Mechanical suture methods in thoracic and abdominal surgery

Wide-lumen stapled anastomosis vs. conventional end-to-end anastomosis in the treatment of Crohn's disease

PURPOSE

Preanastomotic recurrence and stricturing after surgery for ileocolic Crohn's disease is a frequent, unexplained phenomena that may lead to prompt reoperation. The aim of this study was to determine whether a wide-lumen stapled anastomosis (side-to-side, functional end-to-end) provides better outcome than a conventional sutured end-to-end anastomosis

METHOD

A case-control comparative analysis of patients with Crohn's disease from two inflammatory bowel disease centers treated with wide-lumen stapled anastomosis and a matched (age and gender) group treated with conventional sutured end-to-end anastomosis was performed.

RESULTS

A total of 138 patients with Crohn's disease were treated, 69 with wide-lumen stapled anastomosis and 69 with conventional sutured end-to-end anastomosis. Preoperative therapy, number of previous resections, indication for operation, and length of bowel resected were similar in both groups. Fewer complications occurred after wide-lumen stapled anastomosis (P = 0.048). A total of 55 patients developed recurrent Crohn's disease symptoms, 39 (57 percent) in the conventional sutured end-to-end anastomosis and 16 (24 percent) in the wide-lumen stapled anastomosis group. Median follow-up was 70 and 46 months, respectively. After conventional sutured end-to-end anastomosis 18 reoperations were required, 15 for anastomotic stricture and 3 for fistulization. After wide-lumen stapled anastomosis three reoperations were necessary, two for stricture and one for fistulization. The cumulative reoperation rate for anastomotic recurrence was significantly lower (P = 0.017; log-rank test) for the wide-lumen stapled anastomosis group.

CONCLUSION

Wide-lumen stapled anastomosis is as safe as conventional sutured end-to-end anastomosis and results in a lower incidence of symptomatic recurrent Crohn's disease and need for reoperation. Further prospective study of the wide-lumen stapled anastomosis technique is necessary to define the precise role of this operation in patients with Crohn's disease.

Stapled functional end-to-end anastomosis versus sutured end-to-end anastomosis after ileocolonic resection in Crohn disease

BACKGROUND

The aim of this retrospective study was to compare complications and anastomotic recurrence rates after stapled functional end-to-end versus conventional sutured end-to-end anastomosis after ileocolonic resection in Crohn disease.

METHODS

Between 1988 and 1997, 123 patients underwent ileocolonic resection for Crohn disease. Forty-five patients underwent stapled functional end-to-end anastomosis (stapled group), and 78 underwent sutured end-to-end anastomosis (sutured group).

RESULTS

The stapled anastomosis has been more frequently used during the past 3 years; between 1995 and 1997 it was used in 33 (83%) of 40 patients, compared with only 12 (14%) of 83 patients between 1988 and 1994. There was one anastomotic leak (2%) in the stapled group, compared with six (8%) in the sutured group. The overall complication rate was significantly lower in the stapled group (7% versus 23%, P = 0.04). In the stapled group only one patient required reoperation for ileocolonic anastomotic recurrence, compared with 26 in the sutured group. The cumulative 1-, 2- and 5-year rates for ileocolonic recurrences requiring surgery in the stapled group were 0%, 0%, and 3%, which were significantly lower than the 5%, 11%, and 24% in the sutured group (P = 0.007 by log-rank test).

CONCLUSIONS

Although the follow-up duration was short in the stapled group, these results suggest that stapled functional end-to-end ileocolonic anastomosis is associated with a lower incidence of complications and that early anastomotic recurrence is less common than after sutured end-to-end anastomosis. However, a randomized trial would be necessary to draw clear conclusions.

Closure of double-barrel colostomy with stapling instruments

A technique for closure of double-barrel colostomies using the GIA and TA 90 stapling instruments is described. The method is straight forward and time saving, and represents a further application of automatic staplers to gastro-intestinal surgery.

The staple closure of loop colostomy

A technique of colostomy closure using the TA55 stapling instrument is described. No serious complications were encountered using this technique in a series of 20 consecutive loop colostomy closures.

Stapling instruments in upper gastrointestinal surgery: a retrospective study of 362 cases

A retrospective review of 362 upper gastrointestinal operations performed over a 6-year period was undertaken. The incidences of complications following the use of stapling instruments (Autosuture) or the use of conventional anastomotic techniques were compared. Complications considered to be related to anastomotic techniques were: leak or bleeding from the suture line or the development of intra-abdominal or wound sepsis. The complication rates were 21 per cent for operations using conventional suturing techniques and 16 per cent for operations in which the stapling instruments were employed.

Oesophagogastrectomy using the end-to-end anastomosing stapler

The use of a mechanical instrument for accomplishing end-to-side oesophagogastrostomy is described. We report our experience with 30 consecutive patients undergoing oesophagogastrectomy--26 for malignant disease and four for benign peptic stricture. There were two immediate postoperative deaths. One patient developed a chylothorax and died six weeks after operation. The instrument failed to function satisfactorily on one occasion. There were no anastomotic leaks.

Prospective controlled study of gastrointestinal stapled anastomoses

A controlled prospective study was carried out in a university-affiliated community hospital to evaluate the use of gastrointestinal staples compared with conventional sutures for anastomotic construction. The study included 100 randomized cases (50 sutured and 50 stapled) requiring anastomoses. Consecutive patients were accepted into the study, and no patients were excluded. There was no significant difference between the two groups in operating room time or the duration of postoperative hospitalization, nasogastric intubation or intravenous intubation. The complication rate was similar and comparable to previously published results. On three occasions, it was necessary during operation to convert from the use of staples to sutures when immediate disruption was noted at a gastroduodenal anastomosis.

Mechanical suture methods in esophago-gastrointestinal anastomosis

Mechanical suturing procedures have been performed in 10 patients for total gastrectomy, 6 for proximal partial gastrectomy and 7 for esophageal transection. The instrument (SPTU all-round type made in Russia) proved simple to use and produced reliable good quality closures without any other inforcement. There was one minor suture leak in 10 patients with intramediastinal esophagojejunostomy and in 6 with proximal partial gastrectomy respectively, but neither leak nor other problem has been arisen in esophageal transection for varices. It is believed that this staple suturing methods used SPTU all-round type apparatus are safe from anastomotic failure and useful for secure intramediastinal anastomosis in high level, and they represent a significant advance in the technique of thoraco-abdominal surgery.

A lung clamp for use with mechanical staplers

A special lung clamp has been developed for use with mechanical stapling devices. These stapling instruments have been adopted widely for pulmonary operations. A variety of clamps has been used to grasp the pulmonary tissue. The present instrument was designed with vertical grooves and fine tapered spikes with opposing holes in the jaws of the clamp. This particular lung clamp overcomes the problem of slippage previously encountered when performing pulmonary resections with stapling devices.

Transanal stapled anastomosis after resection for Hirschsprung's disease

A treatment of Hirschsprung's disease in an adult is described. It consisted of rectosigmoidectomy, with continuity being restored by means of a transanal end-to-end stapled anastomosis. The implications of this technique are discussed.

The stapled gastrointestinal tract anastomosis: incidence of postoperative complications compared with the sutured anastomosis

Performance of gastrointestinal anastomosis by means of surgical stapling devices has achieved popularity in the last decade even though no detailed study has been reported comparing complications following the stapled anastomosis with those following hand sutured procedures performed by the same surgeons. We have reviewed 812 operative procedures on the gastrointestinal tract performed in one hospital over a four year period. Stapled anastomoses were performed in 472 with 13 (2.8%) complications related to the anastomosis; in 296 sutured anastomoses there were nine (3.0%) related complications. Comparison did not disclose any significant difference in the number of complications in these two groups. In 44 instances wherein the anastomosis contained both staples and sutures, there were no related complications. Further analysis of the patients in each group disclosed that stapling procedures were utilized in a much higher percentage of those operations which were performed under emergency conditions or in the presence of intra-abdominal sepsis, intestinal obstruction, and carcinomatosis. If the technical details of surgical stapling are mastered, this technique appears to be as safe as suturing in the performance of anastomoses in the gastrointestinal tract.