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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 6  |  Issue : 1  |  Page : 1-6

Surgical outcome of stapled and handsewn anastomosis in lower gastrointestinal malignancies: A prospective study


1 Department of General Surgery, Government Medical College, Srinagar, Jammu and Kashmir, India
2 Department of Internal Medicine, Sanjeev Bansal Cygnus Hospital, Karnal, Haryana, India
3 Department of Internal Medicine, Sher e Kashmir Institute of Medical Sciences, Soura, Jammu and Kashmir, India

Date of Web Publication28-Jul-2016

Correspondence Address:
Dr. Waseem Raja Dar
Sanjeev Bansal Cygnus Hospital, Railway Road, Karnal - 132 001, Haryana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2278-9596.187193

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  Abstract 

Background: In spite of the wide range of intestinal anastomotic techniques, surgeons are still not so confident with colorectal anastomosis. Invention of surgical staplers has provided some procedural advantages and sense of security to surgeons as well as to patients, in respect to sphincter-saving procedures and thereby improving the quality of life. Outcome measures of applying these devices should be evaluated to see its efficacy and cost-effectiveness over conventional handsewn technique in treatment plan. The result of such comparative study may help surgeons to improve results of their technique. The aim of this prospective study is to observe the results of using stapler in comparison to handsewn colorectal anastomosis.
Patients and Methods: A total of 60 patients were selected, of which 30 underwent “stapled” and 30 underwent “handsewn” anastomosis. The two groups were compared on the following points (i) mean operating time (min), (ii) resumption of oral feeding, (iii) wound infection rate, (iv) anastomotic leak rate, (v) duration of hospital stay and return to work in days. The procedures were evaluated and presented.
Results: The stapling procedure took shorter operative time compared to the handsewn anastomosis with a mean of 123 ± 21.1 min and 161.5 ± 27.8 min respectively (P < 0.001). Oral feeding was started earlier in patients who underwent stapler anastomosis 4.0 ± 1.0 days, as compared to handsewn anastomosis 5.0 ± 0.83 days (P value = 0.001). There was no significant difference between the two groups in postoperative hospital stay; it was 7.8 ± 1.76 days and in controls group it was 8.1 ± 2.12 (P > 0.0137).
Conclusion: Application of the stapler in treating lower gastrointestinal malignancies demonstrated better effects in terms of mean operating time, resumption of oral feeds, and hospital stay.

Keywords: Gastrointestinal, anastomosis, handsewn, stapled


How to cite this article:
Khan AQ, Awan N, Dar WR, Mehmood M, Latief M, Sofi N, Dar I, Sofi P, Kasana B, Hussain M. Surgical outcome of stapled and handsewn anastomosis in lower gastrointestinal malignancies: A prospective study. Arch Int Surg 2016;6:1-6

How to cite this URL:
Khan AQ, Awan N, Dar WR, Mehmood M, Latief M, Sofi N, Dar I, Sofi P, Kasana B, Hussain M. Surgical outcome of stapled and handsewn anastomosis in lower gastrointestinal malignancies: A prospective study. Arch Int Surg [serial online] 2016 [cited 2021 Sep 16];6:1-6. Available from: https://www.archintsurg.org/text.asp?2016/6/1/1/187193


  Introduction Top


An anastomosis becomes necessary when a segment of the gastrointestinal tract is resected for benign or malignant disease and gastrointestinal continuity needs to be restored. The resected segment can be anywhere between the pharynx and the anus.[1] A successful anastomosis needs a well-nourished patient with no systemic illness, no fecal or purulent contamination, gentle tissue handling, well-vascularized tissues, adequate hemostasis, and meticulous surgical technique besides other factors.[2],[3],[4] Important complications following intestinal anastomosis include anastomotic leak, bleeding, wound infection, anastomotic site stricture, and prolonged functional ileus, especially in children. The two most commonly used anastomotic techniques are handsewn anastomosis and stapled anastomosis.

Surgical sutures

Surgical suture is a medical device used to hold body tissues together after an injury or surgery. It consists of a needle with an attached length of thread. Intestinal segments can be sewn together with various suture materials.[5] The ideal suture material is one that causes minimal inflammation and tissue reaction, while providing maximum strength during the lag phase of wound healing is yet to be discovered. Absorbable sutures include catgut and newer synthetics, e.g., polyglycolic acid (Biovek), polylactic acid, polydioxanone, polygalactine (vicryl), and caprolactone. Nonabsorbable sutures are made of special silk or synthetics polypropylene, polyester, polyethylene glycol (prolene), and nylon.

Mechanical stapling devices

Surgical staples are used in place of sutures to close skin wounds, connect or remove parts of the bowels or lungs.[6] Stapling is much faster, accurate, consistent than suturing by hand. In bowel and lung surgery, staples are primarily used because staple lines are less likely to leak.[7] The technique was pioneered by a Hungarian surgeon, Humer known as the “father of surgical stapling.”[8] Several flaws were associated with older instruments such as enormous weight about 5 kg, complex and cumbersome structure, difficulty of cleansing, time wasting necessity of refilling the clips.[9],[10] Modern surgical staplers are either disposable, made of plastic, or reusable, made of stainless steel. Both types are generally loaded using disposable cartridges. There are several surgical stapler designs on the market, intended for different types of staple placement. Some surgeons like to use disposable staplers that are fitted with disposable cartridges and used on a single patient. Others use reusable staplers made from stainless steel. In this case, a disposable cartridge is used, and the stapler is sterilized after use so that it can be used on another patient. Reusable staplers generate less surgical waste, but energy is required to sterilize them, so the net environmental impact when compared to a disposable product is not very different. Although, most surgical staples are made of titanium, stainless steel is more often used in some skin staples and clips. The aim of this prospective study is to observe the results of using stapler in comparison to handsewn colorectal anastomosis for mean operating time, resumption of oral feeding, wound infection rate, anastomotic leak rate, and duration of hospital stay and return to work.


  Patients and Methods Top


After obtaining the ethical clearance from the Institutional Ethics Committee, the study entitled “Surgical outcome of Stapled and Hand sewn anastomosis in lower gastrointestinal malignancies—a prospective study” was conducted in the Department of General Surgery, Government Medical College Srinagar, Jammu and Kashmir, India. All the patients were first evaluated as per the pro forma.

Inclusion criteria

All patients undergoing handsewn or stapled anastomosis for lower gastrointestinal tract malignancy will be included in the study.

Exclusion criteria

  1. Patients having lower rectal tumors,
  2. Patients having perforated tumors,
  3. Patients had undergone any previous bowel surgery,
  4. Patients who had received and/ or receiving chemotherapy or radiotherapy, and
  5. Immunocompromised patients.


Methodology

A thorough general physical examination and baseline investigations were done in all patients and special investigations such as ultrasonography (USG), computerized tomography (CT) scan, magnetic resonance imaging (MRI), proctoscopy, sigmoidoscopy, colonoscopy, and tumor markers were done whenever needed. Then the patients were prepared for surgery and underwent the respective procedure.

Statistical methods

Using envelop method, patients were randomly allocated into two groups by systematic random sampling. Data was described as mean ± standard deviation (SD) and percentage. Least significant difference for measuring intergroup variance of metric data was done by Student's T test, whereas nonmetric data was analyzed by chi-squared and Mann-Whitney U test. P value of less than 0.05 was considered as significant. Statistical Package for Social Sciences (SPSS) (IBM 2009), Microsoft Excel software was used for data analysis.


  Results Top


Baseline characteristics

Of 60 patients, 30 were in the control group and 30 were in the study group. The mean age of patients in the control group was 48.20 ± 13.36 years, whereas in the study group it was 48.17 ± 12.67 years (P value 0.993). Among the control group, 24 (80.0%) were male and six (20.0%) were female, whereas in the study group, 23 (76.7%) were male and seven (23.3%) were female (P value = 0.50). The lesion in all the patients in this study was malignant.

Mean operating time [Figure 1]
Figure 1: Mean operating time in the two groups

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Mean operating time as recorded from the beginning of the incision to the closure of the wound was compared among the two groups. In the control group, (handsewn) the mean operating time was 161.5 ± 27.8 (110, 210) min, whereas in study group (stapled) it was 123.0 ± 21.1 (90, 170) min. The difference was found to be statistically significant with a P value of <0.001.

Resumption of oral feeding [Figure 2]
Figure 2: Time till resumption of oral feeding in two groups

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Oral feeding was started earlier in patients undergoing stapled anastomosis [4.0 ± 1.01 (2, 6) days], as compared to handsewn anastomosis [5.0 ± 0.83 (4, 6) days]. This difference was found to be statistically significant with a P value of 0.001.

Hospital stay [Figure 3]
Figure 3: Mean hospital stay (in days) in two groups

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Hospital stay in the postoperative period was compared between the two groups. Patients in the control group had a mean hospital stay of 8.1 ± 2.12 (5, 14) days, whereas it was 7.8 ± 1.76 (5, 12) days in the study group. The difference was found to be statistically insignificant with a P value of 0.554.

Infection rate [Figure 4]
Figure 4: Wound infection rate in two groups

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Three out of 30 (10.0%) patients in the control group developed wound infection in the postoperative period, whereas two out of 30 (6.7%) patients developed wound infection in the study group. This difference was found to be statistically insignificant (P value = 0.64).

Anastomotic leak rate [Figure 5]
Figure 5: Anastomotic leak rate in two groups

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Anastomotic leak rate was compared between the two groups in the postoperative period, during the hospital stay. Four out of 30 (13.3%) patients in the control group developed clinical evidence of a leak, as compared to three out of 30 (10.0%) patients in the study group. The difference was statistically insignificant with a P value of 0.688.


  Discussion Top


Numerous surgical conditions require the resection of bowel segments and the creation of reliable anastomosis. As such, anastomotic techniques have been central to the development of modern surgical practice. Traditionally, a wide variety of suture materials have been used to create handsewn anastomosis. Although, surgical stapling devices have existed since the early 20th century, their use in routine gastrointestinal surgery has not been widespread until approximately 30 years ago, when their design became much more efficient and convenient. Today, stapled anastomosis is an integral part of most major abdominal operations. Numerous studies have compared the clinical and laboratory features of hand sewn and stapled anastomotic techniques.

This prospective study was conducted in the Department of General Surgery Government Medical College, Srinagar, Jammu and Kashmir, India with an aim of comparing handsewn and stapled anastomotic techniques with various parameters. A total of 60 patients were randomly distributed into the control and study groups (30 and 30 respectively). There was no significant difference between the two groups in terms of their age and gender. All the patients in both the groups had malignant disease of the various regions of the colon. The various parameters that were compared in the two groups included mean operating time, resumption of oral feeding, wound infection rate, anastomotic leak rate, duration of hospital stay, and return to work in days.[11] One of the earliest controlled clinical trials on staples versus sutures were conducted by Brennan et al. in 1982. One hundred patients were included with colonic or rectal resections to have their anastomosis either handsewn or stapled. Twelve anastomoses leaked. There was no difference in the leak rate between the two anastomotic methods, but patients in the stapled group had a significantly higher incidence of minor wound infection, and spent significantly more days in the hospital after operation. The authors concluded at the end, that stapling instrument was no safer than sutures for colonic and rectal anastomosis, but considerably facilitated the performance of a low anterior resection. As the stapling technique became finer and stapling instruments became more advanced, the results favored stapling techniques more as compared to handsewn methods.[12] Didolkar et al. conducted a study in 1986 comparing sutured versus stapled bowel anastomosis. Eighty-eight cancer patients were prospectively randomized; 45 in the handsewn group and 43 in the stapled group. The anastomosis took an average of 19 min for the sutured and 9 min for the stapled technique. Bowel fistula was seen in one case of stapled anastomosis. The authors concluded that stapled anastomosis was as safe as a sutured one in patients with advanced-stage cancer. It saved time in anastomosis, but no advantage for postoperative return of bowel function and hospital stay.

In our study, we found that mean operating time, as defined from the start of incision to the complete closure of wound, was 161.5 ± 27.64 (110, 210) min in the handsewn group and 123.3 ± 21.1 (90, 170) min in the stapler group. This was statistically significant (P value <0.001). Similarly, resumption of oral feeding, earlier in the stapled group was 4.0 ± 1.01 (2, 6) days, as compared to the sutured group, which was 5.0 ± 0.83 (4, 6) days, which was statistically significant (P value <0.001). This was because of the earlier return of bowel sounds and earlier passage of flatus in the stapled group.[13] A comparative study in 2008 by Damesha et al. comprised 50 patients, 25 treated by the conventional suture method (control group) and 25 by the stapling group (study group). In the sutured group, mean operating time was 145 min and in the stapled group was 125 min. In the sutured group, mean time to appearance of bowel sounds was 54 h and in the stapled group it was 44.5 h. In the sutured group, the resumption of oral feeding was after 5.58 days, in the stapled group it was 4.45 days. In the sutured group, the mean time of mobilization was 2.5 days, in the stapled group it was 2 days. These studies thus strengthen our results that showed lower operating time, earlier resumption of oral feeding, and earlier mobilization in patients with stapled anastomosis. Hospital stay is an important issue in present day medicine, as reduced hospital stay has been shown to lessen time to return to work and lesser hospital associated complications. In our study, the length of hospital stay was compared between the two groups, which was 8.1 ± 2.12 (5, 14) days in hand sewn and 7.8 ± 1.76 (5, 12) days in stapled group) and was found statistically insignificant (P value = 0.554).

There are various complications that are specific to intestinal anastomosis by either handsewn or stapled anastomotic methods such as anastomotic leak and wound infection. These complications were compared between the two groups. In the handsewn group three patients out of 30 (10%) developed wound infection, while in the stapled group two out of 30 patients (6.7%) developed wound infection. There was no significant difference between the two groups (P value = 0.64). In our study we found that the anastomotic leak rate was not statistically significant (P value = 0.688) between the two groups.[14] A comparison between stapled and handsewn anastomosis after right hemicolectomy for carcinoma by Kract et al. in 2004 included 440 patients to compare manual with stapled results, which showed stapled anastomosis was associated with less leakage rates than other combined techniques.[15] Another study done by Jawahar et al. in 2013 found that anastomotic leakage was much lesser in the stapled group (P value = 0.413) as compared to the manual group.[16] Choy et al. in their study found a lower incidence of anastomotic leak in the stapled group (P value 0.01).[17] A study entitled “Comparison of stapled versus hand sewn Loop ileostomy closure” was conducted in 2008 by Terry et al. A metaanalysis was done to compare the rates of small bowel obstruction, anastomotic complications, and wound infections between stapled and handsewn closures of loop ileostomies. Parameters assessed were rates of small bowel obstruction, anastomotic complications, wound infection, length of hospital stay, and operative time. Comparing stapled versus handsewn closures, there were no statistically significant differences in bowel obstruction, wound infection, or anastomotic complication rates. Two studies showed shorter operative times favoring stapled anastomosis. No difference was seen in the length of stay. Current literature suggests no statistically significant differences between stapled and handsewn loop ileostomy closures, but there may be a trend favoring stapled closures with regard to lower small bowel obstruction rates and shorter operative time.[18]

Long-term outcome of anastomotic technique and survival after right hemicolectomy for colorectal cancer was compared in stapled and sutured ileocolonic anastomosis by Anwar et al. in 2004, in which 100 consecutive patients, 59 with hand sutured and 41 stapled anastomosis were included. 24% of the patients studied presented as emergencies and underwent a palliative procedure. There was no difference in anastomotic leaks in either the stapled or sutured groups. In addition, hospital mortality was not significantly different. Overall long-term cancer outcome was the same for both anastomotic techniques; both groups had a median survival of 2.9 years. The study concluded that stapled ileocolonic reconstruction after right hemicolectomy for colonic carcinoma was as safe and reliable as sutured technique surgical. Long-term cancer outcomes were additionally comparable in the two groups. In our study, the number of patients is small and it is not enough to take the results as granted, yet it is an addition to the total number of patients who underwent a lower intestinal anastomosis with either methods.


  Conclusion Top


Stapling devices in surgery are a versatile tool in the armamentarium of a surgeon. Anastomosis by stapling devices in lower gastrointestinal malignancy surgery takes less time and makes resumption of oral feeding earlier due to earlier return of bowel sounds and the passage of first flatus. However, there is no difference in the rate of anastomotic leak and wound infection between the handsewn and stapled anastomosis.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

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Kate V, Roberts KE. Intestinal Anastomosis. Medscape; 2011.  Back to cited text no. 2
    
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Catena F, La Donna M, Gagliardi S, Avanzolini A, Taffurelli M. Stapled versus hand-sewn anastomosis in emergency intestinal surgery. Results of a prospective randomized study. Surg Today 2004;34:123-6.   Back to cited text no. 6
    
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Kolvenbach R, Shiffrin E, Schwierz E, Wassiljew S, Caggianos C. Evaluation of an aortic stapler for an open aortic anastomosis. J Cardiovasc Surg (Torino) 2007;48:659-65.   Back to cited text no. 9
    
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Shifrin EG, Moore WS, Bell PR, Kolvenbach R, Daniline EI. Intravascular stapler for “open” aortic surgery: Preliminary results. Eur J Vasc Endovasc Surg 2007;33:408-11.   Back to cited text no. 10
    
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Didolkar MS, Reed WP, Elias EG, Schnaper LA, Brown SD, Chaudhary SM. A prospective randomized study of sutured versus stapled bowel anastomoses in patients with cancer. Cancer 1986;57:456-60.  Back to cited text no. 12
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Damesha N, Lubana PS, Jain DK, Mathur R. A Comparative Study of Sutured and Stapled Anastomosis in Gastrointestinal Operations. The Internet Journal of Surgery 2008; 15.  Back to cited text no. 13
    
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Kracht M, Hay JM, Fagniez PL, Fingerhut A. Ileocolonic anastomosis after right hemicolectomy for carcinoma: Stapled or hand-sewn? A prospective, multicenter, randomized trial. Int J Colorectal Dis 2004;8:29-33.  Back to cited text no. 14
    
15.
Singha JL, Haq Z, Majid MA. Stapled versus hand-sewn anastomosis in colorectal cancer surgery: A comparative study. Chattagram Maa-O-Shishu Hospital Medical College Journal 2013;12:56-61.  Back to cited text no. 15
    
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Choy PY, Bissett IP, Docherty JG, Parry BR, Merrie AE. Stapled versus hand sewn methods for ileocolic anastomosis. Cochrane Database of Syst Rev 2008.  Back to cited text no. 16
    
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Leung TT, MacLean AR, Buie WD, Dixon E. Comparison of stapled versus handsewn loop ileostomy closure: A meta-analysis. J Gastrointest Surg 2008;12:939-44.  Back to cited text no. 17
    
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    Figures

  [Figure 1], [Figure 2], [Figure 3], [Figure 4], [Figure 5]


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