Journal club: Presenter :- Dr. v.veeranath reddy.

Moderator :- Dr Gopinath Pai.

Professor,

Department of General

Surgery.

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

Archives of International Surgery / January-March 2016 / Vol 6 / Issue 1

Introduction:

• 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.

• 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.

• 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

1. handsewn anastomosis and 2.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.

• 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.

• 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.

• The technique was pioneered by a Hungarian surgeon, Humer known as the “father of surgical stapling.”

• 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.

• 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, andthe 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:

• 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, and5. 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:

• 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

• 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 meanoperating 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:

• 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:

• 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:• 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:

• 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

Discussion:

• 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.

Conclusion:

• 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.

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