Comparative Study between Staplers and Conventional(Hand-Sewn) Anastomosis in Gastrointestinal Surgery

Magnetic Compression Anastomosis for Anorectal Malformations: Feasibility and Efficacy in Swine Model and Clinical Observation

BACKGROUND

Patients with anorectal malformations (ARM) commonly experience post-operative bowel dysfunctions due to inherent neuromuscular dysplasia and surgical damage to extraluminal structures. Magnetic compression anastomosis (MCA) minimizes injury to the perirectal neurovascular bundle and sphincter muscles via an endoluminal approach. We evaluated the preclinical feasibility and healing efficacy of a novel MCA device in a swine model of ARM and applied the device to an ARM patient.

METHODS

Two prototype MCA devices (8 mm and 10 mm diameter) were tested at piglets'abdominal wall tissue to evaluate suitable magnetic force to cause local ischemia and necrosis. Eight piglets underwent ARM modeling and were divided into MCA or hand-sewn (HS) anastomosis groups (n = 4 per group). After two weeks of monitoring, the piglets were sacrificed. Radiography assessed the MCA progression, and anastomosis integrity was evaluated through histology. The device was later modified and applied to an infant with intermediate ARM.

RESULTS

The 10 mm MCA devices successfully aligned at the piglets'abdominal wall tissue, while the 8 mm MCA device failed. The 10 mm MCA devices were selected for rectoanal anastomosis in model and showed an average anal recanalization time of 8 days, with smooth anastomosis sites and no foreign body response. Minimal inflammation was seen in the MCA group compared to HS group. The modified MCA device was applied to the ARM patient, with successful anastomosis by postoperative day 8.

CONCLUSION

MCA is a safe and effective method for anastomosis in ARM, providing a foundation for further clinical applications.

LEVEL OF EVIDENCE

III.

A Comparative Study of Hand-Sewn and Stapled Anastomosis in Gastrointestinal Surgeries

Background Bowel anastomosis is a key part of gastrointestinal surgery where two sections of the intestines are connected. It is a critical step as it restores the digestive tract's continuity after removing damaged or diseased bowel. Stapler devices are a new method that helps connect bowel loops faster and with less tissue damage. This study aimed to evaluate and compare the safety and effectiveness of stapled anastomosis versus hand-sewn anastomosis in surgeries involving the bowel. Methods In this prospective non-randomized study, the study population included 60 patients with various gastrointestinal surgeries admitted to our institution from August 2022 to June 2024 within a single unit. The inclusion criteria included all patients aged over 18 years who underwent surgeries such as gastrojejunostomy, hemicolectomy, and small bowel resection with anastomosis. The exclusion criteria were age under 18, pregnancy, and immunocompromised states. Patients were divided into two groups based on how their digestive tract was reconstructed: 28 had stapled anastomoses and 32 had hand-sewn anastomoses, either as elective or emergency surgery. We examined multiple outcomes such as surgery duration in hours, time until bowel function returned post surgery, length of hospital stay in days, anastomotic leak rate, albumin levels to leak rate, post-surgery pain, and surgical site infection (SSI) rate for the two groups. Southampton wound grading system and the visual analog scale (VAS) were used to assess the SSI and pain score, respectively. Results When comparing the operation time for the suture and staple groups among the elective cases, the p-value was significant (0.02), with 15 patients having prolonged surgery in the suture group compared to only five in the staple group. Regarding the time until the return of bowel sounds post surgery, the p-value was significant (0.02) for elective cases in the two groups, with nine patients having their bowel sounds returning after the third postoperative day (POD) in the suture group. When comparing the duration of stay in the hospital for elective cases for the staple and suture groups, the p-value was significant (0.04), with eight patients staying after the seventh POD in the suture group. When comparing the leak rates for the two groups for elective cases, the p-value was significant (0.04), with four leaks in the suture group and no leaks in the staple group. On comparing the association between the albumin level and anastomotic leak, the p-value was significant at 0.001 and 0.0006 for the suture and staple groups, respectively, with more leaks associated with an albumin level of <3 mg/dl. When comparing pain scores of the suture and staple groups separately in elective and emergency settings, the p-values were both 0.4, which is not significant. Among the elective cases comparing SSIs for the suture and staple groups, the p-value was significant (0.04), with six patients having SSIs in the suture group compared to one patient in the staple group. Among the emergency cases, when comparing SSIs for the suture and staple groups, the p-value was not significant (0.1). Conclusion In elective surgeries, stapled anastomosis reduces surgery time, accelerates bowel function recovery, enables earlier discharge, and lowers anastomotic leak rates compared to sutures. The staples group showed no difference from sutures in the leak rate to albumin levels and pain while offering superior SSI prevention.

A 10-year experience with anastomotic leaks in upper gastrointestinal surgery-Retrospective cohort study

BACKGROUND

Anastomotic leak (AL) in upper gastrointestinal (UGI) surgery continues to be a diagnostic challenge. We seek to identify clinical parameters that predict AL and examine the effectiveness of investigations in evaluating AL following UGI surgeries.

METHODS

592 patients underwent UGI surgeries with an anastomosis between January 2011 and January 2021. Data on patient characteristics, surgery, postoperative investigations and outcomes were prospectively collected and analysed.

RESULTS

The overall occurrence of AL was 6.4 %. Tachycardia >120 BPM (OR 6.959, 95 % CI 1.856-26.100, p = 0.004) and leukocyte count >19 × 109/L (OR 3.327, 95 % CI 1.009-10.967, p = 0.048) were independent predictors of AL. On multivariate analysis, patients whose anastomosis was deemed high risk and had pre-emptive investigation done postoperatively to exclude a leak were less likely to require intervention and were more likely to be managed conservatively (66.7 % vs 14.3 %, p = 0.025). Methylene blue test, oral contrast study and Computed Tomography scan with intravenous and oral contrast had 50.0 %, 20.0 % and 9.1 % false negative results, while esophagogastroduodenoscopy had none. There was no misdiagnosed AL when more than 1 investigation (n = 15, 39.5 %) were performed.

CONCLUSION

Our study demonstrates that the presence of a triad including desaturation, tachycardia and leucocytosis predicts for AL following UGI surgery and for confirmation of a leak, evaluation with 2 or more investigation is needed. A practice of evaluating high risk anastomosis prior to commencement of feeding decreased the need for surgical intervention and improves success of conservative treatment.

Enterotomy Closure after Minimally Invasive Distal Gastrectomy with Intracorporeal Anastomosis: A Multicentric Study

INTRODUCTION

Despite progressive improvements in technical skills and instruments that have facilitated surgeons performing intracorporeal gastro-jejunal and jejuno-jejunal anastomoses, one of the big challenging tasks is handsewn knot tying. We analysed the better way to fashion a handsewn intracorporeal enterotomy closure after a stapled anastomosis.

METHODS

All 579 consecutive patients from January 2009 to December 2019 who underwent minimally invasive partial gastrectomy for gastric cancer were retrospectively analysed. Different ways to fashion intracorporeal anastomoses were investigated: robotic versus laparoscopic approach; laparoscopic high definition versus three-dimensional versus 4K technology; single-layer versus double-layer enterotomies. Double-layer enterotomies were analysed layer by layer, comparing running versus interrupted suture; the presence versus absence of deep corner suture; and type of suture thread.

RESULTS

Significantly lower rates of bleeding (p = 0.011) and leakage (p = 0.048) from gastro-jejunal anastomosis were recorded in the double-layer group. Barbed suture thread was significantly associated with reduced intraluminal bleeding and leakage rates both in the first (p = 0.042 and p = 0.010) and second layer (p = 0.002 and p = 0.029).

CONCLUSIONS

Double-layer sutures using barbed suture thread both in first and second layer to fashion enterotomy closure result in lower intraluminal bleeding and anastomotic leak rates.

Systematic Review and Meta-Analysis on Colorectal Anastomotic Techniques

Purpose

Anastomosis creation after resective gastrointestinal surgery is a crucial task. The present review examines the techniques and implants currently available for anastomosis creation and analyses to which extent they already address our clinical needs, with a special focus on their potential to enable further trauma minimization in visceral surgery.

Methods

A multi-database research was conducted in MEDLINE, Scopus, and Cochrane Library. Comparative controlled and uncontrolled clinical trials dealing with anastomosis creation techniques in the intestinal tract in both German and English were included and statistically significant differences in postoperative complication incidences were assessed using the RevMan5.4 Review Manager (Cochrane Collaboration, Oxford, UK).

Results

All methods and implant types were analyzed and compared with respect to four dimensions, assessing the techniques' current performances and further potentials for surgical trauma reduction. Postoperative outcome measures, such as leakage, stenosis, reoperation and mortality rates, as well as the tendency to cause bleeding, wound infections, abscesses, anastomotic hemorrhages, pulmonary embolisms, and fistulas were assessed, revealing the only statistically significant superiority of hand-suture over stapling anastomoses with respect to the occurrence of obstructions.

Conclusion

Based on the overall complication rates, it is concluded that none of the anastomosis systems addresses the demands of operative trauma minimization sufficiently yet. Major problems are furthermore either low standardization potentials due to dependence on the surgeons' levels of experience, high force application requirements for the actual anastomosis creation, or large and rigid device designs interfering with flexibility demands and size restrictions of the body's natural access routes. There is still a need for innovative technologies, especially with regard to enabling incisionless interventions.

Stapled intestinal anastomoses are more cost effective than hand-sewn anastomoses in a diagnosis related group system

PURPOSE

Creation of an optimal bowel anastomosis with low postoperative leakage rate is an immanent part of colorectal surgery contributing to recovery, length of hospital stay and overall hospital costs. We aimed to investigate costs of small and large bowel resection, length of hospital stay, anastomotic leakage rate and its risk factors depending on the anastomotic technique.

METHODS

Retrospective analysis of 198 patients (67 stapled and 131 hand-sewn anastomoses) undergoing elective bowel resection with a single anastomosis without protective ileostomy either stapled or in double-rowed running suture technique between 1st October 2012 and 30th September 2018 at Charité University Hospital Berlin, Campus Benjamin Franklin. We analyzed costs of treatment, total length of hospital stay, rate of anastomotic leakage and possible risk factors for anastomotic leak.

RESULTS

No significant difference between both anastomotic techniques could be detected for hospital stay (p = 0.754), 30-day-readmission rate (p = 0.827), or anastomotic leakage (p = 606). Neither comorbidities (p = 0.449), underlying disease (p = 0.132), experience of the surgical team (p = 0.828) nor scheduling of the operation (p = 0.531) were associated with anastomotic leakage. Stapled anastomoses took 22 min less operation time than sutured anastomoses (130 vs. 152 min. Median) (p = 0.001). Operations with stapled anastomoses saved 183 € in operation costs and 496 € in overall hospital costs.

CONCLUSION

Stapled and hand-sewn bowel anastomoses can be performed equally safe without differences in postoperative outcome. No patient, procedure or surgeon related risk factors for anastomotic leakage could be detected. Bowel resections with stapled anastomoses take less time and save operation and overall hospital costs.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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