Hand-sewn Bowel Anastomosis: The Only Correct Choice

Ashok Babu, M.D.Department of SurgeryUniversity of Colorado

Outline• History• Trial data in specific applications

– Colorectal– Ileocolic– Esophagogastric– Trauma

• Time efficiency• Cost efficiency

History• Sutureless anastomosis (compression)

– 1826: Donaus• Hand-sewn double layer

– 1882: Connel• Hand-sewn single layer

– 1887 Halsted, 1922 Schiassi, 1951 Gambee, 1975 Matheson

• Stapled– 1908—Hungary—Hultl– Early 1960’s—Moscow– Late 1960’s—USA—Ravitch

The Controversy

Colorectal—Meta-analysis

• 13 PRCT comparing handsewn vs stapled• No study independently showed significant

difference in leak rate, stricture, cancer recurrence, or mortality

MacRae et. al. Dis Colon Rectum 1998.

0.53-1.981.02Wound infection0.57-3.041.3Cancer rec.4.6-4915Tech Problem1.28-7.563.12Stricture0.55-2.931.27Mortality0.78-1.521.09LeakConf. IntervalOdds RatioComplication

ODDS RATIO LESS THAN 1 FAVORS STAPLED ANASTOMOSIS

Colorectal—Meta-analysis

• Cochrane Review—9 PRCT. 1233 patient– 622 stapled– 611 handsewn

• Indications included cancer, diverticulosis, prolapse

• Mostly EEA but some end to side

Lustosa et. al. Cochrane Database. 2001.

CISewnStapledComplicationNS7.1%6.3%LeakNS3.6%2.4%Mortality1.2%-8.1%

2%8%Stricture

NS4.3%5.9%Wound infection

Colorectal—Summary

• No difference between stapled vs. handsewn except for:– higher stricture and technical mishap rate in

stapled– Average of 8 minutes longer time for

handsewn (from one study)

Ileocolic• Very few trials• Largest PRMCT by Kracht et. al.• 440 patients—RADIOLOGIC leak detection• Randomized to side/side stapled (106) or 4

types of sutured– End to end interrupted/continuous (84/77)– End to side interrupted/continuous (82/91)

• 8.3% leak rate in all handsewn groups vs 3% stapled

• Not significant in subgroups

Kracht et. al. Int J Colorectal Dis. 1993

Ileocolic—Crohn’s

• Retrospective study• Wide lumen side to side stapled (69) compared

to Handsewn end to end (69)• Hypothesis: wide lumen leads to less stasis,

pressure, and ischemia resulting in lower leak, stricture , and recurrence rates

Munoz-Juarez. Dis Col Rectum. 2001

24% p=.0457%Recurrence

4% p=.01726%Stricture/fistula

Wide side/sideEnd to End

Ileocolic—Crohn’s

• Retrospective study• Wide lumen side to side stapled (71) compared

to Handsewn end to end (55)• Leak Rate 14.1% end to end vs 2% (p=0.02)

Resegotti. Dis Col Rectum. 2005.

Ileocolic—Summary

• These studies compare anastomoticconfiguration AND stapled vs. handsewntechnique simultaneously

• This makes the data uninterpretable

Esophagogastric anastomosis

• Meta-analysis 5 PRCT’s• Circular stapler vs. end-end hand-sewn• All patients underwent esophagectomy for

cancer and randomized to 2 techniques• No significant difference in leak or stricture

rate, though trend in favor of hand-sewn• RR Mortality 0.45 in hand-sewn (p=0.05)

Trauma Suture is better• Retrospective cohort—Harborview, Seattle• Small bowel and large bowel, blunt and penet.• Hypothesis: bowel edema in trauma renders

fixed depth staple dangerous• Looked for clinically significant leaks

Brundage et. al. JOT 1999

11Fistula.132 (3%)6 (10%)IAA.0404 (7%)Leak

6058npSewnStapled

Trauma Suture is better• Retrospective multicenter• Small bowel and large bowel, blunt and penet.

Brundage et. al. JOT 2001

NS23Fistula.04419IAA.0407Leak

114175npSewnStapled

Trauma No Difference• Retrospective cohort—Minnesota group• Small bowel injury only, blunt and penet.• Compared resections with handsewn vs. stapled

reconstruction

Witzke et. al. JOT 2000

NS02FistulaNS1511IAANS30Leak

34110npSewnStapled

Trauma No Difference• Prospective multicenter nonrandomized• Penetrating colon injuries• Leaks defined as req. draining or operation

Demetriades, Moore et. al. JOT 2002

0.697.8%6.3%Leak0.83.1%3.8%Mortality

0.3915.6%20.3%IAA

12879n0.320.3%26.6%Infection

pSewnStapled

Heterogeneity• Shape

• Technique

• Technical

• Location

• Indication

End-to-EndEnd-to-SideSide-to-Side

StapledHandsewn

CircularLinearContinuousInterrupted

Single LayerDouble Layer

2nd layerNo reinforcement

TensionBlood SupplyTechnical execution

EsophagusStomachSmall bowelLarge bowel Cancer

IBDTraumaInfection

Operative Time

17618051RetroAdloff

163148242PNRTScher

122115118PRCTMcGinn

15417088PRCTDidolkar

1161041004PRCTGeorge

Sewn (min)

Stapled (min)

nDesign1st Author

Single surgeon experienceBruno Cola, Bologna, Italy

Cost Analysis (Euros)

Cola. It. J Coloproct. 2004

Cost Analysis (Euros)

Cola. It. J Coloproct. 2004

Conclusion

• No solid evidence for improved outcomes or decreased operative times with stapled anastomosis of any type

• In an era of morbidly expensive healthcare, the use of staplers for GI anastomosis should ONLY be considered in the setting of special circumstance (laparoscopy, etc.)