1. Staple-Line Reinforcement Dan Geisler, MD, FACS, FASCRS West Penn Allegheny Health System

2. 2 Disclosures  CovidienConsultant

3. 3 Staple Line Reinforcement WHY?  Anastomotic Leak  Staple Line Bleeding

4. 4 Staple Line Reinforcement WHAT?  Synthetic, bioabsorbable staple-line reinforcement  Collagen matrix  Polyglycolic acid

5. 5 Staple Line Reinforcement WHAT?  Gore Seamguard  Synovis Staple Line Reinforcement  Cook biodesign staple line reinforcement  Covidien Duet TRS

6. 6 GORE Seamguard  Bioabsorbable Staple Line Reinforcement Synthetic Absorbable Sleeves (“socks”) held by non-absorbable polyester braided suture Increases thickness of tissue by up to 0.5mm

7. 7 Staple Line Reinforcement  Synovis® Peri-Strips Dry® Biologic tissue prepared from bovine pericardium (U.S. cattle) Strips attached by gel (“glue”) Increases thickness of tissue by 0.5mm to 1.5mm  Synovis® Peri-Strips Dry® with Veritas® Collagen Matrix Prepared from dehydrated bovine pericardium (U.S. cattle) Similar assembly to Peri-Strips Dry®

8. 8 Staple Line Reinforcement  PeriPatch™ Aegis Processed Bovine Pericardial Staple Line Reinforcement Made ONLY for Ethicon staplers (ETS/Flex 45 and Echelon 60) Easier to assemble, but more preparation involved (pre-soak) IFU recommends use of 15mm trocar  PeriPatch™ Aegis EQ Identical in design to PeriPatch™ Aegis, but it is made from equine pericardium

9. 9 Staple Line Reinforcement DUET  Thinnest On the Market will increase the thickness of the tissue to be stapled by approximately 0.12mm – 0.18mm  Clear easily view staple formation  Synthetic Absorbable Consistent Thickness  Optimal Absorption Profile Strength During Critical Wound Healing Time

10. 10 Staple Line Reinforcement WHAT?

11. 11 Covidien | August 21, 2015 | Confidential11 | Duet Tissue Reinforcement – Absorption Profile Reinforcement material is a synthetic absorbable film prepared from synthetic polyester composed of glycolide, dioxanone and trimethylene carbonate Measurable mechanical strength through 14 days Absorption should be complete between 90-110 days

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14. 14 Staple Line Reinforcement WHEN?  High-risk anastomosis  Bleeding  Anastomotic leaks

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16. 16 DATA?

17. 17 Staple Line Reinforcement Gastric Bypass  N = 1073 (568 bovine collagen matrix)  Abdominal septic events 4% versus 1% Staple line leakage Purulent drainage Abscess Callery CD, Filiciotto S, Neil KL

18. 18 Staple Line Reinforcement Colorectal Anastomosis  N = 117 laparoscopic + open  Circular bioabsorbable Seanguard  4 intraoperative leaks  Use of Seamguard may result in a lower incidence of anastomotic leakage Portillo & Franklin

19. 19 Staple Line Reinforcement Colorectal Anastomosis  “most…need to be accepted and optimized”  “not much experience…further investigation is needed”

20. 20 Staple Line Reinforcement  Seems promising  Preventing leakage + bleeding  More studies are needed