Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial

The impact of stapled compared to handsewn repair on anastomotic outcomes in trauma patients: a systematic review and meta-analysis

BACKGROUND

Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta-analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches.

METHODS

A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess.

RESULTS

Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24-2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra-abdominal abscess and intra-abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53-2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders.

DISCUSSION

This meta-analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma.

Robotic-assisted resection of proximal jejunal ischemic stricture and intracorporeal robot-sewn anastomosis

With the advent of robotic surgery as an effective means of minimally invasive surgery in the last decade, more and more surgeries are being performed robotically in today's world. Robotic surgery has several advantages over conventional laparoscopic surgery, such as three-dimensional vision with depth perception, magnified view, tremor filtration, and, more importantly, degrees of freedom of the articulating instruments. While the literature is abundant on robotic cholecystectomy and highly complex hepatobiliary surgeries, there is hardly any literature on robotic small bowel resection with intracorporeal anastomosis. We present a case of a 50-year-old male patient with a symptomatic proximal jejunal ischemic stricture who underwent robotic-assisted resection and robot-sewn intracorporeal anastomosis in two layers. He did well in the postoperative period and was discharged on postoperative day 4 with uneventful recovery. We hereby discuss the advantages and disadvantages of robotic surgery in such a scenario with a review of the literature.

Acute mesenteric ischemia: updated guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is a group of diseases characterized by an interruption of the blood supply to varying portions of the intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process may progress to life-threatening intestinal necrosis. The incidence is low, estimated at 0.09-0.2% of all acute surgical admissions, but increases with age. Although the entity is an uncommon cause of abdominal pain, diligence is required because if untreated, mortality remains in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques is evolving and provides new treatment options. Lastly, a focused multidisciplinary approach based on early diagnosis and individualized treatment is essential. Thus, we believe that updated guidelines from World Society of Emergency Surgery are warranted, in order to provide the most recent and practical recommendations for diagnosis and treatment of AMI.

WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment

The aim of this paper was to review the recent literature to create recommendations for the day-to-day diagnosis and surgical management of small bowel and colon injuries. Where knowledge gaps were identified, expert consensus was pursued during the 8th International Congress of the World Society of Emergency Surgery Annual (September 2021, Edinburgh). This process also aimed to guide future research.

Multifunctional Magnesium Anastomosis Staples for Wound Closure and Inhibition of Tumor Recurrence and Metastasis

Biodegradable magnesium (Mg) implants spontaneously releasing therapeutic agents against tumors are an intriguing therapeutic approach for both tissue repair and tumor treatment. Anastomotic staples are extensively used for wound closure after surgical resection in patients with colorectal tumors. However, the safety of Mg anastomosis implants for intestinal closure and the effect of tumor suppression remain elusive. Here, we used a high-purity Mg staple to study these issues. Based on the results, we found that it has the potential to heal wounds produced after colorectal tumor resection while inhibiting relapse of residual tumor cells in vitro and in vivo. After implantation of Mg staples for 7 weeks in rabbits, the intestinal wound gradually healed with no adverse effects such as leakage or inflammation. Furthermore, the implanted Mg staples inhibit the growth of colorectal tumor cells and block migration to normal organs because of the increased concentration of Mg ions and released hydrogen. Such an antitumor effect is further confirmed by the in vitro cell experiments. Mg significantly induces apoptosis of tumor cells as well as inhibits cell growth and migration. Our work presents a feasible therapeutic opinion to design Mg anastomotic staples to perform wound healing and simultaneously release tumor suppressor elements in vivo to decrease the risk of tumor recurrence and metastasis.

Gastrointestinal thickness, duration, and leak pressure of six intestinal anastomoses in dogs

OBJECTIVE

To compare leak pressures and construct completion time of six intestinal anastomoses and report normal canine gastrointestinal thickness.

STUDY DESIGN

Experimental study.

ANIMALS

Grossly normal jejunal segments (n = 140) from 10 fresh canine cadavers.

METHODS

Gastrointestinal thickness was recorded. Eight-centimeter cooled canine cadaveric jejunal segments were randomly assigned to a control group (20 segments) and six treatment groups (20 segments/group [10 constructs/group]): (1) handsewn anastomosis (HSA), (2) functional end-to-end stapled anastomosis (FEESA)-blue thoracoabdominal (TA; FEESA-TAB), (3) FEESA-green TA (FEESA-TAG), (4) FEESA TA-gastrointestinal anastomosis (GIA), (5) FEESA with suture oversew (FEESA-O), and (6) skin staples (SS). Construct assembly time, initial leak pressure (ILP), maximum intraluminal pressure (MIP), and leakage location were compared.

RESULTS

Initial leak pressures (mean ± SD) for control (308.38 ± 115.91 mm Hg), HSA (41.96 ± 15.97), FEESA-TAB (31.71 ± 15.71), FEESA-TAG (27.24 ± 14.11), FEESA-GIA (25.62 ± 11.22), FEESA-O (31.01 ± 17.38), and SS (44.42 ± 28.88) groups were compared. No difference in ILP (P > .24) or MIP (P > .17) was detected between treatment groups. Sutured anastomoses took up to 10 times longer to complete (P = .0025). The stomach, duodenum, jejunum, and ileum mural thicknesses (mean ± SD) were 3.99 ± 0.44 mm, 2.34 ± 0.16, 2.49 ± 0.28, and 2.30 ± 0.31, respectively.

CONCLUSION

The ILP of all anastomoses exceeded maximum intraluminal peristaltic pressures. Stapled anastomoses were faster to complete.

CLINICAL SIGNIFICANCE

All anastomoses may be considered when performing an intestinal resection and anastomosis, with stapled anastomoses resulting in a shorter surgical time. Canine intestinal thickness may warrant use of a larger staple size.

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.

Intestinal surgery in small animals: historical foundations, current thinking, and future horizons

Intestinal wounds require precise closure after intestinal biopsy, enterotomy, or enterectomy in small animals. Preexisting factors such as intra-abdominal sepsis and hypoalbuminemia as well as poor surgical technique increase the risk of intestinal dehiscence, with considerable negative impact on patient morbidity and mortality. Live dog studies have demonstrated the dangers of mucosal eversion especially in the septic abdomen. Approximating patterns preserve luminal diameter, heal optimally, and have equal bursting strength compared with inverting patterns after 24 hours. Simple interrupted and simple continuous suture patterns and disposable skin staples are established alternatives for manual wound closure. Knotless quilled suture currently used in laparoscopic gastropexy techniques shows bursting strength equal to monofilament sutures in dog cadaveric intestine. Dehiscence rates with hand sewn vs titanium automated stapling anastomosis are similar in uncomplicated cases; however, auto stapling devices may be the preferred method of anastomosis when preexisting abdominal sepsis is present and when patient size allows it. Regardless of the technique, current standard of care involves leak testing and omental wrapping, followed by early postoperative feeding. The past decade has ushered in an exciting new era of laparoscopic assisted techniques that have the potential to reduce postoperative pain and patient morbidity. An understanding of these applications will establish the future of minimally invasive small animal intestinal surgery for veterinary specialists. In summary, surgeons have a variety of methods at their disposal for optimal clinical outcome in small animal intestinal surgery.

Evaluation of suture reinforcement for stapled intestinal anastomoses: 77 dogs (2008-2018)

OBJECTIVE

To determine the influence of oversewing a transverse staple line in functional end-to-end stapled intestinal anastomoses (FEESA) in dogs.

STUDY DESIGN

Retrospective observational study.

SAMPLE POPULATION

Seventy-seven client-owned dogs that underwent 78 FEESA reinforced (n = 30) or not reinforced (n = 48) with suture at the transverse staple line.

METHODS

The medical records database was searched and reviewed for dogs that had undergone a FEESA between January 2008 and September 2018. Data were collected regarding signalment, body weight, clinical presentation, indication for surgery, serum albumin, presence of septic peritonitis, previous surgeries, surgical techniques (ie, oversew, crotch suture, omental wrap, omental patch, serosal patch), histopathology results, and postoperative outcome.

RESULTS

The only differences identified between groups consisted of higher preoperative albumin (2.89 ± 0.56 vs 2.34 ± 0.62 g/dL; P = .006) and lower postoperative dehiscence rate (0/30 vs 7/48; P = .028) in dogs with an oversewn FEESA. Oversewing the FEESA was identified as the significant factor in a model with oversewing and preoperative albumin fit to the outcome of dehiscence (oversew P = .010, albumin P = .761). The location of the dehiscence was specified in four of seven dogs, all along the transverse staple line. Patterns used for oversew were unspecified (n = 11), simple continuous (8), Cushing (4), simple interrupted (2), cruciate (1), interrupted horizontal mattress (1), and Lembert (1).

CONCLUSION

Oversewing the transverse staple line in FEESA was associated with a reduced occurrence of postoperative dehiscence.

CLINICAL SIGNIFICANCE

Our results provide evidence to support additional investigation of suture reinforcement (oversewing) at the transverse staple line of FEESA to reduce postoperative dehiscence.

Endo GIA stapler malfunction in a small bowel loop resection

Endovascular gastrointestinal anastomosis (Endo-GIA) staplers are widely used in various surgical procedures despite difficulties in operating them and associated mechanical failures. We present a case of a patient whose post-operative recovery was complicated by intraoperative Endo-GIA stapler failure, which is rarely reported in literature. Our report describes the behavior and consequences of surgical stapler failure so surgeons can anticipate challenges of newer surgical devices while maintaining optimal patient outcomes.

Characteristics of Combat-Associated Small Bowel Injuries

INTRODUCTION

Although there are multiple studies regarding the management and outcomes of colonic injuries incurred in combat, the literature is limited with regard to small bowel injuries. This study seeks to provide the largest reported review of the characteristics of combat-associated small bowel injuries.

MATERIALS AND METHODS

The Department of Defense Trauma Registry was queried for U.S. Armed Forces members who sustained hollow viscus injuries in the years 2007-2012 during Operations Enduring Freedom, Iraqi Freedom, and New Dawn. Concomitant injuries, procedures, and complications were delineated. Fisher's exact test was used to analyze the relationship of bowel injury pattern to rates of repeat laparotomy, fecal diversion, and complications.

RESULTS

One hundred seventy-one service members had small bowel injuries. The mean age was 25.8 ± 6.6 yr with a mean injury severity score of 27.9 ± 12.4. The majority of injuries were penetrating (94.2%, n = 161) as a result of explosive devices (61.4%, n = 105). The median blood transfusion requirement in the first 24 h was 6.0 units (interquartile range 1.0-17.3 units). The most frequent concomitant injuries were large bowel (64.3%, n = 110), pelvic fracture (35.7%, n = 61), and perineal (26.3%, n = 45). Fifty patients (29.2%) had a colostomy, and nine patients (5.3%) had an ileostomy; 62.6% (n = 107) of soldiers underwent more than one laparotomy. The mortality rate was 1.8% (n = 3). The most common complications were pneumonia (15.2%, n = 26), deep vein thrombosis (14.6%, n = 25), and wound infection (14.6%, n = 25). The need for repeat laparotomy and fecal diversion was found to be significantly associated with injury pattern (p = 0.00052 and p < 0.0001, respectively).

CONCLUSION

We found that two-thirds of service members with small bowel injuries also had a large bowel injury. One-third of the patients required diversion and two-thirds had more than one laparotomy. The pattern of bowel injury significantly affected the need for repeat laparotomy and fecal diversion.

Acute mesenteric ischemia: guidelines of the World Society of Emergency Surgery

Acute mesenteric ischemia (AMI) is typically defined as a group of diseases characterized by an interruption of the blood supply to varying portions of the small intestine, leading to ischemia and secondary inflammatory changes. If untreated, this process will eventuate in life threatening intestinal necrosis. The incidence is low, estimated at 0.09–0.2% of all acute surgical admissions. Therefore, although the entity is an uncommon cause of abdominal pain, diligence is always required because if untreated, mortality has consistently been reported in the range of 50%. Early diagnosis and timely surgical intervention are the cornerstones of modern treatment and are essential to reduce the high mortality associated with this entity. The advent of endovascular approaches in parallel with modern imaging techniques may provide new options. Thus, we believe that a current position paper from World Society of Emergency Surgery (WSES) is warranted, in order to put forth the most recent and practical recommendations for diagnosis and treatment of AMI. This review will address the concepts of AMI with the aim of focusing on specific areas where early diagnosis and management hold the strongest potential for improving outcomes in this disease process.

Some of the key points include the prompt use of CT angiography to establish the diagnosis, evaluation of the potential for revascularization to re-establish blood flow to ischemic bowel, resection of necrotic intestine, and use of damage control techniques when appropriate to allow for re-assessment of bowel viability prior to definitive anastomosis and abdominal closure.

Experience of General Surgery Residents in the Creation of Small Bowel and Colon Anastomoses

BACKGROUND

With the introduction of stapling devices (SDs), the proportion of hand-sewn (HS) intestinal anastomoses (IAs) has declined. As more IAs are constructed with SDs, there are fewer opportunities for general surgery residents (GSRs) to acquire the skills for HS techniques during their training.

STUDY DESIGN

Data for this study were extracted from an existing database of all IAs performed at the Department of Surgery of the Morristown Medical Center since 2003. For the purposes of this study, a 5.5-year timeframe was used between July 2006 and 2011, which contained 1659 IA operations on adult patients with resident involvement. GSRs of the 5-year general surgery residency program were grouped by postgraduate year (PGY) for further analysis.

RESULTS

The number of all IAs created by each resident during the 5-year training was 67.2 on average. Most of these operations were done in the last 2 years of the training: 45.1% of all IAs in PGY5 and 37.3% of all IAs in PGY4. Of all, 1659 IAs performed in the study period, 711 (42.9% of total) were done laparoscopically and 948 (57.1% of all IAs) were done as open operations. Laparoscopic operations had a proportionally higher rate of SD use when compared to open cases (90.9% vs 82.4%). On average, each resident constructed 9.4 HS IAs (13.98% of all IAs) and 57.8 SD IAs (86.02% of total). Out of all anastomoses, ostomy reversals (30.7%) had the highest percentage of HS suturing followed by right colectomies (27.5%), ileal pouch-anal anastomoses and total colectomies and proctocolectomies (23.3%), small bowel resection (17.0%), and left colectomies (5.5%). Regardless of the location of the operation, stapled and sutured anastomoses had similar outcomes measured by the rate of anastomotic leaks. Residents used significantly more SDs in the creation of anastomoses than HS suturing in the PGY3, PGY4, and PGY5 years. We also documented that attending surgeons who are older more often used HS suturing than their younger colleagues when creating IAs.

CONCLUSIONS

The experiences of GSRs in IA operations are heavily weighted toward the use of SDs. There are select cases, however, when HS suturing can have an advantage over stapler use in anastomosis creation. Therefore, we believe that GSRs should continue learning, perfecting, and using the both techniques.

Risk Factors for Dehiscence of Stapled Functional End-to-End Intestinal Anastomoses in Dogs: 53 Cases (2001-2012)

OBJECTIVE

To identify risk factors for dehiscence in stapled functional end-to-end anastomoses (SFEEA) in dogs.

STUDY DESIGN

Retrospective case series.

ANIMALS

Dogs (n = 53) requiring an enterectomy.

METHODS

Medical records from a single institution for all dogs undergoing an enterectomy (2001-2012) were reviewed. Surgeries were included when gastrointestinal (GIA) and thoracoabdominal (TA) stapling equipment was used to create a functional end-to-end anastomosis between segments of small intestine or small and large intestine in dogs. Information regarding preoperative, surgical, and postoperative factors was recorded.

RESULTS

Anastomotic dehiscence was noted in 6 of 53 cases (11%), with a mortality rate of 83%. The only preoperative factor significantly associated with dehiscence was the presence of inflammatory bowel disease (IBD). Surgical factors significantly associated with dehiscence included the presence, duration, and number of intraoperative hypotensive periods, and location of anastomosis, with greater odds of dehiscence in anastomoses involving the large intestine.

CONCLUSION

IBD, location of anastomosis, and intraoperative hypotension are risk factors for intestinal anastomotic dehiscence after SFEEA in dogs. Previously suggested risk factors (low serum albumin concentration, preoperative septic peritonitis, and intestinal foreign body) were not confirmed in this study.

Multicenter prospective evaluation of a new articulating 5-mm endoscopic linear stapler

Background

The objective of this study was to evaluate the safety and efficacy of a novel 5-mm laparoscopic linear stapler in clinical gastrointestinal surgical applications.

Methods

A prospective, single-arm study with an open enrollment of subjects requiring stapling of the gastrointestinal (GI) tract was performed. The study endpoints were the number of complications and technical failures associated with the use of a novel stapler when compared to similar events with conventional staplers as described in the medical literature.

Results

Seven centers enrolled 160 subjects, 150 of which were followed up to at least 30 days postoperatively. Intraoperative success: In 423 deployments, there were two staple line leaks and five staple line bleeds, all of which were intraoperatively resolved. In addition, incomplete staple lines were noted as a result of user error (n = 15) or device-related issues (n = 22), all of which were immediately resolved and none of which resulted in a complication or a change of the surgical procedure. Late outcomes: A total of 13 surgical complications in 160 patients were related to a GI transection or anastomosis, 12 of which related to a hand-sewn anastomosis or use of other commercially available staplers. One event (1/153, 0.065 %) on POD 1, involving bleeding of the staple line, was felt to be related to the use of the new stapler.

Conclusion

The study confirmed that the new device was user-friendly (9 % incidence of problems firing the device), reliable (3 % device failures) and safe (<1 % complication rate related to the stapler). Based on these results, it would seem that this new 5-mm stapler is a safe and effective alternative to standard 12-mm staplers.

Deceased donor liver transplantation performed one week after small bowel resection for complicated umbilical hernia: a case report

Emergent abdominal surgery in cirrhotic patients with ascites can result in dismal postoperative outcomes such as sepsis and hepatic failure. In the present case, small bowel resection followed by anastomosis by the hand-sewn method was performed for small bowel strangulation caused by an umbilical hernia; deceased donor liver transplantation was performed one week after the bowel resection because of deterioration of hepatic function. To the best of our knowledge, this is the first case of liver transplantation performed at only one week after small bowel resection; and although we obtained a good result, the optimal time to perform liver transplantation in this situation requires further evaluation.

Graduating general surgery resident operative confidence: perspective from a national survey

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.

Bowel anastomoses: The theory, the practice and the evidence base

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.

Comparison of standard 4-row versus 6-row3-D linear cutter stapler in creation of gastrointestinal system anastomoses: a prospective randomized trial

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.

The current evidence on stapled versus hand-sewn anastomoses in the digestive tract

The innovation process and developments in technology have given surgeons new products which can improve their performance and benefit our patients. Before the era of laparoscopic surgery one of the most important applications in surgical practice was the introduction of staplers. In this article, the evidence supporting the decision whether to use a mechanical device (stapler) or to make a hand-sewn anastomosis is presented. A sytematic review of the literature was performed. The search included published meta-anaylses, randomized clinical trials and comparative studies. Key words for the initial search were: surgical anastomosis, stapler, hand-sewn. There was no language restriction. The reference lists from the selected articles were also checked by the author. Literature data on main outcomes concerning the application of one or the other surgical technique have been analysed. The literature search yielded published data on various procedures in digestive surgery. Most of the available high-quality evidence was for gastric and colorectal resections. Resection of the esophagus, use of staplers in emergency procedures and some initial reports on pancreatic surgery were also retrieved. The evidence from the literature shows that stapler anastomoses take less operative time and are more costly than hand-sewn anastomoses. Regarding the morbidity and leaks rate the staplers give equal or better results when compared with the hand-sewn technique. Nevertheless, proper handling of staplers and experience remain crucial issues if one wants to gain benefits when using these devices.

A comparison of gastrojejunal anastomoses with or without buttressing in a porcine model

INTRODUCTION

The addition of staple-line reinforcements on circular anastomoses has not been well studied. We histologically and mechanically analyzed circular- stapled anastomoses with and without bioabsorbable staple-line reinforcement (SeamGuard, W. L. Gore & Associates, Flagstaff, AZ) in a porcine model.

METHODS

Gastrojejunal anastomoses were constructed using a #25 EEA Proximate ILS (Ethicon Endo-Surgery, Cincinnati, OH) mechanical stapling device with and without Bioabsorbable SeamGuard (BSG). Gastrojejunal anastomoses were resected acutely and at 1 week, and burst-pressure testing and histological analysis were performed. Standardized grading systems for inflammation, collagen deposition, vascularity, and serosal inflammation were used to compare the two anastomosis types.

RESULTS

Acute burst pressures were significantly higher with BSG than with staples alone (1.37 versus 0.39 psi, p=0.0075). Burst pressures at 1 week were significantly lower with BSG than with staples alone (2.24 versus 3.86 psi, p=0.0353); however, both readings were above normal physiologic intestinal pressures. There was no statistical difference in inflammation (13.4 versus 15.6, p=0.073), width of mucosa (3.2 mm versus 3.2 mm, p=0.974), adhesion formation (0 versus 0.5, p=0.575), number of blood vessels (0.5 versus 1.0, p=0.056), or serosal inflammation (2.0 versus 1.0, p=0.27) between the stapled anastomoses and those buttressed with BSG. Stapled-only anastomoses had statistically more collagen (2.0 versus 1.0, p=0.005) than the anastomoses supported with BSG.

CONCLUSIONS

The addition of BSG as a staple-line reinforcement acutely improves the burst strength of a circular anastomosis but not at 1 week. At 1 week, a decrease in collagen content with the BSG-buttressed stapled anastomosis was the only difference in the histologic parameters studied with no difference in vascularity, adhesions, or inflammation. The long-term effect of BSG on anastomotic strength or scarring is yet to be determined. The clinical implications may include decreased stricture formation and also decreased strength at anastomoses.

The role of video-assisted laparoscopy in management of patients with small bowel injuries in abdominal trauma

BACKGROUND

Patients with small bowel injuries (SBI) in abdominal trauma have no clear clinical or radiological signs on initial examination. This leads to delay in appropriate surgical interventions with consequent high morbidity and mortality. In this paper we demonstrate the role of video-assisted laparoscopy (VAL) in management of such patients.

METHODS AND MATERIALS

819 patients with SBI were evaluated retrospectively between 1994 and 2003. The mechanism of the trauma was blunt in 146 (17.8%) patients and stab wounds in 640; routine investigations and VAL were used for triage of the subjects. All the victims underwent laparotomy or video-assisted laparoscopy. Demographic information, incidence of organs injuries, types of surgery, complications, associated injuries, and hospital mortality were analyzed.

RESULTS

Diagnostic video laparoscopy was sufficient for 518 (63.2%) patients. Small bowel repair was performed in 332 (40.6%) patients, clipping of mesenteric blood vessels in 27 (3.4%) patients, and coagulation and ligation of omental blood vessels in 48 (5.9%) patients. Ninety-seven (11.8%) patients with small bowel injury were associated with postoperative complications. There were 19 (2.3%) deaths associated with hemoperitoneum, severe head injury, and multiple ribs fracture. Generalized peritonitis was revealed in one case and focal abscesses between intestinal loops were identified in another one patient.

CONCLUSION

The DVAL findings of visceral injuries give optimal approach for management of small bowel injuries in abdominal trauma.

Perioperative Vasopressors Are Associated with an Increased Risk of Gastrointestinal Anastomotic Leakage

BACKGROUND

The purpose of this study was to investigate the effect of vasopressors on gastrointestinal (GI) anastomotic leaks. Vasopressors are commonly used in surgical patients admitted to the intensive care unit (ICU) and their effects on GI anastomotic integrity are unknown.

PATIENTS AND METHODS

Surgical patients admitted to the ICU in our tertiary university hospital following the creation of a GI anastomosis were studied by a retrospective chart analysis for anastomotic leaks and complications

RESULTS

A total of 223 patients with 259 GI anastomoses, mostly for cancer, were admitted to the ICU immediately after surgery. Twenty-two patients developed anastomotic leaks (9.9%). The two groups (leak versus no-leak) had similar demographics, surgery type and indication, type of anastomosis, co-morbidities, cancer, steroid use, blood transfusion, drains, and epidural catheters. Vasopressor use was associated with increased anastomotic leakage (p = 0.02, OR 3.25). Multiple vasopressors and prolonged exposure caused even higher leaking rates. This effect was independent of the medical status and operative morbidity (APACHE II, POSSUM). Blood pressure preceding vasopressor use was similar in both groups. Vasopressors might have been occasionally used to treat hypovolemia. Patients with leaks had higher reoperation rates (41% versus 1%, p < 0.0001) and mortality (21% versus 4%, p = 0.002).

CONCLUSIONS

Vasopressors appear to increase anastomotic leaks threefold, independent of clinical/surgical status or hypotension. Evidence-based guidelines are warranted for the optimal use of vasopressors in postoperative patients admitted to the ICU.

[Surgical management of abdominal injury]

PURPOSE

Accompanying abdominal injuries are frequent in multiply injured patients and are a common cause of death. A search of the literature was performed focusing on key aspects of initial surgical procedures in abdominal injury.

METHODS

Literature was searched utilizing PubMed Medline, the Cochrane Central Register of Controlled Clinical Trials, and the German Institute for Medical Documentation and Information (DIMDI) database. The articles were classified according to the level of evidence following the suggestions of the Centre for Evidence Based Medicine.

RESULTS

Vertical laparotomy should be favored for the initial surgical therapy of abdominal injury. Especially in instable patients, principles of "damage control surgery" should be applied. In case of hollow organ injury, a primary anastomosis should be made whenever possible. A hand suture is most suitable for this.

DISCUSSION

Non-surgical treatment of blunt abdominal injury is gaining in importance. However, if a surgical intervention is recommended, especially in hemodynamic, instable patients, damage control principles should be favored.