Received: 28 June 2021 Revised: 5 November 2021
DOI: 10.1111/vsu.13764
ORIGINAL ARTICLE - RESEARCH
Influence of crotch suture augmentation on leakage
pressure and leakage location during functional end-to-end
stapled anastomoses in dogs
Daniel J. Duffy BVM&S (Hons), MS, FHEA, MRCVS, DACVS-SA, DECVS, RCVS and EBVS
Recognized Specialist in Small Animal Surgery1 | Yi-Jen Chang BVetMed, MS1 |
George E. Moore DVM, PhD, ACVIM(SAIM)2
1
Department of Clinical Sciences, College
of Veterinary Medicine, North Carolina
State University, Raleigh, North
Carolina, USA
2
Veterinary Administration, College of
Veterinary Medicine, Purdue University,
West Lafayette, Indiana, USA
Correspondence
Daniel J. Duffy BVM&S(Hons.), MS,
FHEA, MRCVS, DACVS, DECVS,
Department of Clinical Sciences, College
of Veterinary Medicine, North Carolina
State University, 1052 William Moore
Drive, Raleigh, NC 27607, USA.
Email: djduffy@ncsu.edu
Veterinary Surgery. 2022;1–9. wileyonlinelibrary.com/journal/vsu
Accepted: 18 December 2021
Abstract
Objective: To determine the influence of anastomotic crotch suture augmen-
tation on leakage pressures and leakage location following intestinal func-
tional end-to-end stapled anastomosis (FEESA) in dogs.
Study design: Ex vivo, randomized, experimental.
Sample population: Chilled jejunal segments from 3 adult dogs.
Methods: Jejunal specimens were tested within 24 hours of collection. A
FEESA was performed and randomly assigned to 1 of 4 treatment groups
(n = 12/group): (1) no crotch suture (NCS); (2) simple interrupted crotch
suture (SICS); (3) two simple interrupted crotch sutures (TCS) placed laterally
on opposing jejunal limbs; (4) simple continuous crotch suture (SCCS) aug-
mentation. Crotch sutures were performed using 3-0 USP polydioxanone. Ini-
tial (ILP) and maximal (MLP) leakage pressures (Mean ± SD mm Hg) and
leakage location were recorded and compared between groups.
Results: Initial leakage pressure was greater after placement of TCS (37.8
± 6.4, P < .039) and SCCS (47.6 ± 11.0, P < .002) than NCS (27.1 ± 2.5) and
SICS (33.0 ± 6.0). Maximal leakage pressure was greater in specimens includ-
ing SICS, TCS, and SCCS than those without crotch suture augmentation
(P < .043). Leakage occurred at the anastomotic crotch in 8/12 NCS, 6/12
SICS, 11/12 TCS, and 12/12 SCCS constructs (P < .001).
Conclusion: Augmentation of FEESA with TCS and SCCS increased ILP and
decreased the occurrence of leakage from the anastomotic crotch, while all
methods of anastomotic crotch augmentation increased MLP.
Clinical significance: Augmenting the FEESA with crotch suture(s)
improved the resistance of the jejunal anastomosis to leakage in normal cadav-
eric segments. Placing 2 crotch sutures or use of a simple continuous pattern
for anastomotic augmentation appeared to be superior to the placement of a
single suture.
© 2022 American College of Veterinary Surgeons. 1
2 DUFFY ET AL.
1 | INTRODUCTION
The technique employed by small animal surgeons for re-
section and anastomosis is largely dictated by individual
surgeons’ preference and training.1 In dogs, small intesti-
nal anastomosis is typically performed using hand sutur-
ing or surgical stapling equipment to allow the creation
of an intestinal stoma between the 2 segments of apposed
bowel.1–3 Intestinal anastomosis using circular stapling
equipment2 or use of a bipolar vessel sealing device4 has
been described but is not used commonly in dogs. Func-
tional end-to-end stapled anastomosis (FEESA) is per-
formed following removal of portions of compromised
bowel secondary to foreign body obstruction, ischemia,
intussusception, necrosis, infiltrative disease, or neoplas-
tic processes.5–7 Dehiscence with resultant leakage from
the anastomosis site is a devastating complication follow-
ing FEESA, occurring in up to 13% of dogs,5,8–10 with
mortality rates up to 85%.10–12 Small intestinal leakage
typically occurs during the lag phase of intestinal healing,
most often seen 3-5 days following surgical intervention.
This is caused by a reduction in the wound strength of
the anastomoses compared to immediately postopera-
tively.13 A study evaluating the rate of postoperative
dehiscence and resultant peritonitis between hand sutur-
ing and FEESA in dogs concluded that there was no dif-
ference between techniques used for anastomotic
creation.9 Purported advantages of FEESA include
shorter surgical time, decreased requirements for manip-
ulation of the bowel, consistency of staple placement,
higher initial wound strength, decreased inflammation
and necrosis, and improved blood supply to the resultant
anastomosis.8,14–18 Functional end-to-end stapled anasto-
mosis also makes it possible to deal with discrepancies in
luminal diameter between apposed bowel segments.2,17
In companion animals, decreasing the risks of anasto-
motic failure and leakage following FEESA is of critical
importance to improve clinical outcomes following
enterectomy. The ability of crotch suture augmentation
following FEESA to establish a watertight seal is an
important surgical step to determine the safety and effi-
cacy of this technique in dogs.
Creation of a FEESA between opposed jejunal limbs
is performed using a linear gastrointestinal anastomosis
(GIA) stapling device to create a longitudinal staple line.
A GIA or thoraco-abdominal (TA) stapling device is then
used across the top of the anastomosis to complete the
FEESA thus creating a transverse staple line.2,19 Modifi-
cations and technique refinement related to FEESA have
led to recommendations for partial offset of the staple
lines formed by each side of the longitudinal staple
line,20 serosal patch supplementation,21 sutured oversew
of the transverse staple line,22 and placement of a crotch
suture control tension and prevent separation of apposed
jejunal limbs23 to increase leakage pressures or reduce
tension. In a retrospective study of 77 dogs, oversewing of
the transverse staple line prevented the occurrence of
postoperative dehiscence and resultant leakage from this
location.16 Placement of a crotch suture following FEESA
is routinely performed in clinical cases to prevent anasto-
motic separation and oppose the antimesenteric jejunal
surfaces. Direct comparison of crotch suture techniques
and locations is currently lacking within the veterinary
literature. Differences in leakage pressures and leakage
location may aid surgeons in choosing the most appropri-
ate method to prevent anastomotic leakage at the distal
aspect of the longitudinal staple line.
The objective of this study was to determine the influ-
ence of anastomotic crotch suture augmentation on leak-
age pressures and leakage location following FEESA in
dogs using 3 different techniques for anastomotic crotch
suture. We hypothesized that suture augmentation at the
crotch of the anastomosis would increase initial leakage
pressure (ILP) and maximal leakage pressure (MLP). Our
secondary hypothesis was that there would be no differ-
ence among suture techniques regarding the location of
observed leakage from the construct when a crotch
suture was used following FEESA.
2 | MATERIALS AND METHODS
2.1 | Experimental samples
Intestinal specimens were collected following a ventral
midline celiotomy from 3 healthy adult dogs greater than
1 year of age following euthanasia using 1 mL/5 kg
sodium pentobarbital (Euthasol, Virbac AH, Inc., Fort
Worth, Texas). Cadavers weighed between 30-32 kg and
were donated from a local small animal shelter for rea-
sons unrelated to this study. Dogs were excluded if there
was a prior history of vomiting, diarrhea, dietary indiscre-
tion, or if dogs had been administered any medications
within 1 month prior to intestinal harvest. An institu-
tional animal care and use committee protocol was not
required by our institution for the purpose of this study
due to specimen collection after the time of euthanasia
and the secondary use of cadaveric tissues.
The small intestinal tracts from each cadaver were
removed using Metzenbaum scissors starting aboard to the
caudal duodenal flexure and orad to the antimesenteric
ileal vessel. Jejunum were harvested within 2 h of eutha-
nasia. The mesentery was then carefully excised 0.5 cm
from the serosa along the mesenteric border to avoid
bunching of the intestines. Jejunal specimens were then
milked and repeatedly lavaged with room temperature
DUFFY ET AL. 3

(21  C) 0.9% sodium chloride to clear ingesta from the
intestinal lumen until the saline ran clear. Sections of jeju-
num were then further divided into 10 cm sections using
straight Metzenbaum scissors that were positioned next to
a millimeter ruler (surgical ruler, Medline, Illinois). Speci-
mens were then stored at 4  C in an impervious tray for
10 h until the time of testing using a previously validated
technique.24 Jejunal segments were individually inspected
and rejected if there were any visual abnormalities appar-
ent on examination.
2.2 | Anastomotic construct creation
Ninety-six jejunal segments were used for the creation of
48 FEESA constructs within this study. Jejunal segments
used in each FEESA construct were always obtained
from the same dog. A FEESA was performed as previ-
ously described.7 A 60 mm GIA stapling device hand-
piece (DST Series, Medtronic, Dublin, Ireland) was
loaded with a blue 3.8 mm staple cartridge (Medtronic).
Each arm of the GIA stapler was fully seated after being
inserted into the lumen of each respective jejunal seg-
ment. Stay sutures using 4-0 USP polydioxanone (PDS,
Ethicon, Somerville, New Jersey) were used to manually
position and closely oppose the antimesenteric surfaces
of each jejunal segment. Mechanical pressure was then
used to engage the jaws and lock the device in place.
After a precompression time of 5 s was applied, the sta-
pling device was deployed, ejecting 4 staggered rows of
staples. The firing knob was then pushed towards the
jaws of the handpiece while the integrated knife simulta-
neously cut between the central 2 rows of staples to cre-
ate a side-to-side anastomosis between jejunal segments.
Longitudinal staple lines were then visually examined
and checked to ensure correct staple closure, and then
partially offset as previously recommended.20 As the
transverse staple line following FEESA has previously
been reported as the most common site of anastomotic
leakage,1,8,10,16 the end of the anastomosis was occluded
using straight Rochester-Carmalt intestinal forceps
0.5 cm from the luminal opening. Another straight
Rochester-Carmalt intestinal forceps was then placed,
oriented 180 to the first, ensuring at least a 1 cm overlap
between the jaws of each respective instrument. Attached
stay sutures were then cut with scissors.
Anastomotic constructs were then randomly assigned
(www.randomizer.org, Lancaster, Pennsylvania) to 1 of
4 equally sized treatment groups (2 jejunal segments per
construct, n = 12 constructs/group). Following FEESA
creation, 4 techniques were used to augment the anasto-
motic crotch at the distal aspect of the longitudinal staple
line: (1) no crotch suture (NCS) (Figure 1A); (2) place-
ment of a single simple interrupted crotch suture placed
equidistant between anastomosed jejunal limbs (SICS) at
a distance of 3 mm distal to the end of the longitudinal
staple line (Figure 1B);20,25 (3) two simple interrupted
crotch sutures (TCS) placed laterally on either side of
opposed jejunal segments, 3 mm distal to the end of the
longitudinal staple line (Figure 1C); (4) simple continu-
ous crotch sutures (SCCS) with suture bites placed 2-3
mm apart with 2 bites on either side of the crotch and a

F I G U R E 1 Representative photographic image of a modified functional end-to-end stapled anastomosis (FEESA) construct using
canine cadaveric jejunum. (A) Functional end-to-end stapled anastomosis with no crotch suture (NCS) augmentation. (B) Simple-
interrupted crotch suture (SICS) placed equidistant between the antimesenteric border of apposed jejunal limbs. (C) Two simple-interrupted
crotch sutures (TCS) with either suture placed laterally on opposing jejunal limbs 3 mm distal to the end of the longitudinal staple line.
(D) Simple continuous crotch suture (SCCS) was started 3 mm distal to the end of the longitudinal staple line with suture bites placed 2-3
mm apart with 2 bites placed on either side of the crotch and a single bite equidistant between the opposed jejunal segments
4 DUFFY ET AL.
single bite equidistant between the opposed jejunal seg-
ments starting 3 mm distal to the longitudinal staple line
(Figure 1D). All crotch sutures were performed using 3-0
USP polydioxanone (PDS) with a swaged-on taper SH
22 mm 1/2 taper needle, which engaged the submucosa.
All crotch suture techniques, regardless of location
included a square knot followed by 3 throws. All con-
structs were created by a single board-certified surgeon
experienced with use of stapling equipment and FEESA
techniques in dogs (DJD) aided by a trained surgical
assistant (Y-JC).
2.3 | Leak pressure assessment
Leak pressure testing was performed immediately follow-
ing creation of each randomly assigned FEESA construct
at room temperature (21  C). The ends of each respective
jejunal segment was occluded using straight Crile for-
ceps. Two 18 gauge, 1.2 inch IV catheters (Insyte, BD
Vialon Material, Franklin Lakes, New Jersey) were then
inserted at a 45 angle into the intestinal lumen, 5 mm
proximal to the occluding Crile forceps. A 5 L bag of
Hartmann's solution (Vetivex, Dechra, Overland Park,
Kansas) mixed with 8 mL of blue dye (Methylene blue,
Kordon LLC, Hayward, California) was connected to a
fluid line (Lifeshield Plumset, Hospira, Lake Forest, Illi-
nois). This line was in turn connected to a fluid pump
(Plumb A+, Hospira). Dyed solution was infused through
a single catheter at a rate of 500 mL/h26 and the mL
infused recorded while the construct was monitored for
leakage by a single investigator (Y-JC). Intraluminal pres-
sure readings were determined using another catheter
placed in to the lumen of the contralateral jejunal seg-
ment that was connected to a pressure transducer
(Logical, Smiths Medical, Dublin, Ohio) placed at the
same level as each FEESA construct. A pressure monitor
(Passport 2, Mindray, Mahwah, New Jersey) was used for
pressure assessment during infusion of each construct
during testing. Immediately prior to leakage pressure
assessment, FEESA constructs were manually suspended
(Y-JC) above a large white absorbent pad (training pad,
American Kennel Club, New York, NY) under surgical
lighting to aid in leakage detection from the construct.
Leakage pressures recorded during each test included
ILP (mm Hg), which was defined as the intraluminal
pressure at which dyed solution was first observed to leak
extraluminally from the construct. Maximum leakage
pressure (MLP; mm Hg) was defined as the maximum
intraluminal pressure measured during each test or if the
intraluminal pressure plateaued or was sustained for ≥5 s
duration. During pressure assessment the leakage loca-
tion was defined as the site of initial leakage that was
recorded along the length of the longitudinal staple line,
from the transverse opening of the FEESA or from the
anastomotic crotch of the construct.
2.4 | Statistical analysis
A pilot study was performed prior to testing to refine the
method of FEESA creation, the crotch suture augmenta-
tion technique, and the intraluminal pressure assess-
ment. Pilot data were excluded from the final statistical
model. An a priori power analysis determined that a sam-
ple size of ≥11 constructs group would provide an 80%
power to detect a mean difference of 20 ± 5 mm Hg at a
95% confidence level in evaluated measures. Numerical
data were assessed for parametric distribution using the
Shapiro-Wilk test. Assessment of ILP for each group/
augmentation pattern was performed using a generalized
mixed linear model with experimental group as a fixed
effect, mL infused as a covariate, and cadaver as a ran-
dom effect (subject term) as both jejunal segments were
obtained from the same animal. Assessment of MLP for
each group/pattern was performed using the same model
as ILP but with the addition of ILP as a covariate. An
autoregressive covariance structure was used in the statis-
tical model. Comparisons of the proportional distribution
of leakage location by group were compared using a Fish-
er's exact test. A P-value of ≤.05 was considered statisti-
cally significant with analysis performed using a
commercially available software (SAS, v.9.4, SAS Institute
Inc., Cary, North Carolina).
3 | RESULTS
3.1 | Intraluminal pressure assessment
All FEESA constructs were successfully created and
intraluminal pressure testing performed without
observed procedural error, with all constructs included in
the final statistical analysis. Controlling for the volume of
fluid infused, there was a difference in ILP between
groups (P = .0003). Initial leakage pressure was greater
after placement of TCS (P = .032; P = .038) and SCCS
(P = .002; P < .0001) in comparison with NCS and SICS
respectively. There was no difference in ILP between
NCS and SICS (P = .471). Initial leakage pressure was
greater after placement of SCCS in comparison with TCS
(P = .039) (Table 1).
There was a difference in MLP between groups
(P = .005) when controlling for quantity of fluid infused
and ILP. Maximal leakage pressure was greater in FEESA
augmented with TCS (P = .012), SICS (P = .006), and
DUFFY ET AL. 5

T A B L E 1 Mean ± standard deviation for initial leakage pressure (ILP) and maximal leakage pressure (MLP) for each experimental
group measured in mm Hg. Functional end-to-end stapled anastomosis (FEESA) were performed with either no crotch suture (NCS) or the
anastomotic crotch was augmented with a simple-interrupted crotch suture (SICS), two crotch sutures (TCS) or placement of a simple
continuous crotch suture (SCCS). Superscript letters denote significant differences between groups (adjusted P < .05)

NCS SICS TCS SCCS

a a b
ILP (mm Hg) 27.1 ± 2.5 33.0 ± 6.0 37.8 ± 6.4 47.6 ± 11.0 c
MLP (mm Hg) 41.8 ± 10.9 a 70.5 ± 10.4 b 75.3 ± 24.8 b 100.6 ± 24.0 b

SCCS (P = .042) in comparison with NCS, respectively.
Thus, MLP was greater for all groups in which a suture
was used at the crotch of the jejunal anastomosis com-
pared to NCS (Table 1). In the mixed linear model, con-
trolling for the fluid volume infused and ILP, there was
no difference in MLP (P > .21) among TCS, SICS,
and SCCS.
Regardless of experimental group, location of
observed leakage included the longitudinal staple line or
the sutured crotch of the anastomosis. There was no
observed leakage from the transverse opening where the
2 Rochester-Carmalt intestinal forceps were placed in
any construct. Leakage location differed among experi-
mental groups (P < .001). For the NCS group, leakage
occurred from the anastomotic crotch in 8/12 (67%) and
the longitudinal staple line in 4/12 (33%). Leakage
occurred in SICS group at the anastomotic crotch in 6/12
(50%) and the longitudinal staple line in 6/12 (50%). In
the TCS and SCCS group leakage occurred predomi-
nantly from the longitudinal staple line in 11/12 (92%)
and 12/12 (100%) of constructs respectively.
4 | DISCUSSION
In this study we investigated the influence of 3 different
methods for suture augmentation at the anastomotic
crotch following FEESA, to prevent separation and main-
tain apposition of the antimesenteric jejunal surfaces. In
agreement with our hypothesis, the addition of a crotch
suture following FEESA increased ILP and MLP while
decreasing the occurrence of leakage from the anasto-
motic crotch at distal end of the longitudinal staple line.
However, we failed to accept our secondary hypothesis as
TCS and SCCS increased ILP, and decreased the occur-
rence of leakage from the anastomotic crotch, while all
methods of crotch augmentation increased MLP. Crotch
suture augmentation following FEESA is an important
factor that confers increased resistance of the construct to
leakage. Among crotch sutures evaluated, TCS and SCCS
were superior to SICS in dogs.
Due to equipment availability and familiarity with the
technique following enterectomy in dogs, FEESA is com-
monly used by small animal surgeons to remove portions
of devitalized or compromised bowel.10,19 Stapled anasto-
mosis is increasingly being adopted, as a recent study
reported the odds of postoperative dehiscence were lower
in dogs that underwent FEESA in comparison with those
treated with handsewn sutured anastomoses.3 Use of an
augmentation suture placed at the level of the anastomotic
crotch of the longitudinal staple line has previously been
recommended; however, there is currently a paucity of
information to support its use within the veterinary litera-
ture.14 Crotch suture augmentation is commonly reported
and utilized clinically as an additional technique following
FEESA;7,8,16,20,25 however, some publications do not report
the use of a crotch suture.5,10 In a recent study, only 18/30
(60%) of FEESAs that received an oversew of the trans-
verse staple line and 25/48 (52%) of nonoversewn FEESA
were augmented with a crotch suture.16 This highlights
the variability in the utilization of this augmentation
technique following FEESA, and the variation in suture
patterns, even when a crotch suture was used among sur-
geons in a single academic institution.16 In live dogs, free
from gastrointestinal disease, normal peristatic pressures
have been recorded to be 6-25 mm Hg, with fluctuations
in intraluminal pressure occurring due to the occurrence
of peristatic contractions or migrating myoelectric com-
plexes.27 In the study presented here, some FEESA that
were not augmented with a crotch suture (NCS) leaked at
intraluminal pressures of <25 mm Hg and therefore NCS
should not be recommended for clinical use in dogs. It
should be noted, however, that all FEESA constructs
where crotch suture augmentation was performed, had
ILP >25 mm Hg suggesting that all techniques, regardless
of suture pattern used, may effectively create a jejunal
anastomosis that is able withstand physiologic intralu-
minal pressures encountered in clinically normal dogs
devoid of gastrointestinal pathology.
Suture techniques used at the anastomotic crotch fol-
lowing FEESA affected the intraluminal pressure at
which leakage was first observed. The transverse staple
6 DUFFY ET AL.
line, created using either a TA or GIA stapling device, is
the most common site of dehiscence and leakage seen in
dogs.5,17 The crotch region at the base of the longitudinal
staple line between jejunal limbs has previously been
reported to be the area of highest tension.28,29 Use of TCS
and SCCS patterns were associated with greater ILPs in
comparison with SICS. The use of TCS and SCCS
increased ILP by 1.2 and 1.6 respectively in compari-
son with NCS augmentation. Postulated reasons for these
observed findings are that use of TCS and SCCS are able
to control the tension applied to the construct to a greater
degree at the base of the longitudinal staple line upon
luminal filling compared with NCS. The in vivo use of a
SICS has been reported7,8,16 and represents a viable
option to reduce tension and prevent separation at this
site. The use of TCS and SCCS likely create an area of
even tension distribution around the base of the jejunal
anastomosis encountered during luminal filling com-
pared with the use of SICS. Two simple interrupted
crotch sutures and SCCS are likely superior to SICS as
greater force is required to cause separation of jejunal
limbs from one another while minimizing tension that is
concentrated at the base of the longitudinal staple line.
We postulate that SICS prevents jejunal separation ini-
tially; however, as luminal filling continues and pressure
increases, the anastomotic crotch becomes a focal point
for stress concentration. Recent publications in both ex
vivo,22 and in vivo16 canine models have reported the
importance of oversewing the transverse staple line dur-
ing FEESA to increase ILP and reduce the occurrence of
postoperative dehiscence.16,22 In a recent retrospective
study, FEESA in which the transverse staple line was
oversewn had no occurrence of intestinal leakage, com-
pared to nonoversewn FEESA where 15% of stapled
anastomoses dehisced. The mortality rate in that study
was 14%, highlighting the importance of preventing anas-
tomotic leakage from these stapled anastomoses
in vivo.16 It is plausible that mitigating or reducing leak-
age from the transverse staple line by placement of a
sutured oversew following FEESA may indirectly
increase the intraluminal pressure experienced by the
construct. Increased resistance to leakage may increase
the tension placed upon the anastomotic crotch, further
iterating the importance of this supplemental crotch
suture at the distal end of the longitudinal staple line.
In healthy dogs, devoid of gastrointestinal pathology,
maximum intraluminal pressures rarely exceed >40 mm
Hg under normal physiologic conditions.27 Obstruction
at the stoma of the stapled anastomosis is a potential
long-term complication of FEESA,3 with obstruction
known to cause acute rises in intraluminal pressures cau-
sed by luminal distension orad to the site of obstruction.3
Hydrostatic pressure orad to the area of luminal compro-
mise can reach up to 44 mm Hg.30 If the cause of obstruc-
tion at the FEESA site is not addressed or alleviated then
venous stasis, edema of the intestinal wall, and vascular
compromise may predispose to ischemia, ensuing necro-
sis, and eventual perforation of the bowel.30,31 As foreign-
body obstruction has been shown to be a risk factor for
intestinal dehiscence in some studies,11,12 this was a justi-
fication for measurement of MLP in our study. Maximum
intraluminal pressures differed between experimental
groups when a crotch suture was used compared to NCS.
Of suture techniques evaluated, use of SCCS had MLP
that were 1.3, 1.4, and 2.2 greater than TCS, SICS
and NCS, respectively. In 5/12 (42%) NCS construct there
was leakage <40 mm Hg, which shows the importance of
adding a crotch suture following FEESA to prevent anas-
tomotic leakage in dogs. Although all crotch suture aug-
mented constructs withstood supraphysiologic MLP, with
intraluminal pressure readings >40 mm Hg, these ex vivo
findings have clinical relevance to support the use of
SCCS. Due to the catastrophic effects of anastomotic sep-
aration between jejunal limbs and failure at the distal
end of the longitudinal staple line following FEESA,
extraluminal leakage of bowel contents and resultant
peritonitis can lead to mortality rates of up to 83%.10 Due
to the ex vivo nature of this study, we cannot account for
the creation of an early mucosal seal, fibrin production,
and its contribution to acquisition of initial wound
strength during the early phases of intestinal healing. We
recognize that MLP is not as important clinically as ILP
regarding the resistance to construct leakage following
FEESA.1
Leakage location differed among experimental groups
in this study. Compared to the transverse staple line
which is an everting closure, the longitudinal staple line
is an inverting closure and thought to be more resistant
to extraluminal leakage.1 Leakage occurred predomi-
nantly from the anastomotic crotch of the FEESA in 67%
and 50% of NCS and SICS constructs respectively. In the
TCS and SCCS groups, >90% of leakage was observed
along the length of the longitudinal staple line created
following deployment of the GIA stapling handpiece.
Based on these results, TCS and SCCS may be superior at
decreasing leakage from the crotch of the stapled anasto-
mosis. Occurrence of extraluminal leakage from the
sutured crotch of the anastomosis represents a possible
weak point, and this is why small animal surgeons will
often reinforce this area following FEESA in dogs.7,8
Suture augmentation using TCS and SCCS likely controls
and reduces tension on either side of jejunal limbs more
effectively, and prevents separation between the 2 stapled
segments.8 Although subjectively assessed, it should be
DUFFY ET AL.
noted that construct leakage was most evident in the
SICS, TCS and SCCS groups when intraluminal pressures
were around 80% of MLP and the initial location of leak-
age did not change as infusion of dyed fluid into the con-
struct continued. Further work is necessary to evaluate
the optimal suture configuration, number of sutures,
location and suture material used and its effect on ILP
and MLP following FEESA. In live dogs, due to the rapid-
ity of fibrin seal development, the occurrence and fre-
quency of leakage from the crotch of the anastomosis is
unknown, with leakage location rarely reported in prior
veterinary publications. This highlights the need for accu-
rate reporting of leakage location to allow technique
refinement following intestinal anastomosis in future
studies. It should be noted that in this study we used
paired Rochester-Carmalt intestinal forceps to reduce the
effect of extraneous variables that may predispose to leak-
age from the transverse staple line16,22 associated with
staple conflict, staple malformation, staple line offset,
increased tissue thickness, and the everting nature of the
transverse staple line.8,16,20,25 In this study we used 3-0
USP polydioxanone suture based upon prior methods
used in prior veterinary studies alongside what is used
clinically in dogs undergoing FEESA at our hospi-
tal.4,16,22,32,33 We acknowledge that in toy or small breed
dogs and cats, use of size 4-0 USP polydioxanone suture
may be more appropriate when performing suturing of
the crotch of the anastomosis.
This study has several limitations related to its ex vivo
design which prevents evaluation of the normal processes
of intestinal wound healing. These include the effects of
coagulation and inflammatory cell migration on initial
wound strength, which may affect ILP and MLP mea-
surements in vivo. We used a normal population of large
breed canine cadavers free of gross disease; however jeju-
nal specimens were not evaluated using either histopath-
ological analysis or scanning electron microscopy. Our
results may not be applicable to smaller dogs or translate
directly to dogs with known risk factors such as inflam-
matory bowel disease, anastomosis of the large bowel,
intraoperative hypotension, low serum albumin, preoper-
ative or postoperative septic peritonitis, and foreign body
obstruction.5,10–12,34 As part of our study design, only
3 methods of crotch suture augmentation were evaluated.
In a recent study, multiple techniques for suture augmen-
tation at the crotch of the anastomosis were reported.16,35
Different ILP and MLP values may therefore have been
obtained if different suture patterns (ie cruciate sutures)
or techniques to prevent anastomotic separation were
used. Supplemental techniques shown to increase ILP
such as wrapping the FEESA in omentum, serosal patch
7
supplementation, use of surgical sealants or buttressing
materials were not evaluated.21,32 Intraoperatively, leak
testing is routinely performed following FEESA using
saline7,16 or air36 to detect gaps along the anastomotic
line where supplemental sutures may be added at the dis-
cretion of the primary surgeon. This was not performed,
however, which may have led to additional sutures being
placed thus affecting ILP and MLP or sites of observed
leakage. Appropriate training regarding the use of surgi-
cal stapling equipment and tissue handling is assumed,
such as avoidance of use with severely thickened or
edematous bowel, which could negatively affect the resis-
tance of the FEESA to leakage and the ability for correct
staple deployment and staple closure.2 Finally, intestinal
tissues affected by neoplastic disease, edematous pro-
cesses, ischemic necrosis or infiltrative disease may
behave differently in live dogs and therefore impact the
effectiveness staple deployment and crotch suture aug-
mentation in clinical cases.
In conclusion, augmentation of FEESA with TCS and
SCCS increased ILP and decreased the occurrence of leak-
age from the anastomotic crotch, whereas all methods of
crotch augmentation increased MLP. Augmenting the
anastomotic crotch of FEESA with crotch suture(s)
improves jejunal resistance to leakage in normal cadaveric
segments. Placing TCS or the use of SCCS for anastomotic
augmentation appears to be superior to the placement of a
single suture. Prospective clinical trials are warranted to
evaluate the use of suture augmentation at the anasto-
motic crotch following FEESA in clinically affected dogs,
to investigate the effect of crotch sutures on the rate of
postoperative dehiscence and intestinal leakage.
ACKNOWLEDGMENTS
The authors received no financial support. The stapling
devices (DST Series GIA, Medtronic Inc., Mansfield, Mas-
sachusetts) used in this study were kindly donated by
Medtronic Inc. The manufacturer of these stapling
devices had no role in the study methodology and design,
data analysis, decision to publish the experimental data,
or preparation of the resultant manuscript. The authors
have no financial involvement in the Medtronic stapling
products used for this experimental study.
CONFLICT OF INTEREST
The authors declare no conflicts of interest related to this
report.
AUTHOR CONTRIBUTIONS
Duffy DJ, BVM&S (Hons), MS, FHEA, MRCVS: Con-
tributions include the design of the work performed,
8 DUFFY ET AL.
conception of the study, FEESA construct creation, data
collection and interpretation, drafting and writing of the
manuscript, and revision of the manuscript. Chang Y-C,
BVetMed, MS: Contributions include cadaveric collection,
assistance during FEESA creation, and data collection.
Moore GE, DVM, PhD, ACVIM(SAIM): Contributions
include statistical analysis, data interpretation, and review.
All authors gave their final approval of the submitted
manuscript and are accountable for the submitted work.
ORCID
Daniel J. Duffy https://orcid.org/0000-0002-3043-8877
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How to cite this article: Duffy DJ, Chang Y-J,
Moore GE. Influence of crotch suture
augmentation on leakage pressure and leakage
location during functional end-to-end stapled
anastomoses in dogs. Veterinary Surgery. 2022;1-9.
doi:10.1111/vsu.13764