Marano et al. BMC Surgery 2012, 12(Suppl 1):S27
http://www.biomedcentral.com/1471-2482/12/S1/S27
© 2012 Marano et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons
Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in
any medium, provided the original work is properly cited.
General and Gastrointestinal Surgery of the Second Uni-
versity of Naples. Six of these 131 patients (3 males and 3
females) were not resectable in the course of surgery due
to local extent of the tumor; one patient was not operable
due to the presence of restrictive lung disease and aortic
aneurysm, and one refused the operation. The patients
who underwent gastric surgery were 123 (82 males and 41
females). 112 patients had a diagnosis of gastric adenocar-
cinoma, 10 non-Hodgkin lymphoma and 1 gastric carci-
noid. Two groups of patients were obtained based on
anastomosis technique: in the first group of 64 patients
(43 males and 21 females, mean age 64.9) an end-to-side
Roux-and-Y jejunojejunostomy was performed using a
BAR after 57 total gastrectomy and 7 gastric resections. In
the second group of 59 patients (37 males and 22 females,
mean age 63.95) an end-to-side Roux-and-Y jejunojeju-
nostomy suture method anastomosis was performed after
57 total gastrectomy and 2 gastric resections. BAR is made
of 2 identical rings, each composed of 87.5% absorbable
polyglycolic acid and 12.5% barium sulfate acting as a
“radiopaque dye” to enhance x-ray imaging (abdominal
X-ray examination showed BAR fragmentation approxi-
mately between 2 and 3 weeks after surgery [20]) . The
rings have an internal lumen that varies from 11 to
20 mm in diameter, depending on the size and are placed
into the cut bowel ends. When the device is closed a 1.5-
to 2.5-mm gap remains between the 2 rings to prevent
extensive tissue ischemia. The appropriate size of BAR
device is crucial for a successful anastomosis; the ring
must be compatible with the diameter of the bowel and
the thickness of the bowel wall [17-19]. If the gap between
the 2 rings is too large, a proper seroserosal approximation
of the bowel ends will not be achieved, whereas if the
compression zone is too narrow, the closing dynamics of
the BAR can be altered and the tissue grasped in the gap
can be subjected to extensive ischemic necrosis, leading to
early detachment of the BAR [21]. An external diameter of
28 mm was preferred in all our patients for enteric anasto-
mosis, whereas that of 31 mm or more was used in colonic
or rectal anastomosis [19]. During the procedure, excessive
snap pressure should be avoided since the BAR material is
relatively friable [18]. The BAR anastomosis was per-
formed by using a standard technique: after a total gas-
trectomy with an end-to-side esophagojejunostomy or a
partial gastrectomy with side-to-end gastrojejunostomy,
monofilament not- absorbable pursestring suture is placed,
before bowel resection, at the jejunal wall along the purse-
string clamp applied tangentially to antimesenterical fold,
approximately 60 cm down from esophagojejunostomy or
gastrojejunostomy. After bowel resection, a BAR of
28 mm is introduced into the proximal jejunum first by
means of the inserter and then the pursestring suture is
tied (Figure 1). After removal of the inserter, the other
side of the BAR is inserted into the end jejunal wall and
the second pursestring is tied (Figures 2 and 3). The BAR
is snapped shut by index finger and thumb pressure of
two hands, forming a serosa-to-serosa inverted sutureless
anastomosis (Figure 4). Before closing the ring the possible
rotational error at the anastomosis is corrected. The
manually sutured jejunojejunal anastomosis, following the
same procedures as described for suturless anastomosis, is
achieved by continuous 3-0 polyglycolic acid multifilament
in two layers with inversion technique. Patient demo-
graphics, operative procedure, type and location of the
anastomosis, overall operating time, intraoperative blood
loss, postoperative course and complications, if observed,
were recorded for every patient. Postoperative complete-
ness of the BAR anastomosis and fragmentation of the
BAR ring were confirmed by abdominal x-ray at 7th and
30th day after surgery. The study was approved by the
ethics committee of Second University of Naples and
Figure 1 Introduction of 28mm BAR into the proximal jejunum.
Figure 2 The other side of the BAR is inserted into the end jejunal
wall.
Marano et al. BMC Surgery 2012, 12(Suppl 1):S27
http://www.biomedcentral.com/1471-2482/12/S1/S27
Page 2 of 5
conducted according to the ethical standards of the Hel-
sinki declaration. Each patient gave informed written
consent.
Results
64 end-to-side Roux-and-Y jejunojejunostomy were per-
formed using a BAR after 57 total gastrectomy and 7
gastric resections. 59 end-to-side Roux-and-Y jejunojeju-
nostomy suture method anastomosis were performed
after 57 total gastrectomy and 2 gastric resections for
gastric cancer. The mean time spent to complete a BAR
anastomosis was 11±4 min, being the time spent to per-
form hand sewn anastomosis 23±7 min (p=0.030 ). In
the BAR group the estimated operative blood loss was
lower compared to the suture-method group (178±32ml
and 182±23ml respectively), however the difference
didn’t reach a statistical significance (p=0.065). The
postoperative course was uneventful in 75% (n=44)
patients in the suture group and in 95.1% (n=61) the
patients in the BAR group. No intraoperative mortality
for both groups was found. The assessment of surgical
morbidity revealed a complication rate of about 7.8% for
the compression anastomosis group (2 intestinal
obstructions treated with surgery; 1 duodenal fistula
treated with medical therapy; 2 wall infections treated
with medical therapy) compared to 8.5% for the sutured
anastomosis group (1 duodenal fistula treated with med-
ical therapy; 1 pancreatic fistula treated with medical
therapy; 1 intestinal obstruction treated with surgery; 2
esophago-jejunal anastomotic leakages, respectively, trea-
ted with medical and surgical therapy) even if the compli-
cations are independents of the enteroanastomosis. The
non-surgical morbidity was 16.8% for the BAR group and
about 14.1% for the hand sewn group (p=0.183). No sig-
nificant differences were noted between the groups in the
starting time to oral feeding and intestinal canalization
(Table 1). The duration of the postoperative hospital stay
was also similar in both groups (10±2days in the BAR
group; 10±3 in the suture group; p=0.137).
Discussions
The usefulness of BAR is well established in colonic ana-
stomoses, but the effectiveness of a compression ring in
small bowel anastomoses after gastric cancer surgery has
not yet been well proven. Encouraged by little but favor-
able experiences with the device in colonic surgery we
decided to analyze the outcomes of jejuno-jejunal BAR
anastomosis compared with jejuno-jejunal hand sewn
anastomosis. Our results demonstrate that patients with
a jejuno-jejunal BAR anastomosis recover from upper
gastrointestinal resections with no delay when compared
to those with a manually sutured, conventional anasto-
mosis. The most significant complication associated with
anastomosis is anastomotic leakage [19]: although the
occurrence of severe complications was lightly more fre-
quent in the suture group (8.5%) when compared with
sutureless group (7.8%), they were independent of the
enteroanastomosis. In particular, the none overall jejuno-
jejunal leak rate in the present study, as exhibited also by
other Authors (2-4.2%) [10-14,17,18,22,23], probably
indicate that the compression anastomosis is effective
and a safe surgical procedure. Furthermore the surgical
technique of BAR anastomosis represents a standardized
approach with a very low period of the learning curve.
Selection of the appropriate size of the ring and gap
width is thought to be one of the critical determinants
for a successful BAR anastomosis [19]. In the present
study, for ease of use, we preferred to use the ring with
external diameter of 28 mm. without any resistance at
introduction into bowel lumen for all patients. Another
advantage of BAR anastomosis is that it is a faster proce-
dure than hand sewn method, because the mean time of
Figure 3 The second purse-string is tied.
Figure 4 The BAR is snapped forming a serosa-to-serosa inverted
sutureless anastomosis.
Marano et al. BMC Surgery 2012, 12(Suppl 1):S27
http://www.biomedcentral.com/1471-2482/12/S1/S27
Page 3 of 5
compression procedure is approximately 50% less than
the suture procedure, as resulting from our data (11±4
min of BAR anastomoses versus 23±7 min of suture ana-
stomoses (p<0.05)). Therefore it can be applied more
preferably to patients with comorbidities where both
rapidity and security of the anastomosis is required
[14,16,17,22,23].
Conclusions
In our opinion the Biofragmentable Anastomotic Ring
offers a safe and time-saving method for the jejuno-jeju-
nal anastomosis in gastric cancer surgery, and for this
purpose the ring has been approved as a standard
method in our clinic. Nevertheless, currently there are
few studies on upper gastrointestinal BAR anastomoses
and this could be the reason for the low uptake of this
device.
List of abbreviations used
BAR: Biofragmentable Anastomotic Ring.
Acknowledgements
The authors thank Dr Francesco Torelli for participating at some surgical
intervention as surgeon’s assistant.
This article has been published as part of BMC Surgery Volume 12
Supplement 1, 2012: Selected articles from the XXV National Congress of the
Italian Society of Geriatric Surgery. The full contents of the supplement are
available online at http://www.biomedcentral.com/bmcsurg/supplements/12/
S1.
Authors’ contributions
All authors approved the final manuscript. Study concept and design: NDM
and LM; Acquisition of data: BB, MS, RP; Analysis and interpretation of data:
AC, LM, GI, GR, MP; Drafting of the manuscript: LM, BB; Critical revision of the
manuscript for important intellectual content: NDM, LM, GI; Statistical analysis:
MG, GE, AC; Study supervision: NDM, LM.
Competing interests
Authors have no conflicts of interest or financial ties to disclose.
Published: 15 November 2012
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Table 1 Perioperative outcomes of 64 compression end-to-side Roux-and-Y jejunojejunostomy and 59 handsewn end-
to-side Roux-and-Y jejunojejunostomy
Compression anastomosis (n=64) Handsewn anastomosis (n=59) p
Estimated intraoperative blood loss 178±32 ml 182±23 ml .065
Mean jejunojejunostomy time 11±4 min 23±7 min <0.05
Intraoperative mortality 0% 0% N.E.
Surgical morbidity 7.8% 8.5% N.E.
Intestinal obstruction 2 (n) 1 (n) N.E.
Duodenal fistula 1 (n) 1 (n) N.E.
Pancreatic fistula / 1 (n) N.E.
Esophago-jejunal leakage / 1 (n) N.E.
Wall infections 2 (n) / N.E.
Non-surgical morbidity 16.8% 14.1% .183
Starting time to oral feeding 7th day 7th day /
Intestinal canalization 2.1±0.6 min 2.3±0.5 min .321
Mean hospital stay 10±2 days 10±3 days .137
N.E. Not evaluated
Marano et al. BMC Surgery 2012, 12(Suppl 1):S27
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Comparison between the biofragmentable anastomosis ring and stapled
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doi:10.1186/1471-2482-12-S1-S27
Cite this article as: Marano et al.: Sutureless jejuno-jejunal anastomosis
in gastric cancer patients: a comparison with handsewn procedure in a
single institute. BMC Surgery 2012 12(Suppl 1):S27.
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Sutureless jejuno-jejunal anastomosis in gastric cancer patients: a comparison with handsewn procedure in a single institute

Crossref

Archivio della Ricerca - Università degli Studi di Siena

RESEARCH ARTICLE Open AccessSutureless jejuno-jejunal anastomosis in gastriccancer patients: a comparison with handsewnprocedure in a single instituteLuigi Marano*, Bartolomeo Braccio, Michele Schettino, Giuseppe Izzo, Angelo Cosenza, Michele Grassia,Raffaele Porfidia, Gianmarco Reda, Marianna Petrillo, Giuseppe Esposito, Natale Di MartinoFrom XXV National Congress of the Italian Society of Geriatric SurgeryPadova, Italy. 10-11 May 2012AbstractBackground: The biofragmentable anastomotic ring has been used to this day for various types of anastomosis inthe gastrointestinal tract, but it has not yet achieved widespread acceptance among surgeons. The purpose of thisretrospective study is to compare surgical outcomes of sutureless with suture method of Roux-and-Yjejunojejunostomy in patients with gastric cancer.Methods: Two groups of patients were obtained based on anastomosis technique (sutureless group versus handsewn group): perioperative outcomes were recorded for every patient.Results: The mean time spent to complete a sutureless anastomosis was 11±4 min, whereas the time spent toperform hand sewn anastomosis was 23±7 min. Estimated intraoperative blood loss was 178±32ml in thesutureless group and 182±23ml in the suture-method group with no significant differences. No complications wereregistered related to enteroanastomosis. Intraoperative mortality was none for both groups.Conclusions: The Biofragmentable Anastomotic Ring offers a safe and time-saving method for the jejuno-jejunalanastomosis in gastric cancer surgery, and for this purpose the ring has been approved as a standard method inour clinic. Nevertheless currently there are few studies on upper gastrointestinal sutureless anastomoses and thiscould be the reason for the low uptake of this device.BackgroundThe concept of compression anastomosis was intro-duced for the first time in February 1826 at the meetingof the Societe Royale de Medicine de Marseilles byFelix-Nicholas Denans who performed an end-to-endanastomosis using a metallic (silver or zinc) ring in acanine model [1]. At that time, this technique was stillevolving, and in 1892 Murphy developed a new deviceof compression anastomosis in humans [2-6], which hasbeen called “Murphy’s button”, that was extensivelyused. However, its clinical success was limited for rela-tively common anastomotic stenosis [7]. Approximatelyone century after Murphy, in 1985, Hardy et al [8]described the biofragmentable anastomotic ring (BAR).This device has been used so far for various types of ana-stomosis in the upper and lower gastrointestinal tract[6-14], for elective and emergency surgery [8,10-18], butit has not yet achieved widespread acceptance amongsurgeons [19]. The purpose of this retrospective study isto compare surgical outcomes of BAR with suturemethod of Roux-and-Y jejunojejunostomy in patientswith gastric cancer who have undergone to total orpartial gastrectomy.Material and methodsFrom April 2002 to June 2010, 131 patients with a meanage of 64 years (range 37-89), 87 males and 44 femaleswith a diagnosis of gastric cancer referred to the 8th* Correspondence: marano.luigi@email.itInstitution: VIII General and Gastrointestinal Surgery (Chief Prof. N. DiMartino) - School of Medicine - Second University of Naples - Piazza Miraglia2, 80138 Naples, ItalyMarano et al. BMC Surgery 2012, 12(Suppl 1):S27http://www.biomedcentral.com/1471-2482/12/S1/S27© 2012 Marano et al; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative CommonsAttribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction inany medium, provided the original work is properly cited.General and Gastrointestinal Surgery of the Second Uni-versity of Naples. Six of these 131 patients (3 males and 3females) were not resectable in the course of surgery dueto local extent of the tumor; one patient was not operabledue to the presence of restrictive lung disease and aorticaneurysm, and one refused the operation. The patientswho underwent gastric surgery were 123 (82 males and 41females). 112 patients had a diagnosis of gastric adenocar-cinoma, 10 non-Hodgkin lymphoma and 1 gastric carci-noid. Two groups of patients were obtained based onanastomosis technique: in the first group of 64 patients(43 males and 21 females, mean age 64.9) an end-to-sideRoux-and-Y jejunojejunostomy was performed using aBAR after 57 total gastrectomy and 7 gastric resections. Inthe second group of 59 patients (37 males and 22 females,mean age 63.95) an end-to-side Roux-and-Y jejunojeju-nostomy suture method anastomosis was performed after57 total gastrectomy and 2 gastric resections. BAR is madeof 2 identical rings, each composed of 87.5% absorbablepolyglycolic acid and 12.5% barium sulfate acting as a“radiopaque dye” to enhance x-ray imaging (abdominalX-ray examination showed BAR fragmentation approxi-mately between 2 and 3 weeks after surgery [20]) . Therings have an internal lumen that varies from 11 to20 mm in diameter, depending on the size and are placedinto the cut bowel ends. When the device is closed a 1.5-to 2.5-mm gap remains between the 2 rings to preventextensive tissue ischemia. The appropriate size of BARdevice is crucial for a successful anastomosis; the ringmust be compatible with the diameter of the bowel andthe thickness of the bowel wall [17-19]. If the gap betweenthe 2 rings is too large, a proper seroserosal approximationof the bowel ends will not be achieved, whereas if thecompression zone is too narrow, the closing dynamics ofthe BAR can be altered and the tissue grasped in the gapcan be subjected to extensive ischemic necrosis, leading toearly detachment of the BAR [21]. An external diameter of28 mm was preferred in all our patients for enteric anasto-mosis, whereas that of 31 mm or more was used in colonicor rectal anastomosis [19]. During the procedure, excessivesnap pressure should be avoided since the BAR material isrelatively friable [18]. The BAR anastomosis was per-formed by using a standard technique: after a total gas-trectomy with an end-to-side esophagojejunostomy or apartial gastrectomy with side-to-end gastrojejunostomy,monofilament not- absorbable pursestring suture is placed,before bowel resection, at the jejunal wall along the purse-string clamp applied tangentially to antimesenterical fold,approximately 60 cm down from esophagojejunostomy orgastrojejunostomy. After bowel resection, a BAR of28 mm is introduced into the proximal jejunum first bymeans of the inserter and then the pursestring suture istied (Figure 1). After removal of the inserter, the otherside of the BAR is inserted into the end jejunal wall andthe second pursestring is tied (Figures 2 and 3). The BARis snapped shut by index finger and thumb pressure oftwo hands, forming a serosa-to-serosa inverted suturelessanastomosis (Figure 4). Before closing the ring the possiblerotational error at the anastomosis is corrected. Themanually sutured jejunojejunal anastomosis, following thesame procedures as described for suturless anastomosis, isachieved by continuous 3-0 polyglycolic acid multifilamentin two layers with inversion technique. Patient demo-graphics, operative procedure, type and location of theanastomosis, overall operating time, intraoperative bloodloss, postoperative course and complications, if observed,were recorded for every patient. Postoperative complete-ness of the BAR anastomosis and fragmentation of theBAR ring were confirmed by abdominal x-ray at 7th and30th day after surgery. The study was approved by theethics committee of Second University of Naples andFigure 1 Introduction of 28mm BAR into the proximal jejunum.Figure 2 The other side of the BAR is inserted into the end jejunalwall.Marano et al. BMC Surgery 2012, 12(Suppl 1):S27http://www.biomedcentral.com/1471-2482/12/S1/S27Page 2 of 5conducted according to the ethical standards of the Hel-sinki declaration. Each patient gave informed writtenconsent.Results64 end-to-side Roux-and-Y jejunojejunostomy were per-formed using a BAR after 57 total gastrectomy and 7gastric resections. 59 end-to-side Roux-and-Y jejunojeju-nostomy suture method anastomosis were performedafter 57 total gastrectomy and 2 gastric resections forgastric cancer. The mean time spent to complete a BARanastomosis was 11±4 min, being the time spent to per-form hand sewn anastomosis 23±7 min (p=0.030 ). Inthe BAR group the estimated operative blood loss waslower compared to the suture-method group (178±32mland 182±23ml respectively), however the differencedidn’t reach a statistical significance (p=0.065). Thepostoperative course was uneventful in 75% (n=44)patients in the suture group and in 95.1% (n=61) thepatients in the BAR group. No intraoperative mortalityfor both groups was found. The assessment of surgicalmorbidity revealed a complication rate of about 7.8% forthe compression anastomosis group (2 intestinalobstructions treated with surgery; 1 duodenal fistulatreated with medical therapy; 2 wall infections treatedwith medical therapy) compared to 8.5% for the suturedanastomosis group (1 duodenal fistula treated with med-ical therapy; 1 pancreatic fistula treated with medicaltherapy; 1 intestinal obstruction treated with surgery; 2esophago-jejunal anastomotic leakages, respectively, trea-ted with medical and surgical therapy) even if the compli-cations are independents of the enteroanastomosis. Thenon-surgical morbidity was 16.8% for the BAR group andabout 14.1% for the hand sewn group (p=0.183). No sig-nificant differences were noted between the groups in thestarting time to oral feeding and intestinal canalization(Table 1). The duration of the postoperative hospital staywas also similar in both groups (10±2days in the BARgroup; 10±3 in the suture group; p=0.137).DiscussionsThe usefulness of BAR is well established in colonic ana-stomoses, but the effectiveness of a compression ring insmall bowel anastomoses after gastric cancer surgery hasnot yet been well proven. Encouraged by little but favor-able experiences with the device in colonic surgery wedecided to analyze the outcomes of jejuno-jejunal BARanastomosis compared with jejuno-jejunal hand sewnanastomosis. Our results demonstrate that patients witha jejuno-jejunal BAR anastomosis recover from uppergastrointestinal resections with no delay when comparedto those with a manually sutured, conventional anasto-mosis. The most significant complication associated withanastomosis is anastomotic leakage [19]: although theoccurrence of severe complications was lightly more fre-quent in the suture group (8.5%) when compared withsutureless group (7.8%), they were independent of theenteroanastomosis. In particular, the none overall jejuno-jejunal leak rate in the present study, as exhibited also byother Authors (2-4.2%) [10-14,17,18,22,23], probablyindicate that the compression anastomosis is effectiveand a safe surgical procedure. Furthermore the surgicaltechnique of BAR anastomosis represents a standardizedapproach with a very low period of the learning curve.Selection of the appropriate size of the ring and gapwidth is thought to be one of the critical determinantsfor a successful BAR anastomosis [19]. In the presentstudy, for ease of use, we preferred to use the ring withexternal diameter of 28 mm. without any resistance atintroduction into bowel lumen for all patients. Anotheradvantage of BAR anastomosis is that it is a faster proce-dure than hand sewn method, because the mean time ofFigure 3 The second purse-string is tied.Figure 4 The BAR is snapped forming a serosa-to-serosa invertedsutureless anastomosis.Marano et al. BMC Surgery 2012, 12(Suppl 1):S27http://www.biomedcentral.com/1471-2482/12/S1/S27Page 3 of 5compression procedure is approximately 50% less thanthe suture procedure, as resulting from our data (11±4min of BAR anastomoses versus 23±7 min of suture ana-stomoses (p<0.05)). Therefore it can be applied morepreferably to patients with comorbidities where bothrapidity and security of the anastomosis is required[14,16,17,22,23].ConclusionsIn our opinion the Biofragmentable Anastomotic Ringoffers a safe and time-saving method for the jejuno-jeju-nal anastomosis in gastric cancer surgery, and for thispurpose the ring has been approved as a standardmethod in our clinic. Nevertheless, currently there arefew studies on upper gastrointestinal BAR anastomosesand this could be the reason for the low uptake of thisdevice.List of abbreviations usedBAR: Biofragmentable Anastomotic Ring.AcknowledgementsThe authors thank Dr Francesco Torelli for participating at some surgicalintervention as surgeon’s assistant.This article has been published as part of BMC Surgery Volume 12Supplement 1, 2012: Selected articles from the XXV National Congress of theItalian Society of Geriatric Surgery. The full contents of the supplement areavailable online at http://www.biomedcentral.com/bmcsurg/supplements/12/S1.Authors’ contributionsAll authors approved the final manuscript. Study concept and design: NDMand LM; Acquisition of data: BB, MS, RP; Analysis and interpretation of data:AC, LM, GI, GR, MP; Drafting of the manuscript: LM, BB; Critical revision of themanuscript for important intellectual content: NDM, LM, GI; Statistical analysis:MG, GE, AC; Study supervision: NDM, LM.Competing interestsAuthors have no conflicts of interest or financial ties to disclose.Published: 15 November 2012References1. Kaidar-Person O, Rosenthal RJ, Wexner SD, Szomstein S, Person B:Compression anastomoses: history and clinical considerations. Am J Surg2008, 195:818-26.2. Booth CC: What has technology done to gastroenterology? Gut 1985,26:1088-94.3. Amat C: Appareils a sutures: Les viroles de denans; les points deBonnier: Les boutons de Murphy. Arch Med Pharmacie Militaires Paris 1895,25:273-85.4. Murphy JB: Cholecysto-intestinal, gastro-intestinal, entero-intestinalanastomosis, and approximation without sutures. Med Rec N Y 1892,42:665-76.5. Gordon RC, John B: Murphy: unique among American surgeons. J InvestSurg 2006, 19:279-81.6. McCue JL, Phillips RK: Sutureless intestinal anastomoses. Br J Surg 1991,78:1291-6, Sutureless intestinal anastomoses.7. Senn N: Enterorrhaphy: its history, technique and present status. JAMA1893, 21:215-35.8. Hardy TG Jr, Pace WG, Maney JW, Katz AR, Kaganov AL: A biofragmentablering for sutureless bowel anastomosis. An experimental study. Dis ColonRectum 1985, 28:484-90.9. Kanshin NN, Lytkin MI, Knysh VI, Klur Vlu, Khamidov AL: First experiencewith application of compression anastomoses with the apparatus AKA-2in operations on the large intestine. Vestn Khir Im I I Grek 1984, 132:52-7.10. Bubrick MP, Corman ML, Cahill CJ, Hardy TG Jr, Nance FC, Shatney CH:Prospective, randomized trial of the biofragmentable anastomosis ring.The BAR InvestigationalGroup. Am J Surg 1991, 161:136-42.11. Cahill CJ, Betzler M, Gruwez JA, Jeekel J, Patel JC, Zederfeldt B: Suturelesslarge bowel anastomosis: European experience with thebiofragmentable anastomosis ring. Br J Surg 1989, 76:344-7.12. Corman ML, Prager ED, Hardy TG Jr, Bubrick MP: Comparison of theValtrac biofragmentable anastomosis ring with conventional suture andstapled anastomosis in colon surgery. Results of a prospectiverandomized clinical trial. Dis Colon Rectum 1989, 32:183-7.13. Gullichsen R, Ovaska J, Rantala A, Havia T: Small bowel anastomosis withthe biofragmentable anastomosis ring and manual suture: a prospective,randomized study. World J Surg 1992, 16:1006-9.14. Pahlman L, Ejerblad S, Graf W, Kader F, Kressner U, Lindmark G, et al:Randomized trial of a biofragmentable bowel anastomosis ring in high-risk colonic resection. Br J Surg 1997, 84:1291-4.15. Seow-Choen F, Eu KW: Circular staplers versus the biofragmentable ringfor colorectal anastomosis: a prospective randomized study. Br J Surg1994, 81:1790-1.Table 1 Perioperative outcomes of 64 compression end-to-side Roux-and-Y jejunojejunostomy and 59 handsewn end-to-side Roux-and-Y jejunojejunostomyCompression anastomosis (n=64) Handsewn anastomosis (n=59) pEstimated intraoperative blood loss 178±32 ml 182±23 ml .065Mean jejunojejunostomy time 11±4 min 23±7 min <0.05Intraoperative mortality 0% 0% N.E.Surgical morbidity 7.8% 8.5% N.E.Intestinal obstruction 2 (n) 1 (n) N.E.Duodenal fistula 1 (n) 1 (n) N.E.Pancreatic fistula / 1 (n) N.E.Esophago-jejunal leakage / 1 (n) N.E.Wall infections 2 (n) / N.E.Non-surgical morbidity 16.8% 14.1% .183Starting time to oral feeding 7th day 7th day /Intestinal canalization 2.1±0.6 min 2.3±0.5 min .321Mean hospital stay 10±2 days 10±3 days .137N.E. Not evaluatedMarano et al. BMC Surgery 2012, 12(Suppl 1):S27http://www.biomedcentral.com/1471-2482/12/S1/S27Page 4 of 516. Fansler RF, Mero K, Steinberg SM, McSwain NE, Flint LM, Ferrara JJ: Utility ofthe biofragmentable anastomotic ring in traumatic small bowel injury.Am Surg 1994, 60:379-83.17. Thiede A, Geiger D, Dietz UA, Debus ES, Engemann R, Lexer GC, et al:Overview on compression anastomoses: biofragmentable anastomosisring multicenter prospective trial of 1666 anastomoses. World J Surg1998, 22:78-86.18. Choi HJ, Kim HH, Jung GJ, Kim SS: Intestinal anastomosis by use of thebiofragmentable anastomotic ring: is it safe and efficacious inemergency operations as well? Dis Colon Rectum 1998, 41:1281-6.19. Kim SH, Choi HJ, Park KJ, Kim JM, Kim KH, Kim MC, et al: Suturelessintestinal anastomosis with the biofragmentable anastomosis ring:experience of 632 anastomoses in a single institute. Dis Colon Rectum2005, 48(11):2127-32.20. Aggarwal R, Darzi A: Compression anastomoses revisited. J Am Coll Surg2005, 201:965-71.21. Galizia G, Lieto E, Castellano P, Pelosio L, Imperatore V, Canfora F, et al:Comparison between the biofragmentable anastomosis ring and stapledanastomoses in the extraperitoneal rectum: a prospective, randomizedstudy. Int J Colorectal Dis 1999, 14:286-90.22. Di Castro A, Biancari F, Brocato R, Adami EA, Truosolo B, Massi G: Intestinalanastomosis with the biofragmentable anastomosis ring. Am J Surg 1998,176:472-4.23. Ghitulescu GA, Morin N, Jetty P, Belliveau P: Revisiting thebiofragmentable anastomotic ring: is it safe in colonic surgery? Can JSurg 2003, 46:92-8.doi:10.1186/1471-2482-12-S1-S27Cite this article as: Marano et al.: Sutureless jejuno-jejunal anastomosisin gastric cancer patients: a comparison with handsewn procedure in asingle institute. BMC Surgery 2012 12(Suppl 1):S27.Submit your next manuscript to BioMed Centraland take full advantage of: • Convenient online submission• Thorough peer review• No space constraints or color figure charges• Immediate publication on acceptance• Inclusion in PubMed, CAS, Scopus and Google Scholar• Research which is freely available for redistributionSubmit your manuscript at www.biomedcentral.com/submitMarano et al. BMC Surgery 2012, 12(Suppl 1):S27http://www.biomedcentral.com/1471-2482/12/S1/S27Page 5 of 5

AL: A biofragmentable ring for sutureless bowel anastomosis. An experimental study. Dis Colon Rectum

Appareils a sutures: Les viroles de denans; les points de Bonnier: Les boutons de Murphy. Arch Med Pharmacie Militaires Paris 1895,

B: Murphy: unique among American surgeons.

Bubrick MP: Comparison of the Valtrac biofragmentable anastomosis ring with conventional suture and stapled anastomosis in colon surgery. Results of a prospective randomized clinical trial. Dis Colon Rectum

Cholecysto-intestinal, gastro-intestinal, entero-intestinal anastomosis, and approximation without sutures.

Compression anastomoses: history and clinical considerations.

Enterorrhaphy: its history, technique and present status.

et al: Randomized trial of a biofragmentable bowel anastomosis ring in highrisk colonic resection.

Eu KW: Circular staplers versus the biofragmentable ring for colorectal anastomosis: a prospective randomized study.

Havia T: Small bowel anastomosis with the biofragmentable anastomosis ring and manual suture: a prospective, randomized study. World J Surg

Khamidov AL: First experience with application of compression anastomoses with the apparatus AKA-2 in operations on the large intestine. Vestn Khir Im I I Grek

Nance FC, Shatney CH: Prospective, randomized trial of the biofragmentable anastomosis ring. The BAR InvestigationalGroup. Am J Surg

Phillips RK: Sutureless intestinal anastomoses.

What has technology done to gastroenterology? Gut

Zederfeldt B: Sutureless large bowel anastomosis: European experience with the biofragmentable anastomosis ring.

https://usiena-air.unisi.it/bitstream/11365/1067128/1/1471-2482-12-S1-S27.pdf

Sutureless jejuno-jejunal anastomosis in gastric cancer patients: a comparison with handsewn procedure in a single institute

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