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

Impact of Surgical Experience on Burst Pressure of Hand-Sewn and Stapled Anastomoses

INTRODUCTION

Both hand-sewn and stapled techniques for creating small bowel anastomoses are safe and have similar rates for leaks and stricture. Each technique comes with its own benefits and detriments, but a well-trained surgeon should be proficient in both anastomotic techniques. The understanding of tissue layers and meticulous technique needed to perform a proper hand-sewn anastomoses require greater skill and experience than a stapled anastomosis to achieve comparable results. This study is aimed to determine if there is a difference in anastomotic burst pressure between hand-sewn versus stapled anastomoses when they were performed by surgeons with differing years of experience.

METHODS

Attending and resident surgeons with varying experience followed standardized instructions to create a hand-sewn and stapled anastomosis using segments of swine small intestine. Burst pressure was measured by inflating the intestine with air and using a manometer to record the pressure at which air leaked from the anastomosis.

RESULTS

Thirteen participants with 1-11 y of experience took part in this study. Burst pressure ranged between 4 and 76 mmHg for hand-sewn and 9 to 40 mmHg for stapled anastomoses. The mean burst pressures of stapled anastomoses were equal between less (mean = 29.0 mmHg, standard deviation [SD] = 8.54) and more (mean 29.0 mmHg, SD = 12.36) experienced surgeons. The difference in mean burst pressure of hand-sewn anastomoses for less experienced surgeons (mean = 34.6 mmHg, SD = 21.8) and more experienced surgeons (mean = 24.8 mmHg, SD = 5.26) was not statistically significant (P = 0.09). However, there was a significant difference between the SDs of the hand-sewn anastomoses of less and more experienced surgeons (P = 0.01, F = 17.1, F Crit = 9.2). There was no significant difference in our secondary outcome, mean burst pressure between hand-sewn 30.5 mmHg (SD = 18.4) and stapled anastomoses 29.0 mmHg (SD = 11.07) (P = 0.81).

CONCLUSIONS

While unable to detect differences regarding the impact of surgical experience on mean burst pressure of anastomoses, there is a greater range of burst pressures in the hand sewn group. In addition, we feel that the model of anastomotic testing we present represents the value, at all levels of training, of refining and practice advanced surgical technical skills on animal models.

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.

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.

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.