The current evidence on stapled versus hand-sewn anastomoses in the digestive tract. MINIM INVASIV THER. 2008;17:151-154. [PMID: 18609000 DOI: 10.1080/13645700802103423]

Application and evaluation of transitory protective stoma in ovarian cancer surgery

Ovarian cancer is the most fatal of all female reproductive cancers. The fatality rate of OC is the highest among gynecological malignant tumors, and cytoreductive surgery is a common surgical procedure for patients with advanced ovarian cancer. To achieve satisfactory tumor reduction, intraoperative bowel surgery is often involved. Intestinal anastomosis is the traditional way to restore intestinal continuity, but the higher rate of postoperative complications still cannot be ignored. Transitory protective stoma can reduce the severity of postoperative complications and traumatic stress reaction and provide the opportunity for conservative treatment. But there are also many problems, such as stoma-related complications and the impact on social psychology. Therefore, it is essential to select appropriate patients according to the indications for the transitory protective stoma, and a customized postoperative care plan is needed specifically for the stoma population.

Development and Validation of Task-Specific Metrics for the Assessment of Linear Stapler-Based Small Bowel Anastomosis

INTRODUCTION

Task-specific metrics facilitate the assessment of surgeon performance. This 3-phased study was designed to (1) develop task-specific metrics for stapled small bowel anastomosis, (2) obtain expert consensus on the appropriateness of the developed metrics, and (3) establish its discriminant validity.

METHODS

In Phase I, a hierarchical task analysis was used to develop the metrics. In Phase II, a survey of expert colorectal surgeons established the importance of the developed metrics. In Phase III, to establish discriminant validity, surgical trainees and surgeons, divided into novice and experienced groups, constructed a side-to-side anastomosis on porcine small bowel using a linear cutting stapler. The participants' performances were videotaped and rated by 2 independent observers. Partial least squares regression was used to compute the weights for the task-specific metrics to obtain weighted total score.

RESULTS

In Phase II, a total of 45 colorectal surgeons were surveyed: 28 with more than 15 years, 13 with 5 to 15 years, and 4 with less than 5 years of experience. The consensus was obtained on all the task-specific metrics in the more experienced groups. In Phase III, 20 subjects participated equally in both groups. The experienced group performed better than the novice group regardless of the rating scale used: global rating scale (p = 0.009) and the task-specific metrics (p = 0.012). After partial least squares regression, the weighted task-specific metric score continued to show that the experienced group performed better (p < 0.001).

CONCLUSION

Task-specific metric items were developed based on expert consensus and showed good discriminant validity compared with a global rating scale between experienced and novice operators. These items can be used for evaluating technical skills in a stapled small bowel anastomosis model.

Outcomes of side-to-end versus end-to-end colorectal anastomosis in non-emergent sigmoid and rectal cancers: randomized controlled clinical trial

Purpose

The outcomes of open colorectal anastomosis of side-to-end vs. end-to-end in non-emergent sigmoid and rectal cancer surgery in adults were compared.

Methods

A randomized controlled trial on individuals with sigmoid and rectal cancers was conducted between September 2016 and September 2018.

Results

The mean age was 62.58±12.3 years in the side-to-end anastomotic (SEA) group and 61.03±13.98 years in the end-to-end anastomotic (EEA) group. Except for the operative time, intraoperative data revealed no significant differences between the studied groups, and the SEA group revealed that the mean anastomotic time was significantly shorter. Perioperative blood loss, length of stay, reoperation, inpatient death, infection, and bleeding were significantly associated with leakage. There is a statistically significant change regarding the range of bowel frequency in the EEA group only (P=0.04). There is a statistically significant difference regarding incontinence for flatus in the SEA group only (P≤0.001). A statistically significant change in both groups regards incontinence for liquid stools (P≤0.001) and clustering of stools (P≤0.001 and P=0.043). The quality of life in the SEA group significantly dropped at 6 months and then returned to baseline as regards to physical well-being (PWB), functional well-being (FWB), and colorectal cancer symptoms (CCS) with no difference as regards SWB and EWB, while in the EEA group, the exact change happened only as regard PWB and FWB, but SWB and CCS percentage did not return to baseline.

Conclusion

The SEA group offers a safe alternative approach to the EEA group.

Can maneuverability in the robot assisted laparoscopic stapler during ileoileal anastomosis compensate for shorter stapler length? - A randomized experimental porcine study

BACKGROUND

Ileal anastomosis is imperative in patients given a urinary diversion during radical cystectomy. Proper handling and staplers with a certain length are important to prevent stenosis of the bowel. The study aim was to compare the circumference and diameter of ileoileal anastomoses using the Endo GIA tri-stapler 45 mm and 60 mm iDrive systems compared to the RAL Endowrist DaVinci 45 mm. This was to investigate if the better maneuverability of the robotic stapler would compensate for the shorter stapler length in the RAL Endowrist DaVinci 45.

MATERIALS AND METHODS

Twenty ileoileal anastomoses were performed in a total of three pigs after randomization according to the type of anastomosis technique used (depending on stapler and robotic system) allocated to four groups (each with five anastomoses): (1) iDrive 45 mm, (2) iDrive 60 mm, (3) RAL DaVinci 45 mm (Si-system), and (4) RAL DaVinci 45 mm (Xi-system). Diameter (mm) and circumference (mm) were measured and compared.

RESULTS

Diameters and circumferences in Group 1 were significantly smaller compared to all the other groups, which did not differ from each other, except in Group 2 where anastomoses had a significantly higher circumference than Group 4.

CONCLUSION

The iDrive 60 mm makes the anastomoses with the widest diameter and highest circumference compared to the iDrive 45 mm. With the RAL DaVinci 45 mm, the diameter and circumference were comparable to the iDrive 60 mm and significantly better than the iDrive 45 mm. An explanation may be the better maneuverability and surgeon control of the RAL DaVinci stapler.

A comparative study of postoperative outcomes after stapled versus handsewn gastrojejunal anastomosis for pylorus-resecting pancreaticoduodenectomy

Backgrounds/Aims

A stapler is widely used in various surgeries, and there have been recent attempts to use it for performing duodenojejunostomy and gastrojejunostomy during pancreaticoduodenectomy. This study aimed to compare the postoperative results of handsewn gastrojejunostomy (HGJ) and stapled gastrojejunstomy (SGJ) limited to pylorus-resecting pancreaticoduodenectomy (PrPD) performed by a single surgeon.

Methods

This retrospective study was conducted between January 2014 and March 2020, and included 131 patients who underwent PrPD performed by a single surgeon. Of the total subjects, 90 were in the HGJ group and 41 in the SGJ group.

Results

The mean time of surgery was significantly shorter in the stapled group than in the handsewn group (450.4±75.4 min vs. 397.1±66.5 min, p<0.001). However, there were no significant differences between the groups in the rates of postoperative pancreatic fistula, bile leak, chyle leak, intra-abdominal fluid collection, postoperative bleeding, ileus, Clavien-Dindo, rate of reoperation, and 30-day mortality, including delayed gastric emptying (DGE) (n=11 vs. n=6, p=0.92).

Conclusions

Gastrojejunostomy using a stapler in PrPD reduces the reconstruction time without any increase in the rate of complications, including DGE. Therefore, using a stapler for gastrojejunostomy in pancreaticoduodenectomy is feasible and safe.

Evidence according to Cochrane Systematic Reviews on Alterable Risk Factors for Anastomotic Leakage in Colorectal Surgery

Anastomotic leakage reflects a major problem in visceral surgery, leading to increased morbidity, mortality, and costs. This review is aimed at evaluating and summarizing risk factors for colorectal anastomotic leakage. A generalized discussion first introduces risk factors beginning with nonalterable factors. Focus is then brought to alterable impact factors on colorectal anastomoses, utilizing Cochrane systematic reviews assessed via systemic literature search of the Cochrane Central Register of Controlled Trials and Medline until May 2019. Seventeen meta-anaylses covering 20 factors were identified. Thereof, 7 factors were preoperative, 10 intraoperative, and 3 postoperative. Three factors significantly reduced the incidence of anastomotic leaks: high (versus low) surgeon's operative volume (RR = 0.68), stapled (versus handsewn) ileocolic anastomosis (RR = 0.41), and a diverting ostomy in anterior resection for rectal carcinoma (RR = 0.32). Discussion of all alterable factors is made in the setting of the pre-, intra-, and postoperative influencers, with the only significant preoperative risk modifier being a high colorectal volume surgeon and the only significant intraoperative factors being utilizing staples in ileocolic anastomoses and a diverting ostomy in rectal anastomoses. There were no measured postoperative alterable factors affecting anastomotic integrity.

Comparing the surgical outcomes of stapled anastomosis versus hand-sewn anastomosis of duodenojejunostomy in pylorus-preserving pancreaticoduodenectomy

Backgrounds/Aims

This study is to evaluate the perioperative outcomes of the duodenojejunostomy (DJ) procedure in pylorus preserving pancreaticoduodenectomy (PPPD).

Methods

In this study, as noted between 2010 and 2018, there were 77 PPPDs which were performed at our hospital by one surgeon. We began the circular stapled method from 2014, and continue with this procedure for the aforementioned surgeries including and up to today. The clinical data for the study were collected retrospectively to compare clinical outcomes of the two methods, the circular stapled anastomosis and the hand - sewn anastomosis.

Results

There were 34 patients in a circular stapled group, and 43 in a hand-sewn group as identified for this study. The delayed gastric emptying (DGE) occurred in 6 (17.64%) patients in the circular stapled group, and 10 (23.3%) in the hand-sewn group (p=0.547). It is noted that there was a serum albumin level measured on the 14th day after the operation, which was significantly high in the circular stapled group (3.41±0.47 (g/dl) vs 2.92±0.39 (g/dl), p<0.001). There were no significant differences in terms of the incidence of postoperative complications (58.8% vs 58.1%, p=0.952) and mortality rates (5.9% vs 0, p=0.192) among the patient participants in this study.

Conclusions

We conclude that using a circular stapler for the DJ procedure in PPPDs do not increase the development of a DGE, and is also helpful for the benefit of the patient's nutritional status going forward during recovery from the operation.

Stapled anastomosis versus hand-sewn anastomosis of gastro/duodenojejunostomy in pancreaticoduodenectomy: A systematic review and meta-analysis

BACKGROUND

Controversy exists regarding the best anastomotic method for pancreaticoduodenectomy (PD). We aimed to evaluate the perioperative outcomes of PD with stapled anastomosis (SA) versus hand-sewn anastomosis (HA) of gastrojejunostomy or duodenojejunostomy.

METHODS

We conducted a systematic search of electronic information sources, including MEDLINE; EMBASE; CINAHL; the Cochrane Central Register of Controlled Trials (CENTRAL); the World Health Organization International Clinical Trials Registry; ClinicalTrials.gov; ISRCTN Register, and bibliographic reference lists. We applied a combination of free text and controlled vocabulary search adapted to thesaurus headings, search operators and limits in each of the above databases. Delayed gastric emptying (DGE), postoperative pancreatic fistula (POPF), anastomotic bleeding, anastomotic leak, intra-abdominal abscess and mortality were defined as the outcome parameters. Combined overall effect sizes were calculated using fixed-effect or random-effects models.

RESULTS

We identified 1 randomised controlled trial (RCT) and 5 observational studies reporting a total of 890 patients who underwent PD with SA (n = 300) or conventional HA (n = 590). Our analysis demonstrated that SA significantly reduced postoperative DGE (OR: 0.37, 95% CI 0.25-0.54, P < 0.00001) but significantly increased anastomotic bleeding (OR: 13.4, 95% CI 2.96-57.41, P = 0.0007) compared to HA. No significant difference was found in POPF (OR: 0.83, 95% CI 0.56-1.21, P = 0.33); anastomotic leak (OR: 0.50, 95% CI 0.09-3.79, P = 0.58); intra-abdominal abscess (OR: 1.39, 95% CI 0.71-2.70, P = 0.34); or mortality (RD: -0.01, 95% CI 0.03-0.02, P = 0.65) between two groups.

CONCLUSIONS

Our analysis demonstrated that compared to conventional HA, SA may be associated with lower incidence of DGE after PD without increasing the risk of clinically significant POPF, anastomotic leak or mortality. However, it is associated with higher rate of anastomotic bleeding which mandates careful and precise haemostasis of the stapled line. Considering the current limited evidence, no definitive conclusion can be drawn. Future research is required.

Effect of Anti-TNF Agents on Postoperative Outcomes in Inflammatory Bowel Disease Patients: a Single Institution Experience

BACKGROUND

Anti-tumor necrosis factor (TNF) agents have been an integral part in the treatment of inflammatory bowel disease. However, a subset of inflammatory bowel disease patients ultimately requires surgery and up to 30 % of them have undergone treatment with anti-TNF agents. Studies assessing the effect of anti-TNF agents on postoperative outcomes have been inconsistent. The aim of this study is to assess postoperative morbidity in inflammatory bowel disease patients who underwent surgery with anti-TNF therapy prior to surgery.

METHODS

This is a retrospective review of 282 patients with inflammatory bowel disease undergoing intestinal surgery between 2013 and 2015 at the Mount Sinai Hospital. Patients were divided into two groups based on treatment with anti-TNF agents (infliximab, adalimumab, certolizumab) within 8 weeks of surgery. Thirty-day postoperative outcomes were recorded. Univariate and multivariate statistical analyses were carried out.

RESULTS

Seventy-three patients were treated with anti-TNF therapy within 8 weeks of surgery while 209 patients did not have exposure. Thirty-day anastomotic leak, intra-abdominal abscess, wound infection, extra-abdominal infection, readmission, and mortality rates were not significantly different between the two groups.

CONCLUSIONS

The use of anti-TNF medications in inflammatory bowel disease patients within 2 months of intestinal surgery is not associated with an increased risk of 30-day postoperative complications.

Outcomes after aortic graft-to-graft anastomosis with an automated circular stapler: A novel approach

OBJECTIVE

Patients with complex aortic disease often require multistaged repairs with numerous anastomoses. Manual suturing can be time consuming. To reduce ischemic time, a circular stapling device has been used to facilitate prosthetic graft-to-graft anastomoses. Objectives are to describe this technique and assess outcomes.

METHODS

From February 2009 to May 2014, 44 patients underwent complex aortic repair with a circular end-to-end anastomosis (EEA) stapler at Cleveland Clinic. All patients had extensive aneurysms: 17 after ascending dissection repair, 10 chronic type B dissections, and 17 degenerative aneurysms. Stapler was used during total arch repair as an end-to-side anastomosis (n = 36; including first stage elephant trunk [ET] in 32, frozen ET in 3) and an end-to-end anastomosis during redo thoracoabdominal repair (n = 11). Three patients had the stapler used during both stages of repair. Patients underwent early and annual follow-ups with computed tomography analysis.

RESULTS

There were no bleeds, ruptures, or leaks at the stapled site, but 2 patients died. Complications included 7 reoperations not related to the site of stapled anastomosis and 6 tracheostomies, but there was no paralysis or renal failure. Mean circulatory arrest time was 16 ± 5 minutes. Mean follow-up was 26 ± 17 months and consisted of imaging before discharge, at 3 to 6 months, and at 1 year. Planned reinterventions included 21 second-stage ET completion: Endovascular (n = 18) and open (n = 3). There were 4 late deaths.

CONCLUSIONS

Use of an end-to-end anastomotic automated circular stapler is safe, effective, and durable in performing graft-to-graft anastomoses during complex thoracic aortic surgery. Further evaluation and refinement of this technique are warranted.

Changes in Small Intestine Tissue Compressed by a Linear Stapler Based on Cole Y Model

Clarifying changes in gastrointestinal tissue compressed by surgical stapler is a crucial prerequisite for stapler design optimization. For this study, a stapler was modified, and multifrequency bioimpedance of a porcine small intestine tissue compressed by the stapler was measured. The Cole _Y model was fitted to the bioimpedance, and changes in tissue were analyzed using model parameters: G ₀, extracellular fluid conductance; ΔG, intracellular fluid conductance; C _cpeF, equivalent capacitance of cell membrane. The changes could be divided into two stages: first, all parameters decreased sharply with slopes more than 15.70 ± 2.67, 4.25 ± 1.23 μS/s and 72.68 ± 6.99 pF/s respectively; and subsequently, with an increase in compression strength, G ₀ decreased with slopes less than 2.54 ± 0.40 μS/s, ΔG decreased slightly with slope of 0.26 ± 0.04 μS/s after fluctuating mildly, and C _cpeF remained nearly invariant after initially increasing with slope of -2.94 ± 0.64 pF/s. In conclusion, when the stapler is closed, a portion of tissue is squeezed out of the measurement space, causing all parameters' sharp decrease. Subsequently, the stapler continues compressing the tissue, leading to extracellular fluid expulsion. The changes in intracellular fluid are related to the compression strength and may be explained by cell restoration. This study could provide a basis for stapler design optimization.

A Novel Successive Suturing Device for Laparoscopic Surgery

Suturing is one of the more tiresome and difficult tasks during laparoscopic surgeries. To cope with this problem, we aimed to develop a novel successive suturing device. A novel needle holding and locking mechanism is proposed to transfer the needle between the upper and bottom jaws. The device is straightforward to use with intuitive 2-trigger control, and it can perform successive suturing without the need of reload between stiches. Also, it is compact enough to be inserted through a 12-mm trocar. The feasibility of the device is verified through in vitro and in vivo experiments. It was found that the developed device was able to successfully close the wounds without any leakage. The developed successive suturing device offers an easy way of performing suture, and it will greatly help surgeons during laparoscopic surgeries.

Technical characteristics can make the difference in a surgical linear stapler. Or not?

BACKGROUND

Anastomotic leak (AL) after gastrointestinal surgery is a severe complication associated with relevant short- and long-term sequelae. Most of the anastomosis are currently performed with a surgical stapler that is required to have appropriate characteristics to guarantee good performances. The aim of our study was to evaluate, in the laboratory, pressure resistance and tensile strength of anastomosis performed with different surgical linear staplers, available in the market.

MATERIALS AND METHODS

We have been studying three linear staplers, with diverse cartridges and staple heights, of three different companies, used for gastrointestinal anastomosis and gastric or intestinal closure. We performed 50 anastomosis for each device, with the pertinent different cartridges, on fresh pig intestine, for a total of 350 anastomosis, then injected saline solution and recorded the pressure that provokes a leak on the staple line. There were no statistically significant differences between the mean pressure necessary to induce an AL in the various instruments (P > 0.05). For studying the tensile strength, we performed a total of 350 anastomosis with the different linear staplers on a special strong paper (Tyvek), then recorded the maximal tensile force that could open the anastomosis.

RESULTS

There were no statistically significant differences between the different staplers about the strength necessary to open the staple line (P > 0.05).

CONCLUSIONS

we demonstrated that different linear staplers of three companies available in the market give comparable anastomotic pressure resistance and tensile strength. This might suggest that small dissimilarities between different devices are not involved, at least as major parameters, in AL etiology.

Comparison of hand-sewn and stapled anastomoses in surgeries of gastrointestinal tumors based on clinical practice of China

BACKGROUND

There is a lack of studies comparing stapled suturing and hand-sewn suturing in the surgeries of gastrointestinal tumors based on the clinical practice of Chinese surgeons.

METHODS

Data were retrospectively collected from 499 patients who underwent surgery to remove gastrointestinal tumors from January 2008 to December 2009. The patients were divided into two groups according to the method of digestive tract reconstruction: 296 patients received stapled suturing and 203 patients received hand-sewn suturing. The operation time, postoperative hospital stay, postoperative recovery and complications of the patients were evaluated and compared between the two groups.

RESULTS

The stapling procedure took shorter operative time compared to the hand-sewn procedure for gastric carcinoma, colorectal cancer and esophageal carcinoma (P < 0.05). There was no significant difference between the two groups in postoperative hospital stay (P > 0.05). Patients receiving stapled suturing also showed shorter recovery for gastric cancer, colorectal cancer, and shorter time to recovery of normal gastrocolorectal motility compared with patients in the hand-sewn group (P < 0.05). However, there was no difference between the two groups in terms of normal time to commencing liquid diet for esophageal cancer patients (P > 0.05). We also found that the stapled procedure showed a lower incidence of anastomotic leakage, anastomotic hemorrhage and stump leakage in treating colorectal cancer or gastric carcinoma compared with the hand-sewn procedure (P < 0.05).

CONCLUSIONS

Application of the stapler in treating gastrointestinal tumors demonstrated better effects on patients in terms of surgical operation time, recovery time to normal functions, and occurrence of complications compared to hand-sewn anastomosis, especially in gastric carcinoma and colorectal cancer.

Smart tissue anastomosis robot (STAR): a vision-guided robotics system for laparoscopic suturing

This paper introduces the smart tissue anastomosis robot (STAR). Currently, the STAR is a proof-of-concept for a vision-guided robotic system featuring an actuated laparoscopic suturing tool capable of executing running sutures from image-based commands. The STAR tool is designed around a commercially available laparoscopic suturing tool that is attached to a custom-made motor stage and the STAR supervisory control architecture that enables a surgeon to select and track incisions and the placement of stitches. The STAR supervisory-control interface provides two modes: A manual mode that enables a surgeon to specify the placement of each stitch and an automatic mode that automatically computes equally-spaced stitches based on an incision contour. Our experiments on planar phantoms demonstrate that the STAR in either mode is more accurate, up to four times more consistent and five times faster than surgeons using state-of-the-art robotic surgical system, four times faster than surgeons using manual Endo360(°)®, and nine times faster than surgeons using manual laparoscopic tools.

Evaluation of stapled versus hand-sewn techniques for colo- rectal anastomosis after low anterior resection of mid-rectal carcinoma: a study on 50 patients

AIM

To evaluate the outcome of stapled versus sutured colo-rectal anastomosis after low anterior resection of mid-rectal carcinoma.

PATIENTS AND METHODS

A prospective study of fifty patients who underwent colo-rectal anastomosis following low anterior resection (LAR) of T2 mid-rectal cancers at the Egyptian National Cancer Institute during the time period from June 2010 to June 2013 was conducted. Classification was into two groups; a stapled anastomosis group I (25 patients) and a hand-sewn anastomosis group II (25 patients). All operations are evaluated regarding intra-operative complications such as anastomotic line bleeding, visceral injuries or major blood loss. The anastomotic time and operative time are documented for each operation. All patients are evaluated post-operatively for anastomotic leakage (AL), wound infection and ileus.

RESULTS

The distance of the tumor from the anal verge was 9.6 ± 2.0 cm in group I and 9.9 ± 2.4 cm in group II. The mean operative time was 191.5 ± 16.2 min in the stapled group and 208 ± 18.6 min in the sutured group (p=0.002). The mean anastomotic times were 9.0 ± 1.9 min and 19.7 ± 12.2 min (p=0.001). Anastomotic leakage developed in three (12.0%) patients in the stapled group and in four (16.0%) patients in the sutured group (p=1.000). Post-operative ileus was observed in 3 patients in group I and one patient in group II. Wound infection developed in three (12.0%) patients in the stapled group and four (16.0%) patients in the sutured group (p=1.000).

CONCLUSION

Colo-rectal anastomosis after low anterior resection for mid rectal carcinoma can be conducted safely either by stapling or hand-sewn techniques; however the stapling technique showed shorter anastomotic and operative times with no significant advantages regarding intra- or post-operative complications or hospital stay.

Stapled gastro/duodenojejunostomy shortens reconstruction time during pylorus-preserving pancreaticoduodenectomy

AIM: To investigate whether a stapled technique is superior to the conventional hand-sewn technique for gastro/duodenojejunostomy during pylorus-preserving pancreaticoduodenectomy (PpPD).

METHODS: In October 2010, we introduced a mechanical anastomotic technique of gastro- or duodenojejunostomy using staplers during PpPD. We compared clinical outcomes between 19 patients who underwent PpPD with a stapled gastro/duodenojejunostomy (stapled anastomosis group) and 19 patients who underwent PpPD with a conventional hand-sewn duodenojejunostomy (hand-sewn anastomosis group).

RESULTS: The time required for reconstruction was significantly shorter in the stapled anastomosis group than in the hand-sewn anastomosis group (186.0 ± 29.4 min vs 219.7 ± 50.0 min, P = 0.02). In addition, intraoperative blood loss was significantly less (391.0 ± 212.0 mL vs 647.1 ± 482.1 mL, P = 0.03) and the time to oral intake was significantly shorter (5.4 ± 1.7 d vs 11.3 ± 7.9 d, P = 0.002) in the stapled anastomosis group than in the hand-sewn anastomosis group. There were no differences in the incidences of delayed gastric emptying and other postoperative complications between the groups.

CONCLUSION: These results suggest that stapled gastro/duodenojejunostomy shortens reconstruction time during PpPD without affecting the incidence of delayed gastric emptying.

A systematic review of systematic reviews and panoramic meta-analysis: staples versus sutures for surgical procedures

Objective

To systematically evaluate the evidence across surgical specialties as to whether staples or sutures better improve patient and provider level outcomes.

Design

A systematic review of systematic reviews and panoramic meta-analysis of pooled estimates.

Results

Eleven systematic reviews, including 13,661 observations, met the inclusion criteria. In orthopaedic surgery sutures were found to be preferable, and for appendicial stump sutures were protective against both surgical site infection and post surgical complications. However, staples were protective against leak in ilecolic anastomosis. For all other surgery types the evidence was inconclusive with wider confidence intervals including the possibly of preferential outcomes for surgical site infection or post surgical complication for either staples or sutures. Whilst reviews showed substantial variation in mean differences in operating time (I² 94%) there was clear evidence of a reduction in average operating time across all surgery types. Few reviews reported on length of stay, but the three reviews that did (I² 0%, including 950 observations) showed a non significant reduction in length of stay, but showed evidence of publication bias (P-value for Egger test 0.05).

Conclusions

Evidence across surgical specialties indicates that wound closure with staples reduces the mean operating time. Despite including several thousand observations, no clear evidence of superiority emerged for either staples or sutures with respect to surgical site infection, post surgical complications, or length of stay.

Safety and efficacy of the NiTi Shape Memory Compression Anastomosis Ring (CAR/ColonRing) for end-to-end compression anastomosis in anterior resection or low anterior resection

PURPOSE

Compression anastomoses may represent an improvement over traditional hand-sewn or stapled techniques. This prospective exploratory study aimed to assess the efficacy and complication rates in patients undergoing anterior resection (AR) or low anterior resection (LAR) anastomosed with a novel end-to-end compression anastomosis ring, the ColonRing.

METHODS

In all, 20 patients (13 male) undergoing AR or LAR were enrolled to be anastomosed using the NiTi Shape Memory End-to-End Compression Anastomosis Ring (NiTi Medical Technologies Ltd, Netanya, Israel). Demographic, intraoperative, and postoperative data were collected.

RESULTS

Patients underwent AR (11/20) or LAR using laparoscopy (75%), robotic (10%) surgery, or an open laparotomy (15%) approach, with a median anastomotic level of 14.5 cm (range, 4-25 cm). Defunctioning loop ileostomies were formed in 6 patients for low anastomoses. Surgeons rated the ColonRing device as either easy or very easy to use. One patient developed an anastomotic leakage in the early postoperative period; there were no late postoperative complications. Mean time to passage of first flatus and commencement of oral fluids was 2.5 days and 3.2 days, respectively. Average hospital stay was 12.6 days (range, 8-23 days). Finally, the device was expelled on average 15.3 days postoperatively without difficulty.

CONCLUSIONS

This is the first study reporting results in a significant number of LAR patients and the first reported experience from South Korea; it shows that the compression technique is surgically feasible, easy to use, and without significant complication rates. A large randomized controlled trial is warranted to investigate the benefits of the ColonRing over traditional stapling techniques.

Safety and effectiveness of mechanical versus hand suturing of intestinal anastomoses in an animal model of peritonitis

Mechanical stapling for colorectal anastomosis is popular, but the safety of its use for anastomosis in peritonitis is unclear. We evaluated the safety and effectiveness of mechanically stapled vs. hand-sutured anastomosis by comparing wound healing in an animal model of bacterial peritonitis. Male Sprague-Dawley (n=48) rats underwent cecal ligation and puncture. After 24 h, rats were divided into two groups: the stapler group (cecal resection with mechanical stapler, n=24) and the hand-sutured group (cecal resection and stump closure with surgical absorbable suture, n=24). Anastomotic segments were excised and as indicators of wound healing, anastomotic bursting pressure (ABP) and tissue hydroxyproline concentration were determined over time. After harvesting, anastomotic segments were analyzed by quantitative real-time polymerase chain reaction (PCR) to determine relative expression of transforming growth factor-β(1) (TGF-β(1)) and vascular endothelial growth factor (VEGF) normalized to that of a constitutive gene. The operative time was significantly shorter in the stapler vs. the hand-sutured group. Both groups showed progressive increases in ABP over the postoperative period. ABP was significantly higher in the stapler vs. the hand-sutured group on postoperative days (PODs) 0 and 3. Tissue hydroxyproline concentration increased from POD 7 in both groups, but between-group difference was not significant. Both groups showed progressive increases in TGF-β(1) and VEGF expression during the 7-day postoperative period. On POD 5, TGF-β(1) gene expression was higher in the stapler vs. the hand-sutured group. VEGF gene expression was identical in both groups. In conclusion, anastomosis by stapler is safer and more effective than that by hand suturing in bacterial peritonitis, since it requires less operating time and creates stronger anastomoses in the early postoperative period.

Stapled versus handsewn methods for colorectal anastomosis surgery

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.

Inverted Meckel’s diverticulum manifested as adult intussusception: Age does not matter

Adult intussusception due to Meckel’s diverticulum (MD) is an uncommon cause of intestinal obstruction. However, the surgeon should still be suspicious of this condition since the non specific symptoms and the rarity of it make a preoperative diagnosis uncertain. Considering the secondary nature of adult intussusception and the necessity of early surgical intervention to avoid morbidity and mortality, we report two cases of intussusception due to MD in adults. A diverticulectomy using a TA stapler was performed in the first patient. In the second patient extensive fibrosis of the adjacent mesentery and thickening of jejunal mucosa were observed, so a segmental resection of the small bowel or affected ileal part and a hand-sewn anastomosis was performed. The postoperative period along with the long term follow-up was uneventful for both patients. The decision between diverticulectomy vs bowel resection can be based on the intussuscepted bowel condition. Early surgical intervention may ensure a favorable outcome.

Diagnostic evaluation, surgical technique, and perioperative management after esophagectomy: consensus statement of the German Advanced Surgical Treatment Study Group

PURPOSE

Correct diagnosis, surgical treatment, and perioperative management of patients with esophageal carcinoma remain crucial for prognosis within multimodal treatment procedures. This study aims to achieve a consensus regarding current management strategies in esophageal cancer by questioning a panel of experts from the German Advanced Surgical Treatment Study (GAST) group, comprised of 9 centers specialized in esophageal surgery, with a combined total of >220 esophagectomies per year.

MATERIALS AND METHODS

The Delphi method, a systematic and interactive, evidence-based approach, was used to obtain consensus statements from the GAST group regarding ambiguities and disparities in diagnosis, patient selection, surgical technique, and perioperative management of patients with esophageal carcinoma. After four rounds of surveys, agreement was measured by Likert scales and defined as full (100% agreement), near (≥66.6% agreement), or no consensus (<66.6% agreement).

RESULTS

Full or near consensus was obtained for essential aspects of esophageal cancer staging, proper surgical technique, perioperative management and indication for primary surgery, and neoadjuvant treatment or palliative treatment. No consensus was achieved regarding acceptability of minimally invasive technique and postoperative nutrition after esophagectomy.

CONCLUSION

The GAST consensus statement represents a position paper for treatment of patients with esophageal carcinoma which both contributes to the development of clinical treatment guidelines and outlines topics in need of further clinical studies.

Efficacy of NiTi Hand CAC 30 for jejunojejunostomy in gastric cancer surgery: results from a multicenter prospective randomized trial

BACKGROUND

Although a novel technique for the performance of intestinal sutureless anastomosis using a compression device has recently been investigated, it has not yet received widespread acceptance. We performed a multicenter prospective randomized trial in order to determine the clinical efficacy of the NiTi Hand CAC 30, a type of compression anastomosis clip (CAC), for jejunojejunostomy in gastric cancer surgery.

METHODS

Forty-seven patients from 6 institutions, who were diagnosed with gastric adenocarcinoma, were enrolled; these patients were randomized to a CAC group and a hand-sewn (control) group. Three patients dropped out for various reasons, and results for 44 patients were finally analyzed. The CAC group consisted of 20 patients, and there were 24 patients in the control group.

RESULTS

Anastomosis time, the primary endpoint of this trial, was shorter in the CAC group than in the control group (P < 0.001). However, total operation times (P = 0.055) did not differ. All reconstructions were completed by Roux-en-Y anastomosis, and the complication rates of the two groups did not differ (P = 0.908); however, jejunojejunostomy leakage occurred in two patients in the CAC group.

CONCLUSIONS

Our prospective multicenter clinical trial showed that the use of the NiTi Hand CAC™ 30 for jejunojejunostomy in gastric cancer surgery was feasible and could reduce anastomosis time. However, considering that there were two cases of leakage, extended use of the NiTi Hand CAC™ 30 should be carefully applied.

Robot-assisted laparoscopic intracorporeal hand-sewn bowel anastomosis during pediatric bladder reconstructive surgery

Bowel anastomosis performed during robot-assisted laparoscopic surgery in both adult and pediatric populations has typically been performed using endoscopic staplers or with exteriorization of the bowel. In the pediatric population, no articles have been published that explore the possibility of a completely intracorporeal hand-sewn anastomosis during robot-assisted laparoscopic surgery. We report our series of six children who were undergoing robot-assisted laparoscopic intracorporeal hand-sewn bowel anastomosis during bladder reconstructive surgery for neurogenic bladder. The postoperative course was uncomplicated with regard to the bowel anastomosis, demonstrating the feasibility of the technique in experienced hands.

Reduction of anastomotic failure in laparoscopic colorectal surgery using antitraction sutures

BACKGROUND

Anastomotic leakage is a major complication in colorectal surgery. This study investigates a new method for reducing anastomotic failure using antitraction sutures.

METHODS

In 2007, the authors began routine placement of three sutures at every one-third of the circular end-to-end anastomosis to reduce traction. Before the start of the new protocol, 76 patients received laparoscopic colorectal left sided surgery, 21 (28%) of whom received a defunctioning stoma. After the start of the new protocol, 77 patients received laparoscopic colorectal surgery, 6 (8%) of whom received a defunctioning stoma.

RESULTS

Placement of a defunctioning stoma was significantly reduced (n = 21 vs. 6; P = 0.01). Only one patient (1%) in the sutured group experienced anastomotic leakage compared with six patients in the control group (P = 0.025). Other anastomosis-related complications during the follow-up period, including anastomotic stenosis and intraabdominal abscess, occurred more frequently in the control group, although the difference did not reach significance.

CONCLUSION

The use of antitraction sutures to support the anastomosis seems to reduce the occurrence of anastomotic leakage in laparoscopic left colorectal surgery. A prospective randomized trial is necessary to prove the decreasing effect of antitraction sutures on anastomotic leakage as well as the major decreasing effect on the necessity of placement of defunctioning stomas.

[Incident reports with surgical staplers]

BACKGROUND

The study was initiated to evaluate the risks of surgical staplers.

METHODS

In the years 2002-2007, a total of 165 reports of incidents or corrective actions from 3 manufacturers were registered and retrospectively analyzed with respect to the prevalent product default appearance, the results of the manufacturer's investigations and the severity of the consequences for patient.

RESULTS

Severe patient consequences occurred in only 35.2%. In the majority of the cases no patient injury resulted from the reported malfunction and the investigations revealed no product error (52.7%).

CONCLUSION

The surgical staplers are predominantly safe for application in thoracic and abdominal surgery. The incident reports are important for risk assessment and improvement of the surgical staplers.