Handsewn versus stapled anastomosis in penetrating colon injuries requiring resection: a multicenter study

Characterizing the Suture Pullout Force for Human Small Bowel

Performing a small bowel anastomosis, or reconnecting small bowel segments, remains a core competency and critical step for the successful surgical management of numerous bowel and urinary conditions. As surgical education and technology moves toward improving patient outcomes through automation and increasing training opportunities, a detailed characterization of the interventional biomechanical properties of the human bowel is important. This is especially true due to the prevalence of anastomotic leakage as a frequent (3.02%) postoperative complication of small bowel anastomoses. This study aims to characterize the forces required for a suture to tear through human small bowel (suture pullout force, SPOF), while analyzing how these forces are affected by tissue orientation, suture material, suture size, and donor demographics. 803 tests were performed on 35 human small bowel specimens. A uni-axial test frame was used to tension sutures looped through 10 × 20 mm rectangular bowel samples to tissue failure. The mean SPOF of the small bowel was 4.62±1.40 N. We found no significant effect of tissue orientation (p = 0.083), suture material (p = 0.681), suture size (p = 0.131), age (p = 0.158), sex (p = .083), or body mass index (BMI) (p = 0.100) on SPOF. To our knowledge, this is the first study reporting human small bowel SPOF. Little research has been published about procedure-specific data on human small bowel. Filling this gap in research will inform the design of more accurate human bowel synthetic models and provide an accurate baseline for training and clinical applications.

Double-layered hand-sewn anastomosis: a valuable resource for the colorectal surgeon

Hand-sewn anastomosis is an essential and fundamental skill for surgeons dealing with any gastrointestinal anastomosis. Despite the advances in minimally invasive surgery and stapling devices, there are still complex surgical circumstances when the surgeon’s surgical know-how are necessary. Therefore, a safe hand-sewn technique for bowel anastomosis is required to establish a tension-free, well-perfused, and sealed anastomosis that allows gastrointestinal continuity with no unexpected complications. We describe a step-by-step procedure for hand-sewn double-layered anastomosis that reflects these principles and is practical for small and large bowel anastomosis.

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.

Damage control surgical management of combined small and large bowel injuries in penetrating trauma: Are ostomies still pertinent?

Hollow viscus injuries represent a significant portion of overall lesions sustained during penetrating trauma. Currently, isolated small or large bowel injuries are commonly managed via primary anastomosis in patients undergoing definitive laparotomy or deferred anastomosis in patients requiring damage control surgery. The traditional surgical dogma of ostomy has proven to be unnecessary and, in many instances, actually increases morbidity. The aim of this article is to delineate the experience obtained in the management of combined hollow viscus injuries of patients suffering from penetrating trauma. We sought out to determine if primary and/or deferred bowel injury repair via anastomosis is the preferred surgical course in patients suffering from combined small and large bowel penetrating injuries. Our experience shows that more than 90% of all combined penetrating bowel injuries can be managed via primary or deferred anastomosis, even in the most severe cases requiring the application of damage control principles. Applying this strategy, the overall need for an ostomy (primary or deferred) could be reduced to less than 10%.

Colon Trauma: Evidence-Based Practices

Colon injury is not uncommon and occurs in about a half of patients with penetrating hollow viscus injuries. Despite major advances in the operative management of penetrating colon wounds, there remains discussion regarding the appropriate treatment of destructive colon injuries, with a significant amount of scientific evidence supporting segmental resection with primary anastomosis in most patients without comorbidities or large transfusion requirement. Although literature is sparse concerning the management of blunt colon injuries, some studies have shown operative decision based on an algorithm originally defined for penetrating wounds should be considered in blunt colon injuries. The optimal management of colonic injuries in patients requiring damage control surgery (DCS) also remains controversial. Studies have recently reported that there is no increased risk compared with patients treated without DCS if fascial closure is completed on the first reoperation, or that a management algorithm for penetrating colon wounds is probably efficacious for colon injuries in the setting of DCS as well.

Predictive Factors for Small Intestinal and Colonic Anastomotic Leak: a Multivariate Analysis

Anastomotic leak (AL) is a serious complication of intestinal surgery with various predisposing factors. This study aims to assess several risk factors associated with AL after small intestinal and colonic anastomoses through a multivariate analysis. Two hundred twenty-four patients (126 males) with intestinal anastomosis of a median age of 44 years were reviewed. Independent factors associated with AL were male gender (OR = 2.59, P = 0.02), chronic liver disease (CLD) (OR = 8.03, P < 0.0001), more than one associated comorbidity (OR = 5.34, P = 0.017), anastomosis conducted as emergency (OR = 2.73, P = 0.012), colonic anastomosis (OR = 2.51, P = 0.017), preoperative leukocytosis (OR = 2.57, P = 0.015), and intraoperative blood transfusion (OR = 2.25, P = 0.037). Predicative factors significantly associated with AL were male gender, CLD, multiple comorbidities, emergent anastomoses, colonic anastomoses, preoperative leukocytosis, and intraoperative blood transfusion.

Early Experience with Stapled Gastrointestinal Anastomoses in a Nigerian Hospital

Background:

Hand-sewn gastrointestinal anastomoses has been the traditional approach to gastrointestinal anastomosis in Nigeria while stapled anastomoses are infrequently performed in few centers.

Objectives:

To describe the outcome of our initial experience with stapled gastrointestinal anastomoses in a semi-urban patient population.

Patients and Methods:

Consecutive patients who had stapled gastrointestinal anastomoses between January 2011 and June 2014 in a Nigerian tertiary hospital were prospectively evaluated. Indications for operation, procedures performed and anastomoses constructed and postoperative outcome of each patient were documented.

Results:

Nineteen patients including seven males and 12 females had stapled anastomoses within the period. Their ages ranged between 41 and 68 (mean 52.5) years. Six (31.6%) Roux-en-Y gastrojejunostomies, 6 (31.6%) ileo-colic, 3 (15.8%) ileo-ileal, 2 (10.5%) colo-colic, and 2 (10.5%) colo-anal anastomoses were performed. Indications include antral gastric cancer in 4 (21.1%), right colon cancer 4 (21.1%), ileal perforations in 3 (15.8%) while 2 (10.5%) each had left colon cancer, common bile duct obstruction, rectal cancer and ruptured appendix. Mean duration of operation was 108 ± 46 min and mean duration of postoperative stay was 5 ± 2.6 days. No intraoperative complications were recorded and no anastomotic leakage occurred. At a median follow-up of 5 months no staple related stricture had occurred.

Conclusions:

Stapled gastrointestinal anastomoses are associated with a good outcome in our center. We propose a prospective, large-population randomized comparison of the technique with hand-sewn anastomoses.

Historical and current trends in colon trauma

The authors discuss the evolution of the evaluation and management of colonic trauma, as well as the debate regarding primary repair versus fecal diversion. Their evidence-based review covers diagnosis, management, surgical approaches, and perioperative care of patients with colon-related trauma. The management of traumatic colon injuries has evolved significantly over the past 50 years; here the authors describe a practical approach to the treatment and management of traumatic injuries to the colon based on the most current research. However, management of traumatic colon injuries remains a challenge and continues to be associated with significant morbidity. Familiarity with the different methods to the approach and management of colonic injuries will allow surgeons to minimize unnecessary complications and mortality.

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.

A randomized study comparing outcomes of stapled and hand-sutured anastomoses in patients undergoing open gastrointestinal surgery

Although stapling is an alternative to hand-suturing in gastrointestinal surgery, recent trials specifically designed to evaluate differences between the two in surgery time, anastomosis time, and return to bowel activity are lacking. This trial compared the outcomes of the two in subjects undergoing open gastrointestinal surgery. Adult subjects undergoing emergency or elective surgery requiring a single gastric, small, or large bowel anastomosis were enrolled into this open-label, prospective, randomized, interventional, parallel, multicenter, controlled trial. Randomization was assigned in a 1:1 ratio between the hand-sutured group (n = 138) and the stapled group (n = 142). Anastomosis time, surgery time, and time to bowel activity were collected and compared as primary endpoints. A total of 280 subjects were enrolled from April 2009 to September 2010. Only the time of anastomosis was significantly different between the two arms: 17.6 ± 1.90 min (stapled) and 20.6 ± 1.90 min (hand-sutured). This difference was deemed not clinically or economically meaningful. Safety outcomes and other secondary endpoints were similar between the two arms. Mechanical stapling is faster than hand-suturing for the construction of gastrointestinal anastomoses. Apart from this, stapling and hand-suturing are similar with respect to the outcomes measured in this trial.

Enterocutaneous fistulas in the setting of trauma and critical illness

One of the most devastating complications to develop in the general surgical patient is an enterocutaneous fistula (ECF). Critically ill patients suffering trauma, thermal injury, infected necrotizing pancreatitis, and other acute intraabdominal pathology are at unique risk for this complication as well. By using decompressive laparotomy for abdominal compartment syndrome and leaving the abdomen open temporarily for other acute processes, survival in some instances may be improved. However, the exposed viscera are at risk for fistulization in the presence of an open abdomen, a newly defined entity termed the enteroatmospheric fistula (EAF). The purpose of this article is to describe the epidemiology of ECF in the setting of trauma and critical illness, nutrition in injured/critically ill patients with ECF, pharmacologic adjuncts to decrease fistula effluent, wound care, surgical management of the EAF/ECF, and techniques for prevention of these dreaded complications in patients with an open abdomen.

Traumatic injury of the colon and rectum: the evidence vs dogma

BACKGROUND

The treatment of traumatic injuries to the colon and rectum is often driven by dogma, despite the presence of evidence suggesting alternative methods of care.

OBJECTIVE

This is an evidence-based review, in the format of a review article, to determine the ideal treatment of noniatrogenic traumatic injuries to the colon and rectum to improve the care provided to this group of patients. Recommendations and treatment algorithms were based on consensus conclusions of the data.

DATA SOURCES

A search of MEDLINE, PubMed, and the Cochrane Database of Collected Reviews was performed from 1965 through December 2010.

STUDY SELECTION

Authors independently reviewed selected abstracts to determine their scientific merit and relevance based on key-word combinations regarding colorectal trauma. A directed search of the embedded references from the primary articles was also performed in select circumstances. We then performed a complete evaluation of 108 articles and 3 additional abstracts.

MAIN OUTCOME MEASURES

The main outcomes were morbidity, mortality, and colostomy rates.

RESULTS

Evidence-based recommendations and algorithms are presented for the management of traumatic colorectal injuries.

LIMITATIONS

Level I and II evidence was limited.

CONCLUSIONS

Colorectal injuries remain a challenging clinical entity associated with significant morbidity. Familiarity with the different methods to approach and manage these injuries, including "damage control" tactics when necessary, will allow surgeons to minimize unnecessary complications and mortality.

Primary repair of colon injuries: clinical study of nonselective approach

BACKGROUND

This study was designed to determine the role of primary repair and to investigate the possibility of expanding indications for primary repair of colon injuries using nonselective approach.

METHODS

Two groups of patients were analyzed. Retrospective (RS) group included 30 patients managed by primary repair or two stage surgical procedure according to criteria published by Stone (S/F) and Flint (Fl). In this group 18 patients were managed by primary repair. Prospective (PR) group included 33 patients with primary repair as a first choice procedure. In this group, primary repair was performed in 30 cases.

RESULTS

Groups were comparable regarding age, sex, and indexes of trauma severity. Time between injury and surgery was shorter in PR group, (1.3 vs. 3.1 hours). Stab wounds were more frequent in PR group (9:2), and iatrogenic lesions in RS group (6:2). Associated injuries were similar, as well as segmental distribution of colon injuries. S/F criteria and Flint grading were similar.In RS group 15 primary repairs were successful, while in two cases relaparotomy and colostomy was performed due to anastomotic leakage. One patient died. In PR group, 25 primary repairs were successful, with 2 immediate and 3 postoperative (7-10 days) deaths, with no evidence of anastomotic leakage.

CONCLUSIONS

Results of this study justify more liberal use of primary repair in early management of colon injuries.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN94682396.

Predicting the risk of anastomotic leakage in left-sided colorectal surgery using a colon leakage score

BACKGROUND

Anastomotic leakage following colorectal surgery still occurs all too frequently, and this complication is difficult to predict. A nonfunctional stoma may reduce the risk of clinically relevant leaks but is overtreatment for most patients. More accurate assessments of the risk of anastomotic leakage would be very helpful in tailoring treatment in colorectal surgery. Therefore, a Colon Leakage Score (CLS) was developed and tested.

MATERIAL AND METHODS

The CLS was developed based on information from the literature and expert opinions. It was tested in a retrospective cohort of consecutive patients undergoing left-sided colorectal surgery with primary anastomosis in a teaching hospital in The Netherlands.

RESULTS

In the test cohort, 10 of 121 patients who were not treated with a nonfunctional stoma experienced anastomotic leakage. The mean CLS in the leakage group was 16 versus eight in the group that did not have a leak (P < 0.01). Using receiver-operating characteristics, the area under the curve (AUC) showed that the CLS was a good predictor (AUC = 0.95, CI 0.89-1.00) of anastomotic leakage. Furthermore, logistic regression analysis with CLS as a predictor for anastomotic leakage showed an odds ratio of 1.74 (95% CI 1.32-2.28, P < 0.01).

CONCLUSIONS

The CLS can predict the risk of anastomotic leakage following left-sided colorectal surgery. After further validation, this score may help the surgeon make a more individualized, safer decision regarding whether to perform an anastomosis or make a (nonfunctional) stoma.

Stapled intestinal anastomoses in infants

BACKGROUND

We reviewed our experience with stapled intestinal anastomoses in infants younger than 1 year and compared operative data and outcome to that of infants who underwent hand-sewn anastomoses.

METHODS

Infants younger than 1 year who underwent an intestinal anastomosis over an 8-year period were identified. Stapled anastomoses were constructed in a side-to-side fashion using standard or endoscopic linear cutters. Outcome variables including operative time, anastomotic failure, and death were recorded.

RESULTS

Two hundred ninety-five subjects were identified. Hand-sewn anastomoses were performed in 189 cases and stapled anastomoses in 106. Patients who had a stapled anastomosis were older (105 vs 44 days) and larger (5.2 vs 3.1 kg), although 25 stapled anastomoses were performed in infants between 600 and 1000 g. When a stapled anastomosis was used operative time was significantly reduced overall (102 vs 128 minutes) and for individual procedures including resection for necrotizing enterocolitis (85 vs 132 minutes) and colostomy closure (104 vs 141 minutes). There was no difference between hand-sewn and stapled anastomoses in the incidence of adhesive obstruction, stricture, or leak.

CONCLUSIONS

When permitted by intestinal size in infants younger than 1 year, stapled anastomoses were safe and effective and significantly reduced operative time.

Stapled versus handsewn methods for ileocolic anastomoses

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.

Management of peritonitis in the critically ill patient

Severe secondary peritonitis carries significant mortality, despite advancements in critical care support and other therapies. Surgical management requires a multidisciplinary approach to guide the timing and the number of interventions necessary to eradicate the septic foci and create optimal healing with the fewest complications. Research is needed regarding the best surgical strategy for very severe cases. The use of deferred primary anastomosis seems safe in patients presenting with hemodynamic instability and hypoperfusion. These patients have a high risk of anastomotic failure and fistula formation. Allowing for aggressive resuscitation and judicious assessment of the progression of local inflammation are safe strategies to achieve the highest success and minimize serious and protracted complications in patients who survive the initial septic insult.

[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.

Use of icodextrin 4% solution in the prevention of adhesion formation following general surgery: from the multicentre ARIEL Registry

INTRODUCTION

Intra-abdominal adhesions occur in many patients following major abdominal surgery and represent a serious burden to patients and healthcare providers. The multicentre ARIEL (Adept Registry for Clinical Evaluation) Registry was established to gather clinical experiences in the use of icodextrin 4% solution, an approved adhesion-reduction agent, during routine general surgery.

PATIENTS AND METHODS

General surgeons from five European countries completed anonymised data collection forms for patients undergoing laparotomy or laparoscopy. Surgeons recorded patient demographics, use of icodextrin 4% solution and adverse events, and made subjective assessments of ease of use and patient acceptability with the agent.

RESULTS

The general surgery registry included 1738 patients (1469 laparotomies, 269 laparoscopies). Leakage of fluid from the surgical site did not appear to be affected by icodextrin 4% solution and was classified as 'normal' or 'less than normal' in most patients (laparotomies 86%, laparoscopies 88%). Overall, satisfaction with ease of use was rated as 'good' or 'excellent' by the majority of surgeons (laparotomies 77%, laparoscopies 86%). Patient acceptability was also good, with ratings of 'as expected' or 'less than expected' in most cases for both abdominal distension (laparotomies 90%, laparoscopies 91%) and abdominal discomfort (laparotomies 91%, laparoscopies 93%). Adverse events occurred in 30.6% of laparotomy patients and 16.7% of laparoscopy patients; the most common events were septic/infective events (4.2% and 3.4% in the laparotomy and laparoscopy groups, respectively). Anastomotic wound-healing problems were reported in 7.6% of patients in the subset of laparoscopy patients undergoing anastomotic procedures (n = 66).

DISCUSSION

Volumes of icodextrin 4% solution used as an irrigant and instillate were in line with recommendations. Surgeons considered the agent to be easy to use and acceptable to patients. The reported frequencies of adverse events were in line with those published in the literature for surgical procedures, supporting the good safety profile of this agent.

CONCLUSIONS

Icodextrin 4% solution can be used in a wide range of surgical procedures. In combination with good surgical technique, it may play an important role in adhesion reduction.

Anastomotic disruption after large bowel resection

Anastomotic disruption is a feared and serious complication of colon surgery. Decades of research have identified factors favoring successful healing of anastomoses as well as risk factors for anastomotic disruption. However, some factors, such as the role of mechanical bowel preparation, remain controversial. Despite proper caution and excellent surgical technique, some anastomotic leaks are inevitable. The rapid identification of anastomotic leaks and the timely treatment in these cases are paramount.