1
|
Dev S, Luitel P, Paudel S, Shrestha A, Dev B, Sah J. Acute abdomen due to perforated jejunal gastrointestinal stromal tumor: A case report. Int J Surg Case Rep 2024; 121:109922. [PMID: 38908159 DOI: 10.1016/j.ijscr.2024.109922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2024] [Revised: 06/13/2024] [Accepted: 06/18/2024] [Indexed: 06/24/2024] Open
Abstract
INTRODUCTION Gastrointestinal stromal tumors (GISTs) are rare mesenchymal tumors, with jejunal GISTs being particularly uncommon. Jejunal GISTs causing perforation and acute diffuse peritonitis is rare. CASE PRESENTATION A 53-year-old female with a history of hypertension presented with severe, acute abdominal pain and vomiting. Examination revealed abdominal distension, tenderness, and guarding, with imaging suggestive of gastrointestinal perforation. Emergency laparotomy revealed a 9 cm × 8 cm mass with perforation in the jejunum, which was resected which on histopathological examination confirmed a low-grade GIST. The postoperative course was complicated by a wound infection, managed with antibiotics and secondary suturing. At one-year follow-up, the patient remained disease-free without the need for adjuvant therapy. CLINICAL DISCUSSION The most common symptoms of jejunal GISTs include vague abdominal pain or discomfort, early satiety, obstruction or hemorrhage. Preoperative diagnosis and confirmation of GIST is difficult due to nonspecific symptoms and none of the radiographic procedures can establish the diagnosis with certainty. The surgical excision of the tumor along with infiltrated tissues is the treatment of choice for GIST. CONCLUSION This case underscores the necessity of considering GISTs in differential diagnoses of acute abdomen and the critical role of prompt surgical management and multidisciplinary care in achieving favorable outcomes.
Collapse
Affiliation(s)
- Santosh Dev
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Prajjwol Luitel
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal; Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal.
| | - Sujan Paudel
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal; Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Asim Shrestha
- Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| | - Barsha Dev
- Nepalgunj Medical College Teaching Hospital, Nepalgunj, Nepal
| | - Jayant Sah
- Department of General Surgery, Maharajgunj Medical Campus, Tribhuvan University Teaching Hospital, Nepal
| |
Collapse
|
2
|
Iguchi K, Sato S, Shiozawa M, Mushiake H, Uchiyama M, Numata K, Nukada S, Kohmura T, Miakayama Y, Ono Y, Kazama K, Katayama Y, Numata M, Higuchi A, Godai T, Sugano N, Rino Y, Saito A. Usefulness of the one-step technique in functional end-to-end anastomosis for colonic surgery: results of a prospective multicentre cohort study from the Japanese KYCC group. Tech Coloproctol 2024; 28:82. [PMID: 38981897 DOI: 10.1007/s10151-024-02958-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/12/2023] [Accepted: 06/08/2024] [Indexed: 07/11/2024]
Abstract
BACKGROUND Although functional end-to-end anastomosis (FEEA) using a stapler in the colorectal field has been recognised worldwide, the technique varies by surgeon, and the safety of anastomosis using different techniques is unknown. METHODS This multicentre prospective observational cohort study was conducted by the KYCC Study Group in Yokohama, Japan, and included patients who underwent colonic resection at seven centres between April 2020 and March 2022. This study compared the incidence of surgery-related abdominal complications (SAC: anastomotic leakage [AL], anastomotic bleeding, intra-abdominal abscess, enteritis, ileus, surgical site infection, and other abdominal complications) between two different methods of FEEA (one-step [OS] method: simultaneous anastomosis and bowel resection; two-step [TS] method: anastomosis after bowel resection). Complications of Clavien-Dindo classification grade 2 or higher were assessed. RESULTS Among 293 eligible cases, the OS and TS methods were used in 194 (66.2%) and 99 (33.8%) patients, respectively. The baseline characteristics were similar between the groups. The OS method used fewer staplers (three vs. four staplers, p < 0.00001). There were no significant differences in SAC rate between the OS (19.1%) and the TS (16.2%) groups (p = 0.44). The OS group had four cases (2.1%) of AL (two patients; grade 3, two patients; grade 2) while the TS group had one case (1.0%) of grade 2 AL (p = 0.67). Multivariate logistic regression analysis showed that male sex (odds ratio [OR] 3.95; p < 0.00001), an open surgical approach (OR 2.36; p = 0.03), and longer operative duration (OR,2.79; p = 0.002) were independent predictors of complications, whereas the OS method was not an independent predictor (OR 1.17; p = 0.66). CONCLUSIONS The OS and the TS technique for stapled colonic anastomosis in a FEEA had a similar postoperative complication rate. TRIAL REGISTRATION NUMBER UMIN000039902 (registration date 23 March 2020).
Collapse
Affiliation(s)
- K Iguchi
- Department of Colorectal Surgery, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, 241-8515, Japan.
| | - S Sato
- Department of Colorectal Surgery, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - M Shiozawa
- Department of Colorectal Surgery, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - H Mushiake
- Department of Surgery, Saiseikai Yokohamashi Nanbu Hospital, Yokohama, Japan
| | - M Uchiyama
- Department of Colorectal Surgery, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - K Numata
- Department of Surgery, Hiratsuka Kyosai Hospital, Hiratsuka, Japan
| | - S Nukada
- Department of Colorectal Surgery, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - T Kohmura
- Department of Colorectal Surgery, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - Y Miakayama
- Department of Colorectal Surgery, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - Y Ono
- Department of Colorectal Surgery, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - K Kazama
- Department of Surgery, School of Medicine, Yokohama City University, Yokohama, Japan
| | - Y Katayama
- Department of Surgery, Japanese Red Cross Hadano Hospital, Hadano, Japan
| | - M Numata
- Department of Surgery, School of Medicine, Yokohama City University, Yokohama, Japan
| | - A Higuchi
- Department of Surgery, Yokohama Minami Kyosai Hospital, Yokohama, Japan
| | - T Godai
- Department of Surgery, Fujisawa Shonandai Hospital, Fujisawa, Japan
| | - N Sugano
- Department of Colorectal Surgery, Kanagawa Cancer Center, 2-3-2, Nakao, Asahi-ku, Yokohama, 241-8515, Japan
| | - Y Rino
- Department of Surgery, School of Medicine, Yokohama City University, Yokohama, Japan
| | - A Saito
- Department of Surgery, School of Medicine, Yokohama City University, Yokohama, Japan
| |
Collapse
|
3
|
Perforated proximal jejunal gastrointestinal stromal tumor pT4N0M0 presenting with severe sepsis: A case report and literature review. Ann Med Surg (Lond) 2020; 57:76-81. [PMID: 32728434 PMCID: PMC7381426 DOI: 10.1016/j.amsu.2020.07.024] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2020] [Accepted: 07/12/2020] [Indexed: 11/20/2022] Open
Abstract
Introduction Gastrointestinal stromal tumors (GISTs) are mesenchymal tumors that occur along the alimentary tract, and are most commonly found in the stomach. Rarely, these tumors can occur in the small bowel, and when located in the duodenum or proximal jejunum, they may require challenging reconstruction of the alimentary tract. Patients with GISTs often present with non-specific abdominal pain or symptoms of obstruction, hemorrhage, and less commonly perforation. Presentation of case A 46-year-old male presented to the hospital with a one-day history of left upper quadrant pain with fevers and chills. Physical examination was significant for signs of peritonitis, and laboratory results revealed leukocytosis and lactic acidosis. CT abdomen showed a large soft tissue mass in the proximal jejunum. In the operating theater he was found to have a perforated jejunal tumor. Pathology report revealed a 13cm GIST, pT4N0M0, Stage IIIa. He had an uneventful recovery and was discharged nine days after surgery. Discussion Proximal jejunal GISTs are a rare entity and when present, perforation is unlikely. Pathological diagnosis of GISTs are relies on immunohistochemistry demonstrating c-KIT or CD34 positivity. The prognosis of GISTs are dependent on the size and the mitotic index. Definitive treatment of non-metastatic GISTs is R0 resection. When located in the duodenum or proximal jejunum, resection can be very challenging and may require clinical expertise in order to safely perform complex alimentary tract reconstruction. Conclusion Further investigation is required in order to determine best practice management for patients who present with proximal GISTs. A rare presentation of proximal jejunal GIST as a necrotic perforated mass causing severe sepsis. Successful treatment of a pT4N0M0 (Stage IIIa) proximal jejunal GIST in the emergency setting with an uneventful hospital recovery. R0 resection of the proximal jejunal GIST with hand-sewn end-to-side anastomosis.
Collapse
|
4
|
Davis DJ, Demianiuk RM, Musser J, Podsiedlik M, Hauptman J. Influence of preoperative septic peritonitis and anastomotic technique on the dehiscence of enterectomy sites in dogs: A retrospective review of 210 anastomoses. Vet Surg 2017; 47:125-129. [DOI: 10.1111/vsu.12704] [Citation(s) in RCA: 22] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2015] [Revised: 03/10/2017] [Accepted: 04/30/2017] [Indexed: 12/29/2022]
Affiliation(s)
- Daniel J. Davis
- Department of Small Animal Clinical Sciences; Michigan State University; East Lansing Michigan
| | - Ryan M. Demianiuk
- Department of Small Animal Clinical Sciences; Michigan State University; East Lansing Michigan
| | - Jon Musser
- Department of Small Animal Clinical Sciences; Michigan State University; East Lansing Michigan
| | - Maria Podsiedlik
- Department of Small Animal Clinical Sciences; Michigan State University; East Lansing Michigan
| | - Joe Hauptman
- Department of Small Animal Clinical Sciences; Michigan State University; East Lansing Michigan
| |
Collapse
|
5
|
Kano M, Hanari N, Gunji H, Hayano K, Hayashi H, Matsubara H. Is "functional end-to-end anastomosis" really functional? A review of the literature on stapled anastomosis using linear staplers. Surg Today 2016; 47:1-7. [PMID: 26988855 DOI: 10.1007/s00595-016-1321-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2015] [Accepted: 11/30/2015] [Indexed: 12/25/2022]
Abstract
PURPOSES Anastomosis is one of the basic skills of a gastrointestinal surgeon. Stapling devices are widely used because stapled anastomosis (SA) can shorten operation times. Antiperistaltic stapled side-to-side anastomosis (SSSA) using linear staplers is a popular SA technique that is often referred to as "functional end-to-end anastomosis (FEEA)." The term "FEEA" has spread without any definite validation of its "function." The aim of this review is to show the heterogeneity of SA and conventional hand-sewn end-to-end anastomosis (HEEA) and to advocate the renaming of "FEEA." METHODS We conducted a narrative review of the literature on SSSA. We reviewed the literature on ileocolic and small intestinal anastomosis in colonic cancer, Crohn's disease and ileostomy closure due to the simplicity of the technique. RESULTS The superiority of SSSA in comparison to HEEA has been demonstrated in previous clinical studies concerning gastrointestinal anastomosis. Additionally, experimental studies have shown the differences between the two anastomotic techniques on peristalsis and the intestinal bacteria at the anastomotic site. CONCLUSIONS SSSA and HEEA affect the postoperative clinical outcome, electrophysiological peristalsis, and bacteriology in different manners; no current studies have shown the functional equality of SSSA and HEEA. However, the use of the terms "functional end-to-end anastomosis" and/or "FEEA" could cause confusion for surgeons and researchers and should therefore be avoided.
Collapse
Affiliation(s)
- Masayuki Kano
- Department of Frontier Surgery, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-0856, Japan.
| | - Naoyuki Hanari
- Department of Frontier Surgery, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-0856, Japan
| | - Hisashi Gunji
- Department of Frontier Surgery, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-0856, Japan
| | - Koichi Hayano
- Department of Frontier Surgery, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-0856, Japan
| | - Hideki Hayashi
- Department of Frontier Surgery, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-0856, Japan
| | - Hisahiro Matsubara
- Department of Frontier Surgery, Chiba University, 1-8-1 Inohana, Chuo-Ku, Chiba, Chiba, 260-0856, Japan
| |
Collapse
|
6
|
Fonseca AL, Reddy V, Longo WE, Gusberg RJ. Graduating general surgery resident operative confidence: perspective from a national survey. J Surg Res 2014; 190:419-28. [PMID: 24908164 DOI: 10.1016/j.jss.2014.05.014] [Citation(s) in RCA: 96] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2014] [Revised: 04/21/2014] [Accepted: 05/02/2014] [Indexed: 01/19/2023]
Abstract
BACKGROUND General surgical training has changed significantly over the last decade with work hour restrictions, increasing subspecialization, the expanding use of minimally invasive techniques, and nonoperative management for solid organ trauma. Given these changes, this study was undertaken to assess the confidence of graduating general surgery residents in performing open surgical operations and to determine factors associated with increased confidence. METHODS A survey was developed and sent to general surgery residents nationally. We queried them regarding demographics and program characteristics, asked them to rate their confidence (rated 1-5 on a Likert scale) in performing open surgical procedures and compared those who indicated confidence with those who did not. RESULTS We received 653 responses from the fifth year (postgraduate year 5) surgical residents: 69% male, 68% from university programs, and 51% from programs affiliated with a Veterans Affairs hospital; 22% from small programs, 34% from medium programs, and 44% from large programs. Anticipated postresidency operative confidence was 72%. More than 25% of residents reported a lack of confidence in performing eight of the 13 operations they were queried about. Training at a university program, a large program, dedicated research years, future fellowship plans, and training at a program that performed a large percentage of operations laparoscopically was associated with decreased confidence in performing a number of open surgical procedures. Increased surgical volume was associated with increased operative confidence. Confidence in performing open surgery also varied regionally. CONCLUSIONS Graduating surgical residents indicated a significant lack of confidence in performing a variety of open surgical procedures. This decreased confidence was associated with age, operative volume as well as type, and location of training program. Analyzing and addressing this confidence deficit merits further study.
Collapse
Affiliation(s)
- Annabelle L Fonseca
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut.
| | - Vikram Reddy
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Walter E Longo
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| | - Richard J Gusberg
- Department of Surgery, Yale University School of Medicine, New Haven, Connecticut
| |
Collapse
|
7
|
Stapled versus hand-sewn anastomoses in emergency general surgery. J Trauma Acute Care Surg 2013; 74:1187-92; discussion 1192-4. [DOI: 10.1097/ta.0b013e31828cc9c4] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
|
8
|
Stapled versus hand-sewn anastomoses in emergency general surgery: A retrospective review of outcomes in a unique patient population. J Trauma Acute Care Surg 2013. [DOI: 10.1097/01586154-201305000-00001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
|
9
|
Goulder F. Bowel anastomoses: The theory, the practice and the evidence base. World J Gastrointest Surg 2012; 4:208-13. [PMID: 23293735 PMCID: PMC3536859 DOI: 10.4240/wjgs.v4.i9.208] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2011] [Revised: 09/04/2012] [Accepted: 09/17/2012] [Indexed: 02/06/2023] Open
Abstract
Since the introduction of stapling instruments in the 1970s various studies have compared the results of sutured and stapled bowel anastomoses. A literature search was performed from 1960 to 2010 and articles relating to small bowel, colonic and colorectal anastomotic techniques were reviewed. References from these articles were also reviewed, and relevant articles obtained. Either a stapled or sutured gastrointestinal tract anastomosis is acceptable in most situations. The available evidence suggests that in the following situations, however, particular anastomotic techniques may result in fewer complications: A stapled side-to-side ileocolic anastomosis is preferable following a right hemicolectomy for cancer. A stapled side-to-side anastomosis is likely also preferable after an ileocolic resection for Crohn’s disease. Colorectal anastomoses can be sutured or stapled with similar results, although the incidence of strictures is higher following stapled anastomoses. Following reversal of loop ileostomy there is some evidence to suggest that a stapled side-to-side anastomosis or sutured enterotomy closure (rather than spout resection and sutured anastomosis) results in fewer complications. Non-randomised data has indicated that small bowel anastomoses are best sutured in the trauma patient. This article reviews the theory, practice and evidence base behind the various gastrointestinal anastomoses to help the practising general surgeon make evidence based operative decisions.
Collapse
Affiliation(s)
- Frances Goulder
- Frances Goulder, Department of Colorectal Surgery, University Hospital Lewisham, Lewisham High Street, London, SE13 6LH, United Kingdom
| |
Collapse
|
10
|
Sozutek A, Colak T, Dag A, Olmez T. Comparison of standard 4-row versus 6-row3-D linear cutter stapler in creation of gastrointestinal system anastomoses: a prospective randomized trial. Clinics (Sao Paulo) 2012; 67:1035-8. [PMID: 23018300 PMCID: PMC3438243 DOI: 10.6061/clinics/2012(09)09] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Accepted: 05/10/2012] [Indexed: 11/23/2022] Open
Abstract
OBJECTIVE This prospective study was conducted to compare the clinical outcomes of a 6-row 3-D linear cutter with the standard 4-row linear cutter in patients who underwent elective gastrointestinal surgery anastomosis. METHOD Patients who underwent elective open gastrointestinal surgery that included stapled anastomosis using a linear cutter (Proximate®, Ethicon Endo-Surgery, Cincinnati, OH) between January 2011 and May 2011 were included in the study. The patients were randomly assigned to two groups according to the linear cutter that was used in the surgery: the standard 4-row cutter (the S group) or the new 6-row cutter (the N group). The groups were compared based on the patient demographic data, the laboratory parameters, the preoperative diagnosis, the surgery performed, the operation time, intra-or postoperative complications, the time to oral tolerance and the length of the hospital stay. RESULTS The S group included 11 male and nine female patients with a mean age of 65 ± 12 (35-84) years, while the N group included 13 male and eight female patients with a mean age of 62 ± 11 (46-79) years (p =0.448, p = 0.443, respectively). Anastomotic line bleeding was observed in eight (40%) patients in the S group and in one (4.7%) patient in the N group (p = 0.006). Dehiscence of the anastomosis line was observed in two (10%) patients in the S group and none in the N group (p =0.131). Anastomotic leakage developed in three (15%) patients in the S group and in one (4.7%) patient in the N group (p = 0.269). The mean hospital stay was 12.65 ± 6.1 days in theS group and 9.52 ± 2.9 days in the N group (p = 0.043). CONCLUSION The 6-row 3-D linear cutter is a safe and easily applied instrument that can be used to create anastomoses in gastrointestinal surgery. The new stapler provides some usage benefits and is also superior to the standard linear cutter with regard to anastomotic line bleeding.
Collapse
Affiliation(s)
- Alper Sozutek
- Department of Gastroenterological Surgery, Mersin University Medical Faculty, Mersin, Turkey.
| | | | | | | |
Collapse
|
11
|
Bangaru H, Veitla RMR, Pigilam M, Kunwargiri GK. Comparative Study between Staplers and Conventional(Hand-Sewn) Anastomosis in Gastrointestinal Surgery. Indian J Surg 2012; 74:462-7. [PMID: 24293900 DOI: 10.1007/s12262-012-0450-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2011] [Accepted: 03/05/2012] [Indexed: 11/30/2022] Open
Abstract
Conventional (hand-sewn) technique of intestinal anastomosis has been in vogue for decades. Staplers which were developed to simplify surgery began to have significant impact. To compare staplers versus conventional anastomosis with respect to certain intra operative and post operative parameters. Prospective study from November 2008 to October 2010 in Hyderabad at OSMANIA, GANDHI, MNJ CANCER hospitals. 120 patients were divided into three groups of 40 each, depending on the surgery like posterior gastrojejunostomy, distal gastrectomy and reconstruction (Billroth II) and colorectal anastomosis. Of these 40 patients, 20 were in hand-sewn group and the other 20 in stapler group. Unpaired 't' test was used to find 'p' value . 'p' value less than 0.05 was considered statistically significant. Total operating time was shortened in stapler group. No significant difference was found in terms of restoration of intestinal function, post-operative hospital stay, post-operative complications like anastomotic leak. Staplers can expedite surgery. They have better access to difficult-to-reach areas. Thus staplers can be beneficial though one should not forget the art of conventional suturing.
Collapse
Affiliation(s)
- Himabindu Bangaru
- General Surgery, Osmania General Hospital, D/O B. Balachandra H.NO:3-12-117/140 P.S. Colony, OPP.T.V Studio, Ramantapur, Hyderabad, 500013 AP India
| | | | | | | |
Collapse
|
12
|
Neutzling CB, Lustosa SAS, Proenca IM, da Silva EMK, Matos D. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2012:CD003144. [PMID: 22336786 DOI: 10.1002/14651858.cd003144.pub2] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND Previous systematic reviews comparing stapled and handsewn colorectal anastomosis that are available in the medical literature have not shown either technique to be superior. An update of this systematic review was performed to find out if there are any data that properly answer this question. OBJECTIVES To compare the safety and effectiveness of stapled and handsewn colorectal anastomosis surgery. The following primary hypothesis was tested: the stapled technique is more effective because it decreases the level of complications. SEARCH METHODS A computerized search was performed in the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE according to the strategies of the Colorectal Cancer Group of The Cochrane Collaboration. There were no limits upon language, date or other criteria. A revised search strategy was performed for this updated version of the review May 2011. SELECTION CRITERIA All randomised controlled trials (RCTs) in which stapled and handsewn colorectal anastomosis techniques were compared. Participants were adult patients undergoing elective colorectal anastomosis surgery. The interventions were endoluminal circular stapler and handsewn colorectal anastomosis surgery. Outcomes considered were a) mortality; b) overall anastomotic dehiscence; c) clinical anastomotic dehiscence; d) radiological anastomotic dehiscence; e) stricture; f) anastomotic haemorrhage; g) reoperation; h) wound infection; i) anastomosis duration; and j) hospital stay. DATA COLLECTION AND ANALYSIS Data were independently analysed by the two review authors (CBN, SASL) and cross-checked. The methodological quality of each trial was assessed by the same two authors. After searching the literature for this update, no study was added to those in the previous version of this review. Details of randomizations (generation and concealment), blinding, whether an intention-to-treat analysis was done or not, and the number of patients lost to follow-up were recorded. The analysis of the risk of bias was updated according to the software Review Manager 5.1. The results of each RCT were summarized on an intention-to-treat basis in 2 x 2 tables for each outcome. External validity was defined by the characteristics of the participants, interventions and the outcomes. The RCTs were stratified according to the level of colorectal anastomosis. The risk difference (RD) method (random-effects model) and number needed to treat (NNT) for dichotomous outcome measures and weighted mean differences (WMD) for continuous outcomes measures, with the corresponding 95% confidence intervals (CI), were presented in this review. Statistical heterogeneity was evaluated using a funnel plot and the Chi(2) test. MAIN RESULTS Of the 1233 patients enrolled in nine identified trials, 622 were treated with staples and 611 with manual suture. The following main results were obtained. a) Mortality, result based on 901 patients: RD -0.6%, 95% CI -2.8% to +1.6%. b) Overall dehiscence, result based on 1233 patients: RD 0.2%, 95% CI -5.0% to +5.3%. c) Clinical anastomotic dehiscence, result based on 1233 patients: RD -1.4%, 95% CI -5.2 to +2.3%. d) Radiological anastomotic dehiscence, result based on 825 patients: RD 1.2%, 95% CI -4.8% to +7.3%. e) Stricture, result based on 1042 patients: RD 4.6%, 95% CI 1.2% to 8.1%; NNT 17, 95% CI 12 to 31. f) Anastomotic haemorrhage, result based on 662 patients: RD 2.7%, 95% CI -0.1% to +5.5%. g) Reoperation, result based on 544 patients: RD 3.9%, 95% CI 0.3% to 7.4%. h) Wound infection, result based on 567 patients: RD 1.0%, 95% CI -2.2% to +4.3%. i) Anastomosis duration, result based on one study (159 patients): WMD -7.6 minutes, 95% CI -12.9 to -2.2 minutes. j) Hospital stay, result based on one study (159 patients): WMD 2.0 days, 95% CI -3.27 to +7.2 days. AUTHORS' CONCLUSIONS The evidence found was insufficient to demonstrate any superiority of stapled over handsewn techniques in colorectal anastomosis surgery, regardless of the level of anastomosis. There were no randomised clinical trials comparing these two types of anastomosis in elective conditions in the last decade. The relevance of this research question has possibly lost its strength where elective surgery is concerned. However, in risk situations, such as emergency surgery, trauma and inflammatory bowel disease, new clinical trials are needed.
Collapse
Affiliation(s)
- Cristiane B Neutzling
- Interdisciplinary Surgical Science Program,UNIFESP-Escola Paulista deMedicina, São Paulo, Brazil
| | | | | | | | | |
Collapse
|
13
|
Choy PYG, Bissett IP, Docherty JG, Parry BR, Merrie A, Fitzgerald A. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev 2011:CD004320. [PMID: 21901690 DOI: 10.1002/14651858.cd004320.pub3] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. This is an update of a Cochrane review first published in 2007. OBJECTIVES To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications. SEARCH STRATEGY MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005 and were updated in December 2010. Abstracts presented to the following society meetings between 1970 and 2010 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology. SELECTION CRITERIA Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults. DATA COLLECTION AND ANALYSIS Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer inflammatory bowel disease as indication for ileocolic anastomoses were performed. MAIN RESULTS After obtaining individual data from authors for studies that include other anastomoses, seven trials (including one unpublished) with 1125 ileocolic participants (441 stapled, 684 handsewn) were included. The five largest trials had adequate allocation concealment.Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=11/441, HS=42/684, OR 0.48 [0.24, 0.95] p=0.03). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significantly fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). In subgroup analysis of non-cancer patients (3 studies, 264 patients) there were no differences for any reported outcomes. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference. AUTHORS' CONCLUSIONS Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.
Collapse
|
14
|
Melis M, Karl RC, Wong SL, Brennan MF, Matthews JB, Roggin KK. Evidence-based surgical practice in academic medical centers: consistently anecdotal? J Gastrointest Surg 2010; 14:904-9. [PMID: 20213210 DOI: 10.1007/s11605-010-1175-1] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2009] [Accepted: 02/09/2010] [Indexed: 01/31/2023]
Abstract
INTRODUCTION Randomized trials, meta-analyses, and guidelines form the basis of clinical decision making. We queried a small sample of surgeons at three academic medical centers to determine whether key elements of surgical practice were concordant with available evidence. MATERIALS AND METHODS A French Society of Digestive Surgery (FSDS) questionnaire was submitted to general surgery trainees and faculty at the University of South Florida and University of Chicago and to surgical oncology fellows at the Memorial Sloan-Kettering Cancer Center. Participants were asked to respond "never," "rarely," "often," or "always" to 13 questions involving different aspects of gastrointestinal surgery. For each question, a correct evidence-based answer was available from published studies. RESULTS AND DISCUSSION One hundred ten surgeons (79% of eligible participants) completed the survey. Only 60% of the answers were concordant with existing data. The percentages of correct answers did not differ significantly according to institution or level of experience of participants. The low frequency of correct responses in our subjects paralleled the findings from the 2004 FSDS study. Variability in the quality of evidence and ambiguity in the survey questions may have influenced the responses, but evidence-based medicine does not appear to uniformly influence clinical decision making.
Collapse
Affiliation(s)
- Marcovalerio Melis
- Division of Surgical Oncology, Department of Surgery, New York University School of Medicine, New York Harbor Healthcare System VAMC, 423 East 23rd Street, Room 4153 N, New York, NY 10017, USA.
| | | | | | | | | | | |
Collapse
|
15
|
Fujita T, Katai H, Morita S, Saka M, Fukagawa T, Sano T. Short-term outcomes of Roux-en-Y stapled anastomosis after distal gastrectomy for gastric adenocarcinoma. J Gastrointest Surg 2010; 14:289-94. [PMID: 19904576 DOI: 10.1007/s11605-009-1082-5] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2009] [Accepted: 10/26/2009] [Indexed: 02/07/2023]
Abstract
BACKGROUND Since 2003, we have begun to perform gastrojejunostomy by mechanical stapling for Roux-en-Y reconstruction in distal gastrectomy. We performed a retrospective study to compare the short-term outcomes of anastomosis by mechanical stapling and hand suturing. METHODS We evaluated the data of 701 consecutive patients of gastric adenocarcinoma who underwent conventional open distal gastrectomy with Roux-en-Y reconstruction. The data collected included details on the method used for the Roux-en-Y reconstruction, the disease stage, extent of lymph node dissection, performance rate of truncal vagotomy, operation time, operative blood loss, length of hospital stay, and postoperative complications. RESULTS The operation time was significantly shorter in the group in which mechanical stapling was used for the anastomosis (MS group) than in the group in which anastomosis was performed by hand suturing (HS group; 241.1 +/- 56.8 vs. 166.4 +/- 48.3 min; p < 0.05). Postoperatively, delayed gastric emptying occurred in 14 (1.9%) patients, including seven (4.2%) from the MS group and seven (1.3%) from the HS group (p = 0.038). CONCLUSION There were no significant disadvantages of employing mechanical stapling for anastomosis, except for the high rate of delayed gastric emptying. More consideration therefore needs to be given to decreasing the frequency of gastric emptying disturbance post surgery using mechanical staples.
Collapse
Affiliation(s)
- Takeshi Fujita
- Gastric Surgery Division, National Cancer Center Hospital, 5-1-1 Tsukiji, Chuo-ku, Tokyo 104-0045, Japan
| | | | | | | | | | | |
Collapse
|
16
|
STOLOFF DAVID, SNIDER THERONG, CRAWFORD MPATRICK, TAYLOR HW, COX HOLLISUTAH. End-to-End Colonic Anastomosis A Comparison of Techniques in Normal Dogs. Vet Surg 2008. [DOI: 10.1111/j.1532-950x.1984.tb00764.x] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
|
17
|
Choy PYG, Bissett IP, Docherty JG, Parry BR, Merrie AEH. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev 2007:CD004320. [PMID: 17636751 DOI: 10.1002/14651858.cd004320.pub2] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. To our knowledge, this is the first systematic review specifically investigating ileocolic anastomosis. OBJECTIVES To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications. SEARCH STRATEGY MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005. Abstracts presented to the following society meetings between 1970 and 2002 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology. SELECTION CRITERIA Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults. DATA COLLECTION AND ANALYSIS Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 4.2 Analysis version 1.0.5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer and inflammatory bowel disease as indication for ileocolic anastomoses were performed. MAIN RESULTS After obtaining individual data from authors for studies that include other anastomoses, six trials (including one unpublished) with 955 ileocolic participants (357 stapled, 598 handsewn) were included. The three largest trials had adequate allocation concealment. Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=5/357, HS=36/598, OR 0.34 [0.14, 0.82] p=0.02). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significant fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). There were too few Crohn's disease patients to perform sub-group analysis. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference. AUTHORS' CONCLUSIONS Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.
Collapse
|
18
|
Anwar S, Hughes S, Eadie AJ, Scott NA. Anastomotic technique and survival after right hemicolectomy for colorectal cancer. Surgeon 2004; 2:277-80. [PMID: 15570847 DOI: 10.1016/s1479-666x(04)80097-0] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM To compare the long-term outcome of patients after right hemicolectomy for colorectal cancer undergoing ileocolonic reconstruction either by a sutured technique or by side-to-side stapled anastomosis. METHODS Single surgeon series from 1992 to 2001 comprising 100 consecutive patients, 59 with hand sutured reconstruction and 41 undergoing TLC 55mm stapled side-to-side anastomosis. Details of gender, patient age, and elective versus emergency presentation, Dukes stage, and curative versus palliative resection were recorded prospectively. In addition, post-operative hospital stay and subsequent survival were determined by prospective protocol follow-up. RESULTS Overall 24% of the patients studied presented as emergencies and underwent a palliative procedure. There were no anastomotic leaks in either the stapled or sutured groups. Hospital mortality was also not significantly different--stapled reconstruction, 7%, sutured reconstruction, 10% (p value 0.624). Overall long-term cancer outcome was the same for both anastomotic techniques, both stapled and sutured groups having a median survival of 2.9 years. CONCLUSIONS Stapled ileocolonic reconstruction after right hemicolectomy for colonic carcinoma is a safe and reliable surgical technique associated with long-term cancer outcomes comparable with those obtained by the sutured anastomotic technique.
Collapse
Affiliation(s)
- S Anwar
- Department of Colorectal Surgery, Hope Hospital, Salford, Manchester, UK.
| | | | | | | |
Collapse
|
19
|
Kirkpatrick AW, Baxter KA, Simons RK, Germann E, Lucas CE, Ledgerwood AM. Intra-abdominal Complications after Surgical Repair of Small Bowel Injuries: An International Review. ACTA ACUST UNITED AC 2003; 55:399-406. [PMID: 14501878 DOI: 10.1097/01.ta.0000060248.87046.ee] [Citation(s) in RCA: 41] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND The ideal method of repairing serious small bowel injuries remains unknown. Prior reports suggest a higher rate of enteric anastomotic-related complications (EACs) with stapled posttraumatic bowel anastomosis but did not specifically focus on the small bowel or clarify fully the actual anastomotic construction. METHODS This was a retrospective review of patients requiring surgical repair of small bowel perforations at a Level I urban American center (Detroit Receiving Hospital [DRH]) and a Canadian provincial trauma center (Vancouver Hospital and Health Sciences Center [VHHSC]). All patients requiring a primary repair and/or resection were included. Anastomoses were hand-sewn, stapled, or combined stapling and sewing with mucosal inversion. Leaks, anastomotic fistulae, and intra-abdominal abscesses were considered specific EACs. A sample size of 53 per group was obtained to detect a 17% difference at alpha = 0.05 (one-sided) and beta = 0.2. RESULTS Full-thickness small bowel injuries were repaired in 232 patients (DRH, 165; VHHSC, 67). Injuries were penetrating at DRH (91.5%) and blunt at VHHSC (65.7%). Anastomotic repairs in 127 patients (158 anastomotic repairs [DRH, 113; VHHSC, 55]) were 64 (40.5%) stapled, 38 (24.1%) hand-sewn, and 56 (35.4%) combined. Also, 105 patients had 349 primary closures of an injury. Overall, there were 24 EACs. After anastomosis, there were 11 intra-abdominal abscesses: 6 after stapling, 3 after being sewn, and 2 after a combined construction. There were four small bowel anastomotic fistulae: three after stapled-only anastomosis and one after hand-sewing. After enteroenterostomy, the EAC rate was 10.2% per patient, or 8.4% per anastomosis. After primary repairs, one patient had an anastomotic fistula, which closed spontaneously, and 11 had intra-abdominal abscesses, yielding an EAC rate of 10.6% per patient or 3.4% per repair. A primary repair was significantly less likely to be associated with an EAC than any anastomosis (p = 0.035). No method of anastomosis was statistically safer in relation to EACs, whether analyzed by patient, by anastomosis, or by considering primarily either the use of a linear stapler or the principle of inverting the mucosal approximation. Only damage control procedures and associated pancreaticoduodenal injuries were identified as statistically significant predictors using multiple logistic regression analysis. CONCLUSION Anastomotic complications after enteroenterostomy or primary repair for trauma are uncommon regardless of the technique, but surgeons must be especially cautious during or after damage control. Primary repairs are desirable, but when anastomosis is unavoidable, the method of repair should reflect that with which the surgeon is the most comfortable.
Collapse
|
20
|
Brundage SI, Jurkovich GJ, Hoyt DB, Patel NY, Ross SE, Marburger R, Stoner M, Ivatury RR, Ku J, Rutherford EJ, Maier RV. Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial. THE JOURNAL OF TRAUMA 2001; 51:1054-61. [PMID: 11740250 DOI: 10.1097/00005373-200112000-00005] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Construction of gastrointestinal anastomoses utilizing stapling devices has become a familiar procedure. In elective surgery, studies have shown no significant differences in complications between stapled and sutured anastomoses. Controversy has recently arisen regarding the accurate incidence of complications associated with anastomoses in the trauma patient. The objective of this multi-institutional study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses following the emergent repair of traumatic bowel injuries. METHODS Using a retrospective cohort design, all trauma registry records from five Level I trauma centers over a period of 4 years were reviewed. RESULTS A total of 199 patients with 289 anastomoses were identified. A surgical stapling device was used to create 175 separate anastomoses, while a hand-sutured method was employed in 114 anastomoses. A complication was defined as an anastomotic leak verified at reoperation, an intra-abdominal abscess, or an enterocutaneous fistula. The mean abdominal Abbreviated Injury Scale score and Injury Severity Score were similar in the two cohort groups. Stapling and suturing techniques were evenly distributed in both small and large bowel repairs. Seven of the total 175 stapled anastomoses and none of the 114 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (RR = undefined, 95% CI 1.08-infinity, p = 0.04). Each anastomotic leak occurred in a separate individual. Nineteen stapled anastomoses and four sutured anastomoses were associated with an intra-abdominal abscess (RR = 2.7, 95% CI 0.96-7.57, p = 0.04). Enterocutaneous fistula formation was not statistically associated with either type of anastomoses (stapled cohort = 3 of 175 and sutured cohort = 2 of 114). Overall, 22 (13%) stapled anastomoses and 6 (5%) sutured anastomoses were associated with an intra-abdominal complication (RR = 2.08, 95% CI 0.89-4.86, p = 0.076). CONCLUSION Anastomotic leaks and intra-abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastomoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.
Collapse
Affiliation(s)
- S I Brundage
- Department of Surgery, Baylor College Of Medicine, Houston, Texas 77030, USA.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
21
|
Muñoz-Juárez M, Yamamoto T, Wolff BG, Keighley MR. Wide-lumen stapled anastomosis vs. conventional end-to-end anastomosis in the treatment of Crohn's disease. Dis Colon Rectum 2001; 44:20-5; discussion 25-6. [PMID: 11805559 DOI: 10.1007/bf02234814] [Citation(s) in RCA: 100] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
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.
Collapse
Affiliation(s)
- M Muñoz-Juárez
- Division of Colon and Rectal Surgery, Mayo Clinic and Mayo Foundation, Rochester, Minnesota 55905, USA
| | | | | | | |
Collapse
|
22
|
Lustosa SA, Matos D, Atallah AN, Castro AA. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev 2001:CD003144. [PMID: 11687041 DOI: 10.1002/14651858.cd003144] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Randomized controlled trials comparing stapled with handsewn colorectal anastomosis have not shown either technique to be superior, perhaps because individual studies lacked statistical power. A systematic review, with pooled analysis of results, might provide a more definitive answer. OBJECTIVES To compare the safety and effectiveness of stapled and handsewn colorectal anastomosis. The following primary hypothesis was tested: the stapled technique is more effective because it decreases the level of complications. SEARCH STRATEGY The RCT register of the Cochrane Review Group was searched for any trial or reference to a relevant trial (published, in-press, or in progress). All publications were sought through computerised searches of EMBASE, LILACS, MEDLINE, the Cochrane Controlled Clinical Trials Database, and through letters to industrial companies and authors. There were no limits upon language, date, or other criteria. STUDIES All randomized clinical trials (RCTs) in which stapled and handsewn colorectal anastomosis were compared. PARTICIPANTS Adult patients submitted electively to colorectal anastomosis. INTERVENTIONS Endoluminal circular stapler and handsewn colorectal anastomosis. OUTCOMES a) Mortality b) Overall Anastomotic Dehiscence c) Clinical Anastomotic Dehiscence d) Radiological Anastomotic Dehiscence e) Stricture f) Anastomotic Haemorrhage g) Reoperation h) Wound Infection i) Anastomosis Duration j) Hospital Stay. DATA COLLECTION AND ANALYSIS Data were independently extracted by the two reviewers (SASL, DM) and cross-checked. The methodological quality of each trial was assessed by the same two reviewers. Details of the randomization (generation and concealment), blinding, whether an intention-to-treat analysis was done, and the number of patients lost to follow-up were recorded. The results of each RCT were summarised on an intention-to-treat basis in 2 x 2 tables for each outcome. External validity was defined by characteristics of the participants, the interventions and the outcomes. The RCTs were stratified according to the level of colorectal anastomosis. The Risk Difference method (random effects model) and NNT for dichotomous outcomes measures and weighted mean difference for continuous outcomes measures, with the corresponding 95% confidence interval, were presented in this review. Statistical heterogeneity was evaluated by using funnel plot and chi-square testing. MAIN RESULTS Of the 1233 patients enrolled ( in 9 trials), 622 were treated with stapled, and 611 with manual, suture. The following main results were obtained: a) Mortality: result based on 901 patients; Risk Difference - 0.6% Confidence Interval -2.8% to +1.6%. b) Overall Dehiscence: result based on 1233 patients; Risk Difference 0.2%, 95% Confidence Interval -5.0% to +5.3%. c) Clinical Anastomotic Dehiscence : result based on 1233 patients; Risk Difference -1.4%, 95% Confidence Interval -5.2 to +2.3%. d) Radiological Anastomotic Dehiscence : result based on 825 patients; Risk Difference 1.2%, 95% Confidence Interval -4.8% to +7.3%. e) Stricture: result based on 1042 patients; Risk Difference 4.6%, 95% Confidence Interval 1.2% to 8.1%. Number needed to treat 17, 95% confidence interval 12 to 31. f) Anastomotic Hemorrhage: result based on 662 patients; Risk Difference 2.7%, 95% Confidence Interval - 0.1% to +5.5%. g) Reoperation: result based on 544 patients; Risk Difference 3.9%, 95% Confidence Interval 0.3% to 7.4%. h) Wound Infection: result based on 567 patients; Risk Difference 1.0%, 95% Confidence Interval -2.2% to +4.3%. i) Anastomosis duration: result based on one study (159 patients); Weighted Mean Difference -7.6 minutes, 95% Confidence Interval -12.9 to -2.2 minutes. j) Hospital Stay: result based on one study (159 patients), Weighted Mean Difference 2.0 days, 95% Confidence Interval -3.27 to +7.2 days. REVIEWER'S CONCLUSIONS The evidence found was insufficient to demonstrate any superiority of stapled over handsewn techniques in colorectal anastomosis, regardless of the level of anastomosis.
Collapse
Affiliation(s)
- S A Lustosa
- Surgical Gastroenterology Department, Federal University of São Paulo, Rua Edson 278, AP61., São Paulo, São Paulo, Brazil, 04618-031.
| | | | | | | |
Collapse
|
23
|
Witzke JD, Kraatz JJ, Morken JM, Ney AL, West MA, Van Camp JM, Zera RT, Rodriguez JL. Stapled versus hand sewn anastomoses in patients with small bowel injury: a changing perspective. THE JOURNAL OF TRAUMA 2000; 49:660-5; discussion 665-6. [PMID: 11038083 DOI: 10.1097/00005373-200010000-00013] [Citation(s) in RCA: 35] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
INTRODUCTION Recent studies indicate that trauma patients with hollow viscus injuries requiring anastomosis who are managed with stapling have a higher rate of complications than do those in whom a hand-sewn anastomosis is used. We undertook this study to determine whether this finding applied to patients with small bowel trauma at our institution. METHODS Records of patients with small bowel injuries were retrospectively reviewed. Demographics, severity of injury, injury management, and outcome data were collected. RESULTS Patients who had their small bowel injuries managed by hand-sewn repair versus resection and stapled anastomosis demonstrated a nonsignificant decrease in overall complication rate (35% vs. 44%) and rate of intra-abdominal complication (10% vs. 18%). Yet the rate of intra-abdominal abscess formation was significantly lower with hand-sewn repair than with resection and stapled anastomosis (4% vs. 13%). However, when hand-sewn primary repairs were excluded from the analysis and injuries that required resection and either stapled or hand-sewn anastomosis were compared, there was a similar overall complication rate (41% vs. 41%) and rate of intra-abdominal complications (17% vs. 21%). CONCLUSION The rate of intra-abdominal complications did not differ significantly between patients requiring small bowel resection and reanastomosis managed by either a stapled or hand-sewn technique. In our experience, surgical stapling devices appear to be safe for use in repairing traumatic small bowel injury.
Collapse
Affiliation(s)
- J D Witzke
- Department of Surgery, Hennepin County Medical Center, University of Minnesota Medical School, Minneapolis 55415, USA
| | | | | | | | | | | | | | | |
Collapse
|
24
|
Yamamoto T, Allan RN, Keighley MR. Risk factors for intra-abdominal sepsis after surgery in Crohn's disease. Dis Colon Rectum 2000; 43:1141-5. [PMID: 10950014 DOI: 10.1007/bf02236563] [Citation(s) in RCA: 260] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
PURPOSE This study examined risk factors for intra-abdominal sepsis after surgery in Crohn's disease. METHODS We reviewed 343 patients who underwent 1,008 intestinal anastomoses during 566 operations for primary or recurrent Crohn's disease between 1980 and 1997. Possible factors for intra-abdominal sepsis were analyzed by both univariate (chi-squared test) and multivariate (multiple regression) analyses. RESULTS Intra-abdominal septic complications, defined as anastomotic leak, intra-abdominal abscess, or enterocutaneous fistula, developed after 76 operations (13 percent). Intra-abdominal septic complications were significantly associated with preoperative low albumin level (< 30 g/l; P = 0.04), preoperative steroids use (P = 0.03), abscess at the time of laparotomy (P = 0.03), and fistula at the time of laparotomy (P = 0.04). The intra-abdominal septic complication rate was 50 percent (8/16 operations) in patients with all of these four risk factors, 29 percent (10/35 operations) in patients with three risk factors, 14 percent (14/98 operations) in patients with two risk factors, 16 percent (33/209 operations) in patients with only one risk factor, and 5 percent (11/208 operations) in patients with none of these risk factors (P<0.0001). The following factors did not affect the incidence of septic complications; age, duration of symptoms, number of previous bowel resections, site of disease, type of operation (resection, strictureplasty, or bypass), covering stoma, and number, site, or method (sutured or stapled) of anastomoses. CONCLUSIONS Preoperative low albumin level, steroid use, and the presence of abscess or fistula at the time of laparotomy significantly increased the risk of septic complications after surgery in Crohn's disease.
Collapse
Affiliation(s)
- T Yamamoto
- University Department of Surgery, Queen Elizabeth Hospital, Birmingham, United Kingdom
| | | | | |
Collapse
|
25
|
Brundage SI, Jurkovich GJ, Grossman DC, Tong WC, Mack CD, Maier RV. Stapled versus sutured gastrointestinal anastomoses in the trauma patient. THE JOURNAL OF TRAUMA 1999; 47:500-7; discussion 507-8. [PMID: 10498304 DOI: 10.1097/00005373-199909000-00011] [Citation(s) in RCA: 32] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Construction of gastrointestinal anastomoses by using stapling devices has become a familiar procedure. Most studies have shown no significant differences in complication rates between stapled and sutured anastomoses performed during elective surgery. To date, no study has evaluated the incidence of complications of stapled anastomoses in the trauma patient. The purpose of our study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses after the emergent repair of traumatic bowel injuries. METHODS A retrospective analysis of the medical and institutional trauma registry records of patients identified to have undergone a gastrointestinal anastomosis in a regional Level I trauma center over a 4-year period. RESULTS A total of 84 patients with 118 gastrointestinal anastomoses were identified. A surgical stapling device was used to create 58 separate anastomoses, whereas a hand-sutured method was used in 60 anastomoses. A complication was defined as an anastomotic leak verified at reoperation. The ratio of blunt versus penetrating injuries, mean abdominal Abbreviated Injury Scale score, and Injury Severity Score were similar in the two groups. Stapling and suturing techniques were evenly distributed between small and large bowel repairs. Mean intensive care unit length of stay was comparable in both cohorts. However, inpatient length of stay was longer in patients with solely a stapled anastomosis compared with sutured anastomoses. Four of the 58 stapled anastomoses and none of the 60 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (relative risk = undefined; 95% confidence interval, 1.14-infinity; p = 0.037). Each anastomotic leak occurred in a separate individual. The only death occurred in the stapled cohort secondary to peritonitis and subsequent sepsis. CONCLUSION Anastomotic leaks seem to be associated with stapled bowel repairs compared with sutured anastomoses in the traumatically injured patient.
Collapse
Affiliation(s)
- S I Brundage
- Department of Surgery, The University of Washington, Seattle, USA
| | | | | | | | | | | |
Collapse
|
26
|
Yamamoto T, Bain IM, Mylonakis E, Allan RN, Keighley MR. Stapled functional end-to-end anastomosis versus sutured end-to-end anastomosis after ileocolonic resection in Crohn disease. Scand J Gastroenterol 1999; 34:708-13. [PMID: 10466883 DOI: 10.1080/003655299750025921] [Citation(s) in RCA: 82] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
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.
Collapse
Affiliation(s)
- T Yamamoto
- University Dept. of Surgery, Queen Elizabeth Hospital, Birmingham, UK
| | | | | | | | | |
Collapse
|
27
|
Abstract
PURPOSE Trials comparing handsewn with stapled anastomoses in colon and rectal surgery have not found statistical differences. Despite this, authors have differed in their conclusions as to which technique is superior. To help determine whether differences in patient outcomes are present, a meta-analysis of all trials was performed. METHOD A meta-analysis of all randomized, controlled trials assessing handsewn and stapled colon and rectal anastomoses was done using a fixed-effects model. Outcome variables were mortality, technical problems, leak rates, wound infections, strictures, and cancer recurrence. Outcomes were assessed for all anastomoses involving the colon and for the subset of colorectal anastomoses. RESULTS Thirteen distinct trials met the inclusion criteria. Intraoperative technical problems were more likely to occur with stapled than with handsewn anastomoses for all anastomoses (P < 0.0001) and for colorectal anastomoses (P < 0.001). Strictures were also more common following stapled anastomoses (P = 0.015 for all anastomoses; P = 0.028 for colorectal anastomoses). All other outcome measures, including mortality, clinical and radiologic leak rates, and local cancer recurrence rates showed no difference between groups. CONCLUSION Although intraoperative technical problems and postoperative strictures were more common with stapled anastomoses, other outcome measures showed no difference between groups. Thus, both techniques are effective, and the choice may be based on personal preference.
Collapse
Affiliation(s)
- H M MacRae
- Department of Surgery, Mount Sinai Hospital, University of Toronto, Ontario, Canada
| | | |
Collapse
|
28
|
Valverde A, Hay JM, Fingerhut A, Elhadad A. Manual versus mechanical esophagogastric anastomosis after resection for carcinoma: a controlled trial. French Associations for Surgical Research. Surgery 1996; 120:476-83. [PMID: 8784400 DOI: 10.1016/s0039-6060(96)80066-3] [Citation(s) in RCA: 94] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND Mechanical anastomosis has been claimed to reduce the rate of leakage compared with manual anastomosis. No randomized trials have been performed to date to prove this specifically in esophagogastric anastomosis. METHODS One hundred fifty-four patients, 139 men and 15 women ranging in age from 36 to 83 years (mean, 50 +/- 10 years) and undergoing elective resection of esophageal or cardial carcinoma, were included in this multiinstitutional (14 centers) randomized study comparing the rate of anastomotic leakage after esophagogastric anastomosis performed manually or mechanically. Eligible for this study were patients with esophageal or cardial carcinoma located between the esophagogastric junction (included) and the upper border of the aortic arch. The choice between resection with or without thoracotomy was left to the discretion of the operating surgeon. Proximal resection of the fundus was mandatory. Intestinal tract continuity was reestablished in a one-stage procedure by an esophagogastric anastomosis without interposition of either the jejunum or the colon. The site of the anastomosis could be either intrathoracic or cervical. The principal end point was anastomotic leakage as judged by (1) egress of intestinal fluids or orally ingested methylene blue through drains, (2) sodium diatrozate swallow prescribed either routinely for all patients between postoperative days 3 and 8 or because of signs of leakage, or (3) reoperation or autopsy. RESULTS After two patients were withdrawn for protocol violation, 152 patients, 74 in the manual group and 78 in the mechanical group, were studied. The number of anastomotic leakages was identical in both groups (n = 12, 16% and 15%, respectively). Overall 30-day mortality was 11%. Fewer deaths occurred in the manual group (7%), which had three anastomotic leakages, than in the mechanical group (15%), which had five anastomotic leakages, and fewer repeat operations were done in the manual group (n = 9) than in the mechanical group (n = 13), but both of these differences were not statistically significant. The duration of anastomosis and of operation was similar in both groups. In the mechanical group 16 anastomoses (20%) gave rise to technical mishaps (either in the fashioning of the purse-string, dilation of the esophagus, or in stapling). Among the factors recognized as potentially preventing leakage, only testing for airtightness was significantly correlated with less postoperative leakage (p < 0.05). Eight postoperative strictures were recorded at 3 months in 62 (13%) patients in the manual group, whereas seven strictures occurred in 53 (13%) patients in the mechanical group. CONCLUSIONS When mechanical staples rather than manual sutures are chosen, the disadvantages (technical mishaps and higher costs) are not counterbalanced by a gain of time or a decrease in the rate or severity of anastomotic leakage.
Collapse
Affiliation(s)
- A Valverde
- Surgical Unit, Hôpital Louis Mourìer, Colombes, France
| | | | | | | |
Collapse
|
29
|
Fingerhut A, Hay JM, Elhadad A, Lacaine F, Flamant Y. Supraperitoneal colorectal anastomosis: hand-sewn versus circular staples--a controlled clinical trial. French Associations for Surgical Research. Surgery 1995; 118:479-85. [PMID: 7652682 DOI: 10.1016/s0039-6060(05)80362-9] [Citation(s) in RCA: 67] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND Although used widely for supraperitoneal anastomoses, circular stapled anastomoses have never been proved better than hand-sewn anastomoses. In the one prospective controlled trial that studied these anastomoses specifically, the only significant difference found was that there were more clinically obvious leakages with the circular stapled variety, but not in the overall clinical and roentgenologic leakage rates. METHODS One hundred fifty-nine consecutive patients (88 men and 71 women, mean age 65.8 +/- 12.1 years) were randomized to undergo hand-sewn (n = 74) or circular stapled (n = 85) supraperitoneal colorectal anastomosis after left colectomy. RESULTS Patient demographics were similar in both groups. Overall mortality was 1.3% (2 of 159; one in each group). No statistically significant difference (NS) was found in the rate of early complications, including anastomotic leakage (4 of 74 versus 6 of 85) in the hand-sewn and stapled anastomoses, respectively). Mishaps (n = 10) and hemorrhage (n = 5) occurred in the stapled group only. Stapled anastomoses took an average of 8 minutes less to perform (p < 0.001), but this time gain did not significantly influence the overall duration of operation (identical median times). The median duration of hospitalization was 13 and 14 days, respectively (NS). At 8 months there were 2 of 74 strictures in the hand-sewn group and 4 of 85 strictures in the stapled group (NS). CONCLUSIONS According to these results, there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis.
Collapse
|
30
|
Docherty JG, McGregor JR, Akyol AM, Murray GD, Galloway DJ. Comparison of manually constructed and stapled anastomoses in colorectal surgery. West of Scotland and Highland Anastomosis Study Group. Ann Surg 1995; 221:176-84. [PMID: 7857145 PMCID: PMC1234951 DOI: 10.1097/00000658-199502000-00008] [Citation(s) in RCA: 156] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE The authors compared both the initial and the long-term outcomes of patients undergoing stapled and sutured colorectal anastomoses. SUMMARY BACKGROUND DATA Sutured and stapled large bowel anastomoses are perceived to be equally safe, but concern has been raised about increased rates of tumor recurrence with the use of stapling instruments. METHODS The outcome of patients with sutured and stapled colorectal anastomoses were compared in a prospective, multicenter, randomized study. Factors affecting long-term outcomes were assessed by both univariate and multivariate analysis. RESULTS Seven hundred thirty-two patients were recruited. There was a significant increase in radiologic leakage in the sutured group (14.4% vs. 5.2%, p < 0.05), but there was no difference in clinical anastomotic leak rates, morbidity, or postoperative mortality. Tumor recurrence and cancer-specific mortality were higher in the sutured patients (7.5% and 6.7%, respectively) and in patients with anastomotic leaks. CONCLUSIONS This study shows that suturing or stapling are equally safe in large bowel surgery. However, it also shows a long-term benefit of stapling in colorectal cancer patients.
Collapse
Affiliation(s)
- J G Docherty
- Department of Surgical Gastroenterology, Gartnavel General Hospital, Glasgow, Scotland, United Kingdom
| | | | | | | | | |
Collapse
|
31
|
Abstract
Intestinal resection and anastomosis, bypass enterostomy, and typhlectomy are indicated for many intestinal disorders. The thoracoabdominal and end-to-end anastomosis stapling instruments all may be used to perform a variety of small intestinal surgical procedures.
Collapse
Affiliation(s)
- S L Ullman
- Veterinary Surgical Associates, Concord, California
| |
Collapse
|
32
|
Senagore A, Milsom JW, Walshaw RK, Dunston R, Chaudry IH. Direct comparison between Czerny-Lembert and circular-stapled anastomotic techniques in colorectal anastomosis: a similar pattern of healing for both. Dis Colon Rectum 1992; 35:862-9. [PMID: 1511647 DOI: 10.1007/bf02047874] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
There are scant experimental data directly comparing the healing of the circular-stapled (CS) anastomotic technique with the standard Czerny-Lembert two-layer hand-sewn (HS) anastomotic technique during the acute and chronic phases of healing. The purpose of this study, therefore, was to serially evaluate wound healing in CS and HS anastomoses in the normal porcine colorectum. Forty-two adult female mixed-breed pigs randomly underwent either HS or CS anastomosis at the sacral promontory. Laser Doppler velocimetry (LDV), was used to measure perianastomotic blood flow. Groups of animals underwent a second surgery at 3, 5, 11, 60, or 120 days postoperatively, and anastomoses were restudied using LDV, gross and microscopic grading of inflammation, bursting pressures, and hydroxyproline content. Additionally, the 60-day and 120-day groups of animals underwent preoperative biplanar barium enemas to identify leaks or stenoses. No significant differences in perianastomotic blood flow between the HS and CS techniques were obtained over the entire 120-day study period. Serial evaluation of wound healing revealed no significant differences between the two anastomotic techniques with respect to bursting pressures, gross or microscopic inflammatory scores, or hydroxyproline content. There were no leaks or stenoses with either technique. Despite earlier reports to the contrary, there appears to be no fundamental difference in the mode of healing in the porcine colorectum comparing the HS technique with the CS technique.
Collapse
Affiliation(s)
- A Senagore
- Department of Surgical Research, Ferguson Clinic, Grand Rapids, Michigan
| | | | | | | | | |
Collapse
|
33
|
Steiner A, Braun U, Waldvogel A. Comparison of staple and suture techniques for partial typhlectomy in the cow: a prospective clinical study of 40 cases. ZENTRALBLATT FUR VETERINARMEDIZIN. REIHE A 1992; 39:26-37. [PMID: 1553837 DOI: 10.1111/j.1439-0442.1992.tb00153.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Two techniques for partial typhlectomy were evaluated on 20 cows each suffering from dilatation/torsion of the cecum. In a preliminary study on two cows the suitability of a stainless steel staple pattern using two TA 90 cartridges of 4.8 mm and 3.5 mm staples respectively was examined and the technique standardized. In the main clinical study the stapling pattern (group I) was compared with a simple continuous full thickness appositional suture oversewn with a continuous Cushing suture (group II). The cartridges with the 4.8 mm staples were used in 7 clinical cases, with intestinal wall edema and the 3.5 mm staples were used in 13 cases. Arterial bleeding from the cecal stump occurred in 20 out of 22 cases (including the results of the preliminary study). The number of arteries that had to be ligated was statistically significantly higher (p less than 0.05) with the 4.8 mm staples than with the 3.5 mm staples. The additional ligation of bleeding vessels prolonged the surgical procedure. Seventeen out of 20 cows (85%) of each group were discharged from the clinic. The duration of the hospital stay was 6 days for both groups. Fourteen cows (70%) of each group were still alive upon inquiry. One cow of the stapling group was slaughtered because of a severe fibrinous peritonitis at the resection site. In the other 11 cows there was no evidence of a connection between the surgery and the slaughtering.
Collapse
Affiliation(s)
- A Steiner
- Department of Veterinary Surgery, University of Zürich, Switzerland
| | | | | |
Collapse
|
34
|
Roberts PL, Williamson WA, Sanders LB. Pitfalls in use of stapler in gastrointestinal tract surgery. Surg Clin North Am 1991; 71:1247-57. [PMID: 1948572 DOI: 10.1016/s0039-6109(16)45588-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The development of stapling instruments has been an enormous advancement in surgery of the gastrointestinal tract. No instrument, however, can replace sound surgical judgment and technique.
Collapse
Affiliation(s)
- P L Roberts
- Department of Colon and Rectal Surgery, Lahey Clinic Medical Center, Burlington, Massachusetts
| | | | | |
Collapse
|
35
|
Ullman SL, Pavletic MM, Clark GN. Open Intestinal Anastomosis with Surgical Stapling Equipment in 24 Dogs and Cats. Vet Surg 1991; 20:385-91. [PMID: 1369520 DOI: 10.1111/j.1532-950x.1991.tb00344.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Surgical stapling equipment was used to perform open antiperistaltic side-to-side ("functional end-to-end") entero-anastomoses in 20 dogs and 4 cats. Twenty-one anastomoses healed uneventfully. Seven animals with severe bacterial peritonitis required open peritoneal drainage and delayed abdominal closure. There was postoperative leakage at the anastomotic site in two dogs and a localized abscess at the staple line in one cat. No long-term complications occurred in follow-up periods of 3 to 29 months.
Collapse
Affiliation(s)
- S L Ullman
- Department of Surgery, Tufts University School of Veterinary Medicine, North Grafton, MA 01536, USA
| | | | | |
Collapse
|
36
|
Corman ML. Principles of surgical technique in the treatment of carcinoma of the large bowel. World J Surg 1991; 15:592-6. [PMID: 1949857 DOI: 10.1007/bf01789204] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The principles of surgical technique for the operative management of colon cancer are described. With the background of the evolution of anastomotic alternatives, the methods for reestablishing intestinal continuity and the approach to the treatment of complicated presentations of colonic cancer are reviewed. While one may construe this paper to have a certain author bias, I have tried to present diverse options where pertinent, but there should be little question as to where my opinion lies.
Collapse
Affiliation(s)
- M L Corman
- Department of Colon and Rectal Surgery, Sansum Medical Clinic, Santa Barbara, California
| |
Collapse
|
37
|
Demartines N, Rothenbühler JM, Chevalley JP, Harder F. The single-layer continuous suture for gastric anastomosis. World J Surg 1991; 15:522-5. [PMID: 1891939 DOI: 10.1007/bf01675652] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
The single-layer continuous suture technique has proven to be safe for all intestinal anastomoses of intraperitoneal small and large bowel segments. Since 1985, this technique has also been increasingly applied for gastroduodenostomy and gastrojejunostomy following partial gastrectomy. Through December 1989, we performed 96 gastroenteric anastomoses with the single-layer continuous suture technique. This accounts for 64% of all partial gastrectomies performed between 1985 and 1989. The technique was applied in 89.5% of the gastroenteric anastomoses during 1988 and 1989. The rate of complications after gastroenteric single-layer continuous suture technique was low; 2.1% clinical leakage was found, always in patients with perforated ulcer and peritonitis. We conclude that the single-layer continuous suture technique for gastroenteric anastomosis is safe, simple, easy to perform, quick and reliable.
Collapse
Affiliation(s)
- N Demartines
- Department of Surgery, University of Basle Medical School, Switzerland
| | | | | | | |
Collapse
|
38
|
George WD. Suturing or stapling in gastrointestinal surgery: a prospective randomized study. West of Scotland and Highland Anastomosis Study Group. Br J Surg 1991; 78:337-41. [PMID: 2021851 DOI: 10.1002/bjs.1800780322] [Citation(s) in RCA: 83] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
A prospective randomized study of 1004 patients is reported, comparing surgical stapling and manual suturing techniques in the construction of gastrointestinal anastomoses. The incidence of clinical leaks was similar between the two groups (sutured 3.2 per cent, stapled 4.7 per cent; P = 0.22), while for radiological leaks the incidence was significantly higher in the sutured group (12.2 per cent versus 4.1 per cent, P less than 0.05). Stapling instruments afforded significantly quicker anastomoses, mean(s.e.m.) 28.1(0.7) versus 14.3(0.5) min (P less than 0.001), and quicker operations, 115.5(2.4) versus 103.8(2.2) min (P less than 0.001). The two groups were found to be comparable in other respects such as operative mortality, requirements for blood transfusion, incidence of infective complications, recovery of gastrointestinal function and postoperative hospital stay.
Collapse
Affiliation(s)
- W D George
- University Department of Surgery, Western Infirmary, Glasgow, UK
- Gartnavel General Hospital, Glasgow, UK
- Raigmore Hospital, Inverness, UK
- Crosshouse Hospital, Kilmarnock, UK
- Inverclyde Royal Hospital, Greenock, UK
| |
Collapse
|
39
|
Prospective, randomized trial of the biofragmentable anastomosis ring. The BAR Investigational Group. Am J Surg 1991; 161:136-42; discussion 142-3. [PMID: 1987848 DOI: 10.1016/0002-9610(91)90374-m] [Citation(s) in RCA: 75] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
A randomized trial was undertaken to compare the biofragmental anastomotic ring (BAR) with conventional intraperitoneal colorectal anastomotic techniques. Patients were randomized into one of two schemes: BAR versus sutured or BAR versus stapled anastomosis. There were 782 patients entered into the study and 283 patients (36%) had a sutured anastomosis, 104 patients (13%) had a stapled anastomosis, and 395 (51%) had the BAR. Comparison of the BAR with combined suture and stapled controls revealed no significant differences in wound complication, abscess rate, bleeding, anastomotic leaks, ileus, obstruction, or deaths. There were no differences in return of bowel function, return to normal diet, or hospital stay. Intraoperative difficulties occurred in 46 BAR patients (17%), and this was significantly higher (p less than 0.001) than for sutured (3%) but not for stapled anastomoses (11%). The occurrence of these problems did not adversely effect the outcome. The data suggest that the BAR is a safe, satisfactory alternative to sutured or stapled colorectal anastomoses.
Collapse
|
40
|
Troidl H, Büechl S, Kusche J, Gauda P. [The devil's advocate--commentary on sutures]. LANGENBECKS ARCHIV FUR CHIRURGIE 1987; 372:113-20. [PMID: 3323719 DOI: 10.1007/bf01297800] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
The decision between hand suture or stapler was tested for the large bowel in randomized trials whereas retrospectively only in the upper gastrointestinal and respiratory tract. No clear difference was seen concerning patient's security and cost-time consumption. The stapler is more comfortable but the handsuture technique is still recommended. By the stapler anatomically very difficult anastomoses can be performed. Whether this is an advantage for the patient has to be tested because the technical progress may decrease physical function (incontinence!) and quality of life. In summary, the stapler, if applied critically, seems to be useful.
Collapse
Affiliation(s)
- H Troidl
- II. Lehrstuhl für Chirurgie der Universität zu Köln
| | | | | | | |
Collapse
|
41
|
Year 1980 clinical trial publications. Clin Trials 1986. [DOI: 10.1093/acprof:oso/9780195035681.005.0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
|
42
|
Thiede A, Fuchs KH, Wirtz HJ, Hamelmann H. [Roux-Y reconstruction following distal stomach resection using only staplers]. LANGENBECKS ARCHIV FUR CHIRURGIE 1986; 367:119-27. [PMID: 3959680 DOI: 10.1007/bf01259261] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The spreading of stapled suture techniques has also entailed the utilization of staplers in gastric surgery. A functional, up-to-date, and exclusively stapled reconstruction procedure, Roux-Y-reconstruction, after subtotal gastrectomy was established and analyzed in a pilot study (n = 25). In doing so, one proceeded as follows after subtotal gastrectomy and systematic lymphadenectomy in cases of carcinoma: duodenal closure (GIA or TA30), gastric resection (TA90), jejunojejunostomy (EEA25), gastrojejunostomy (EEA25/28), closure of the projecting efferent loop (GIA). This study intended to achieve the following advantages: increased suture safety, saving of time, reduction of complications, and especially the extension of indications regarding age and localization of the tumor. A special program to eliminate mistakes in handling is required for the sole and systematic application of staplers in the upper gastrointestinal tract. Every complication occurring during and after surgery was carefully recorded in this study and the attainable quality of life after subtotal gastrectomy was assessed.
Collapse
|
43
|
Didolkar MS, Reed WP, Elias EG, Schnaper LA, Brown SD, Chaudhary SM. A prospective randomized study of sutured versus stapled bowel anastomoses in patients with cancer. Cancer 1986; 57:456-60. [PMID: 3510704 DOI: 10.1002/1097-0142(19860201)57:3<456::aid-cncr2820570309>3.0.co;2-3] [Citation(s) in RCA: 43] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Eighty-eight cancer patients with the presence of one or more adverse factors for healing (carcinomatosis, adhesions, prior chemotherapy and radiation therapy, bowel obstruction, anemia, and low leukocyte count or albumin value) were prospectively randomized to undergo conventional two-layer hand suturing (45 patients) or mechanical stapling with a GIA/TA instrument (U.S. Surgical Corp., Norwalk, CT) (43 patients) of the large or small bowel anastomosis. Age, sex, complete blood count findings, and all biochemical plasma values were comparable in both groups. The anastomosis took an average of 19 minutes for the sutured and 9 minutes for the stapled technique (P = 0.0001), but the average length of operation, postoperative return of bowel function, and hospital stay were comparable in both groups. Bowel fistula was seen in one case of stapled anastomosis (P = not significant). The pulmonary and wound complication rates were the same in both groups. Of the four deaths (4.5%) due to causes unrelated to bowel anastomosis, three occurred in the stapled and one in the sutured group. It was concluded that a stapled anastomosis is as safe as a sutured one in patients with advanced-stage cancer. It saves time in anastomosis, but does not save time in postoperative return of the bowel function and hospital stay.
Collapse
|
44
|
Meinert CL, Tonascia S, Higgins K. Content of reports on clinical trials: a critical review. CONTROLLED CLINICAL TRIALS 1984; 5:328-47. [PMID: 6394208 DOI: 10.1016/s0197-2456(84)80013-6] [Citation(s) in RCA: 42] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
A 10% sample of English language papers, published in 1980, listed in Index Medicus, and classified under the heading, Clinical Trials, was used to assess the state of trials and reports from them. Tabulations are presented concerning the design of the trials represented by the papers in the sample. The manuscript concludes with a discussion of reporting responsibilities for investigators involved in trials and of methods for meeting those responsibilities.
Collapse
|
45
|
|
46
|
Khoury GA, Waxman BP. Large bowel anastomoses. I. The healing process and sutured anastomoses. A review. Br J Surg 1983; 70:61-3. [PMID: 6337673 DOI: 10.1002/bjs.1800700202] [Citation(s) in RCA: 59] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
|
47
|
Nahtapparate in der Chirurgie. Eur Surg 1982. [DOI: 10.1007/bf02601866] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
|
48
|
Lowdon IM, Gear MW, Kilby JO. Stapling instruments in upper gastrointestinal surgery: a retrospective study of 362 cases. Br J Surg 1982; 69:333-5. [PMID: 6979372 DOI: 10.1002/bjs.1800690614] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
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.
Collapse
|
49
|
Abstract
Although gastrointestinal staplers have a definite place in surgery because they are safe and effective, their distinct advantages are not clear cut. Surgeons in training should be accomplished in conventional suturing techniques before learning stapler techniques for similar anastomoses.
Collapse
|