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Le KDR, Martin K, Read D. The impact of stapled compared to handsewn repair on anastomotic outcomes in trauma patients: a systematic review and meta-analysis. ANZ J Surg 2024; 94:604-613. [PMID: 38456319 DOI: 10.1111/ans.18925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Revised: 02/19/2024] [Accepted: 02/20/2024] [Indexed: 03/09/2024]
Abstract
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.
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Affiliation(s)
- Khang Duy Ricky Le
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Geelong Clinical School, Deakin University, Geelong, Victoria, Australia
- Department of Surgical Oncology, The Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Katherine Martin
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
| | - David Read
- Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
- Department of Surgery, The University of Melbourne, Melbourne, Victoria, Australia
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Robotic-assisted resection of proximal jejunal ischemic stricture and intracorporeal robot-sewn anastomosis. JOURNAL OF MINIMALLY INVASIVE SURGERY 2022; 25:152-157. [PMID: 36601491 PMCID: PMC9763486 DOI: 10.7602/jmis.2022.25.4.152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/09/2022] [Revised: 12/04/2022] [Accepted: 12/09/2022] [Indexed: 12/23/2022]
Abstract
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.
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Smyth L, Bendinelli C, Lee N, Reeds MG, Loh EJ, Amico F, Balogh ZJ, Di Saverio S, Weber D, Ten Broek RP, Abu-Zidan FM, Campanelli G, Beka SG, Chiarugi M, Shelat VG, Tan E, Moore E, Bonavina L, Latifi R, Hecker A, Khan J, Coimbra R, Tebala GD, Søreide K, Wani I, Inaba K, Kirkpatrick AW, Koike K, Sganga G, Biffl WL, Chiara O, Scalea TM, Fraga GP, Peitzman AB, Catena F. WSES guidelines on blunt and penetrating bowel injury: diagnosis, investigations, and treatment. World J Emerg Surg 2022; 17:13. [PMID: 35246190 PMCID: PMC8896237 DOI: 10.1186/s13017-022-00418-y] [Citation(s) in RCA: 34] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2021] [Accepted: 01/26/2022] [Indexed: 02/08/2023] Open
Abstract
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.
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Affiliation(s)
- Luke Smyth
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Cino Bendinelli
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.
| | - Nicholas Lee
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Matthew G Reeds
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Eu Jhin Loh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Francesco Amico
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Zsolt J Balogh
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Dieter Weber
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Fikri M Abu-Zidan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Solomon Gurmu Beka
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Massimo Chiarugi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Vishal G Shelat
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Edward Tan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Ernest Moore
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Luigi Bonavina
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Rifat Latifi
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andreas Hecker
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Jim Khan
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Raul Coimbra
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Giovanni D Tebala
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kjetil Søreide
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Imtiaz Wani
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Kenji Inaba
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | | | - Kaoru Koike
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gabriele Sganga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Walter L Biffl
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Osvaldo Chiara
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Thomas M Scalea
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Gustavo P Fraga
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew B Peitzman
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Fausto Catena
- John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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Development of a polymeric biomedical device platform with controlled disassembly and in vivo testing in a swine intestinal model. Sci Rep 2022; 12:3208. [PMID: 35217701 PMCID: PMC8881572 DOI: 10.1038/s41598-022-06339-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2021] [Accepted: 12/10/2021] [Indexed: 11/09/2022] Open
Abstract
The aim of this study was to create a surgical guide platform that maintains its integrity while the surgeon performs an intestinal anastomosis or another similar procedure, which then breaks apart and is eliminated from the body in a controlled manner. The device contains mixed polymeric structures that give it a controlled rate of disassembly that could meet the requirements of a specific surgical purpose. The intraluminal anastomotic guide was manufactured as a hollow cylinder composed of layers of porous polyurethane/PCL with polyvinylpyrrolidone as the binding agent similar to a "brick-mortar" architecture. This combination of polymeric structures is a promising manufacturing method from which a variety of tunable devices can be fabricated for specific medical procedures and site-specific indications. The guide was designed to rapidly disassemble within the intestinal lumen after use, reliably degrading while maintaining sufficient mechanical rigidity and stability to support manipulation during complex surgical procedures. The nature of the device's disassembly makes it suitable for use in hollow structures that discharge their contents, resulting in their elimination from the body. A swine model of intestinal anastomosis was utilized to validate the use and function of the device.
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Cioffi SPB, Chiara O, Del Prete L, Bonomi A, Altomare M, Spota A, Bini R, Cimbanassi S. Failure to Rescue (FTR) and Pitfalls in the Management of Complex Enteric Fistulas (CEF): From Rescue Surgery to Rescue Strategy. J Pers Med 2022; 12:jpm12020292. [PMID: 35207780 PMCID: PMC8875978 DOI: 10.3390/jpm12020292] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 02/14/2022] [Accepted: 02/15/2022] [Indexed: 11/16/2022] Open
Abstract
Purpose: Complex enteric fistulas (CEF) represent general surgeons’ nightmare. This paper aims to explore the impact on failure-to-rescue (FTR) rate of a standardised and integrated surgical and critical care step-up approach. Methods: This was a retrospective observational cohort study. Patients treated for CEF from 2009 to 2019 at Niguarda Hospital were included. Each patient was approached following a three-step approach: study phase, sepsis control and strategy definition phase, and surgical rescue phase. Results: Sixteen patients were treated for CEF. Seven fistulas were classified as complex entero-cutaneous (ECF) and nine as entero-atmospheric fistula (EAF). Median number of surgical procedures for fistula control before definitive surgical attempt was 11 (IQR 2–33.5). The median time from culprit surgery and the first access at Niguarda Hospital to definitive surgical attempt were 279 days (IQR 231–409) and 120 days (IQR 34–231), respectively. Median ICU LOS was 71 days (IQR 28–101), and effective hospital LOS was 117 days, (IQR 69.5–188.8). Three patients (18.75%) experienced spontaneous fistula closure after conversion to simple ECF, whereas 13 (81.25%) underwent definitive surgery for fistula takedown. Surgical rescue was possible in nine patients. Nine patients underwent multiple postoperative revision for surgical complications. Four patients failed to be rescued. Conclusion: An integrated step-up rescue strategy is crucial to standardise the approach to CEF and go beyond the basic surgical rescue procedure. The definition of FTR is dependent from the examined population. CEF patients are a unique cluster of emergency general surgery patients who may need a tailored definition of FTR considering the burden of postoperative events influencing their outcome.
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Affiliation(s)
- Stefano Piero Bernardo Cioffi
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
| | - Osvaldo Chiara
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
- Department of Pathophysiology and Transplants, State University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy
| | - Luca Del Prete
- General and Liver Transplant Surgery Unit, Fondazione IRCCS Ca’ Granda, Ospedale Maggiore Policlinico, 20122 Milan, Italy;
| | - Alessandro Bonomi
- General Surgery Residency Program, State University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy;
| | - Michele Altomare
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
- Department of Surgical Sciences, Sapienza University of Rome, Piazzale Aldo Moro 5, 00185 Rome, Italy
| | - Andrea Spota
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
| | - Roberto Bini
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
| | - Stefania Cimbanassi
- General Surgery and Trauma Team, ASST GOM Niguarda, Piazza Ospedale Maggiore 3, 20162 Milan, Italy; (S.P.B.C.); (O.C.); (M.A.); (A.S.); (R.B.)
- Department of Pathophysiology and Transplants, State University of Milan, Via Festa del Perdono 7, 20122 Milan, Italy
- Correspondence:
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Mullen KM, Regier PJ, Waln M, Fox-Alvarez WA, Colee J. Gastrointestinal thickness, duration, and leak pressure of six intestinal anastomoses in dogs. Vet Surg 2020; 49:1315-1325. [PMID: 32697359 DOI: 10.1111/vsu.13490] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Revised: 05/17/2020] [Accepted: 06/18/2020] [Indexed: 12/13/2022]
Abstract
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.
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Affiliation(s)
- Kaitlyn M Mullen
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Florida, USA
| | - Penny J Regier
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Florida, USA
| | - Monica Waln
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Florida, USA
| | - W Alexander Fox-Alvarez
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Florida, USA
| | - James Colee
- Department of Statistics, College of Liberal Arts and Sciences University of Florida, Florida, USA
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Fealey MJ, Regier PJ, Steadman Bs C, Brad Case J, Garcia-Pereira F. Initial leak pressures of four anastomosis techniques in cooled cadaveric canine jejunum. Vet Surg 2020; 49:480-486. [PMID: 32034924 DOI: 10.1111/vsu.13392] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 12/10/2019] [Accepted: 01/11/2020] [Indexed: 12/18/2022]
Abstract
OBJECTIVE To compare the effectiveness of four different intestinal anastomosis techniques at preventing leakage after enterectomy. STUDY DESIGN Experimental study. SAMPLE POPULATION Grossly normal jejunal segments (N = 70) from three fresh canine cadavers. METHODS Eight-centimeter cooled canine cadaveric jejunal segments were randomly assigned to a control group (six segments) and four treatment groups (16 segments each [two segments/anastomotic construct]): (1) handsewn anastomosis (HSA), (2) barbed suture anastomosis (B-HSA), (3) stapled functional end-to-end anastomosis (SFEEA), and (4) stapled functional end-to-end anastomosis with an oversew (SFEEA-O). Control segments and anastomotic constructs were infused intraluminally to the point of leakage. Initial leak pressures were recorded and compared. RESULTS Initial leak pressures (median + range) for jejunal control segments, HSA, B-HSA, SFEEA, and SFEEA-O were 331.88 mmHg (range, 315.34-346.64), 35.17 (20.29-56.24), 24.99 (6.08-38.64), 28.77 (18.80-85.09), and 35.92 (12.05-80.71), respectively. No difference was detected between leak pressures of anastomosed segments (P = .35), all of which were more variable and lower than those of intact segments. CONCLUSION No difference in initial leak pressures was detected between the four anastomosis techniques tested in cooled canine cadaveric jejunum. CLINICAL SIGNIFICANCE All four anastomosis techniques evaluated in this study may be suitable in dogs.
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Affiliation(s)
- Mark J Fealey
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Penny J Regier
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Charles Steadman Bs
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - J Brad Case
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
| | - Fernando Garcia-Pereira
- Department of Small Animal Clinical Sciences, College of Veterinary Medicine, University of Florida, Gainesville, Florida
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Abstract
PURPOSE Mechanical gastro-intestinal anastomosis using stapler is a critical step in laparoscopic Roux-en-Y gastric bypass (RYGB). To date the effect of the direction of staples on anastomotic leak has not been investigated. The study aim was to investigate the impact of the direction of staples on the integrity of the gastro-jejunal anastomosis. MATERIALS AND METHODS Eight gastro-jejunostomy (GJ) models were performed using porcine stomach and small intestine. Specimens were divided into group A where the cartridge was in the gastric lumen with the anvil in the jejunal lumen and vice versa in group B. Enterotomy was closed and gastric and jejunal ends were stapled off. Burst pressure (BP) was measured by infusion of methylene blue saline into the GJ model until leak occurred. Site of leak, BP, and total volume (TV) infused were recorded. Compliance (C) was calculated from the equation ΔTV/ΔBP. RESULTS The BP was greater in group A compared to group B (18 mmHg (range 15-25) versus 11 mmHg (range 8-15); p = 0.045) despite similar TV between the groups 60.00 mL (range 55.00-65.00) versus 51.25 mL (range 40.00-60.00); p = 0.11). The compliance did not significantly differ between groups A and B (6.38 mL/mmHg (range 4.34-8.59) versus 5.61 mL/mmHg (range 3.93-7.21); p = 0.48). CONCLUSION BP recorded when the stapler cartridge was introduced in the gastric lumen was higher than when it was introduced from the jejunal lumen. The lack of difference in compliance between groups suggests that the difference in BP was due to the difference in the direction of staples.
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Bowel Anastomosis in Acute Care Surgery. CURRENT SURGERY REPORTS 2017. [DOI: 10.1007/s40137-017-0191-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Nemeth ZH, Lazar EL, Paglinco SR, Hicks AS, Lei J, Barratt-Stopper PA, Rolandelli RH. Experience of General Surgery Residents in the Creation of Small Bowel and Colon Anastomoses. JOURNAL OF SURGICAL EDUCATION 2016; 73:844-850. [PMID: 27321982 DOI: 10.1016/j.jsurg.2016.04.011] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/12/2016] [Revised: 04/04/2016] [Accepted: 04/14/2016] [Indexed: 06/06/2023]
Abstract
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.
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Affiliation(s)
- Zoltan H Nemeth
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey.
| | - Eric L Lazar
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
| | | | - Addison S Hicks
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
| | - Jason Lei
- Department of Surgery, Morristown Medical Center, Morristown, New Jersey
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11
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Shwaartz C, Fields AC, Sobrero M, Cohen BD, Divino CM. Effect of Anti-TNF Agents on Postoperative Outcomes in Inflammatory Bowel Disease Patients: a Single Institution Experience. J Gastrointest Surg 2016; 20:1636-42. [PMID: 27405310 DOI: 10.1007/s11605-016-3194-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/02/2016] [Accepted: 06/15/2016] [Indexed: 01/31/2023]
Abstract
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.
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Affiliation(s)
- Chaya Shwaartz
- Department of Surgery, Division of General Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1041, New York, NY, 10029, USA
| | - Adam C Fields
- Department of Surgery, Division of General Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1041, New York, NY, 10029, USA
| | - Maximiliano Sobrero
- Department of Surgery, Division of General Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1041, New York, NY, 10029, USA
| | - Brian D Cohen
- Department of Surgery, Division of General Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1041, New York, NY, 10029, USA
| | - Celia M Divino
- Department of Surgery, Division of General Surgery, Icahn School of Medicine at Mount Sinai, 1 Gustave L. Levy Place, Box 1041, New York, NY, 10029, USA.
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Duell JR, Thieman Mankin KM, Rochat MC, Regier PJ, Singh A, Luther JK, Mison MB, Leeman JJ, Budke CM. Frequency of Dehiscence in Hand-Sutured and Stapled Intestinal Anastomoses in Dogs. Vet Surg 2016; 45:100-3. [DOI: 10.1111/vsu.12428] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Jason R. Duell
- Veterinary Clinical Sciences; Oklahoma State University; Stillwater Oklahoma
| | | | - Mark C. Rochat
- Veterinary Clinical Sciences; Oklahoma State University; Stillwater Oklahoma
| | - Penny J. Regier
- Veterinary Clinical Sciences; Oklahoma State University; Stillwater Oklahoma
| | - Ameet Singh
- Department of Clinical Studies, Ontario Veterinary College; University of Guelph; Guelph Ontario
| | - Jill K. Luther
- Midwest Veterinary Referral Center; Chesterfield Missouri
| | | | | | - Christine M. Budke
- Veterinary Integrative Biosciences; Texas A&M University, College Station; Texas
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13
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Snowdon KA, Smeak DD, Chiang S. Risk Factors for Dehiscence of Stapled Functional End-to-End Intestinal Anastomoses in Dogs: 53 Cases (2001-2012). Vet Surg 2015; 45:91-9. [PMID: 26565990 DOI: 10.1111/vsu.12413] [Citation(s) in RCA: 42] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
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.
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Affiliation(s)
- Kyle A Snowdon
- College of Veterinary Medicine, Michigan State University, East Lansing, Michigan
| | - Daniel D Smeak
- College of Veterinary Medicine, Colorado State University, Fort Collins, Colorado
| | - Sharon Chiang
- Department of Statistics, Rice University, Houston, Texas
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14
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Adisa AO, Olasehinde O, Arowolo OA, Alatise OI, Agbakwuru EA. Early Experience with Stapled Gastrointestinal Anastomoses in a Nigerian Hospital. Niger J Surg 2015; 21:140-2. [PMID: 26425069 PMCID: PMC4566321 DOI: 10.4103/1117-6806.162584] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
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.
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Affiliation(s)
- A O Adisa
- Department of Surgery, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, 220005, Nigeria
| | - O Olasehinde
- Department of Surgery, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, 220005, Nigeria
| | - O A Arowolo
- Department of Surgery, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, 220005, Nigeria
| | - O I Alatise
- Department of Surgery, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, 220005, Nigeria
| | - E A Agbakwuru
- Department of Surgery, Obafemi Awolowo University, Obafemi Awolowo University Teaching Hospitals Complex, Ile-Ife, 220005, Nigeria
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15
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Stapled versus handsewn intestinal anastomosis in emergency laparotomy: a systemic review and meta-analysis. Surgery 2015; 157:609-18. [PMID: 25731781 DOI: 10.1016/j.surg.2014.09.030] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2014] [Revised: 09/19/2014] [Accepted: 09/26/2014] [Indexed: 12/15/2022]
Abstract
BACKGROUND The optimal technique for gastrointestinal anastomosis remains controversial in emergency laparotomy. The aim of this meta-analysis was to compare outcomes of stapled versus handsewn anastomosis after emergency bowel resection. METHODS A systematic review was performed for studies comparing outcomes after emergency laparotomy using stapled versus handsewn anastomosis until July 2014 (PROSPERO registry number: CRD42013006183). The primary endpoint was anastomotic failure, a composite measure of leak, abscess and fistula. Odds ratio (OR; with 95% CI) and weighted mean differences were calculated using meta-analytical techniques. Subgroup analysis was conducted for trauma surgery (TS) and emergency general surgery (EGS) cohorts. Risk of bias for each study was calculated using the Newcastle-Ottawa scale for cohort studies, and Cochrane Collaboration's tool for randomized trials. RESULTS The final analysis included 7 studies of 1,120 patients, with a total of 1,205 anastomoses. There were 5 TS studies and 2 EGS studies. There were no differences in anastomotic failure between handsewn and stapled techniques on an individual anastomosis level (OR, 1.53; 95% CI, 0.97-2.43; P = .070), or on an individual patient level (OR, 1.44; 95% CI, 0.92-2.25; P = .110). There were no differences in the individual rates of anastomotic leak, abscess, fistulae, or postoperative deaths between techniques. Subgroup analysis of EGS and TS studies demonstrated no superior operative technique. CONCLUSION Available evidence is sparse and at high risk of bias, and neither stapling nor handsewing is justifiably favored in emergency laparotomy. Surgeons might therefore select the technique of their own choice with caution owing to unresolved uncertainty.
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