title: Radiofrequency-induced small bowel thermofusion: an ex vivo study of intestinal seal adequacy using mechanical and imaging modalities.
abstract: BACKGROUND
  Bipolar radiofrequency (RF) induced tissue fusion is believed to have the potential to seal and anastomose intestinal tissue thereby providing an alternative to current techniques which are associated with technical and functional complications. This study examines the mechanical and cellular effects of RF energy and varying compressive pressures when applied to create ex vivo intestinal seals.
  
  
  METHODS
  A total of 299 mucosa-to-mucosa fusions were formed on ex vivo porcine small bowel segments using a prototype bipolar RF device powered by a closed-loop, feedback-controlled RF generator. Compressive pressures were increased at 0.05 MPa intervals from 0.00 to 0.49 MPa and RF energy was applied for a set time period to achieve bowel tissue fusion. Seal strength was subsequently assessed using burst pressure and tensile strength testing, whilst morphological changes were determined through light microscopy. To further identify the subcellular tissue changes that occur as a result of RF energy application, the collagen matrix in the fused area of a single bowel segment sealed at an optimal pressure was examined using transmission electron microscopy (TEM).
  
  
  RESULTS
  An optimal applied compressive pressure range was observed between 0.10 and 0.25 MPa. Light microscopy demonstrated a step change between fused and unfused tissues but was ineffective in distinguishing between pressure levels once tissues were sealed. Non uniform collagen damage was observed in the sealed tissue area using TEM, with some areas showing complete collagen denaturation and others showing none, despite the seal being complete. This finding has not been described previously in RF-fused tissue and may have implications for in vivo healing.
  
  
  CONCLUSIONS
  This study shows that both bipolar RF energy and optimal compressive pressures are needed to create strong intestinal seals. This finding suggests that RF fusion technology can be effectively applied for bowel sealing and may lead to the development of novel anastomosis tools.
authors.affiliation: Division of Surgery, Department of Surgery and Cancer, Imperial College London, St. Mary's Hospital, 10th Floor, QEQM Building, South Wharf Road, London W2 1NY, UK. s.arya@imperial.ac.uk
authors.forename: Shobhit
authors.initials: S
authors.lastname: Arya
authors.forename: Nancy
authors.initials: N
authors.lastname: Hadjievangelou
authors.forename: Su
authors.initials: S
authors.lastname: Lei
authors.forename: Hiromi
authors.initials: H
authors.lastname: Kudo
authors.forename: Robert D
authors.initials: RD
authors.lastname: Goldin
authors.forename: Ara W
authors.initials: AW
authors.lastname: Darzi
authors.forename: Daniel S
authors.initials: DS
authors.lastname: Elson
authors.forename: George B
authors.initials: GB
authors.lastname: Hanna
mesh_terms: D000714:Anastomosis, Surgical; D000818:Animals; D017115:Catheter Ablation / Q000295:instrumentation / Q000379:methods*; D004867:Equipment Design; D066298:In Vitro Techniques; D007421:Intestine, Small / Q000601:surgery*; D008854:Microscopy, Electron; D011312:Pressure; D011846:Radio Waves; D013552:Swine; D013718:Tensile Strength