Effect of Transition to Stapled Anastomosis on Anastomotic Leak Rates

and Operating Times in Colon Cancer Surgery

Ramzi Amri,1,2 Liliana G Bordeianou,1,2 Patricia Sylla,1,2 David L Berger 1,2

1 Massachusetts General Hospital, Division of General and Gastrointestinal Surgery.2 Harvard Medical School, Department of Surgery.

02/05/159th Annual Academic Surgical Congress, February 4-6 2014

Integrated Quick Shot Session I: Oncology 3: Colorectal (10.11)

Introduction

• Stapled GI anastomosis: easy, fast and safe• Laparoscopy has gained wide adoption• Stapling is a great tool for small port surgery• Growing adoption for CRC at MGH

Did this affect:• Complication rates?• Outcomes?

Methods

• Colon cancer surgeries at MGH (2004-11)• Patients with primary anastomosis

(n=998)• Hand-sewn vs. stapled techniques• 2004-2007 vs. 2008-2011

Results

NS: BMI, obesity, Charlson comorbidity

Stapled Hand-sewn P-value

N (%) Total 622 (62.3%) 376 (37.7%)

- 2004-2007 238 (45.8%) ***

282 (54.2%) ***

2008-2011 384 (80.3%) 94 (19.7%)

Age (median) Total 66 68 0.028 2004-2007 66 68 0.13 2008-2011 66 69.5 0.058

Laparoscopic (%) Total 38.1% 6.7% <0.001 2004-2007 29.8%

** 4.6%

* <0.001

2008-2011 43.3% 12.8% <0.001

Duration of surgery (M) Total 139 100 <0.001 2004-2007 147.5

*** 94

** <0.001

2008-2011 124 118.5 0.85

Results Stapled Hand-sewn P-value

N (%) Total 622 (62.3%) 376 (37.7%)

- 2004-2007 238 (45.8%) ***

282 (54.2%) ***

2008-2011 384 (80.3%) 94 (19.7%)

Anastomotic Leak (%) Total 1.6% 2.4% 0.38

2004-2007 1.7% 2.5% 0.53

2008-2011 1.6% 2.1% 0.70

Delayed bowel function (%) Total 9.6% 10.9% 0.52

2004-2007 13.0% *

10.6% 0.40

2008-2011 7.6% 11.7% 0.19

Fascial dehiscence Total 0.6% 0.8% 1F

2004-2007 0.8% 0.7% 1F

2008-2011 0.5% 1.1% 0.56

Colonic obstruction Total 0.5% 0.3% 1F

2004-2007 0.8% 0.4% 0.59 F

2008-2011 0.3% 0% 0.85

Stay duration (M) Total 4 5 0.024

2004-2007 4 5 0.86

2008-2011 4 6 <0.001

30-day readmission (%) Total 6.4% 9.0% 0.13

2004-2007 6.3% 7.8% 0.66

2008-2011 6.5% 12.8% 0.046

F= Fischer’s exact test

Results Covariates B (95% CI) P

Duration of surgery 2004-2007 vs. 2008-2011 (B=change in minutes)

Stapled

- univariate - -15.8 (-28.8, -2.7) 0.018

Surgeon -5.8 (-18.4, 6.7) 0.36

Laparoscopic -17.3 (-30.5, -4.1) 0.010

Hand-sewn - univariate - 21.1 (4.7, 37.5) 0.012 Laparoscopic 18.7 (2.1, 35,2) 0.027

Multivisceral 15.8 (0.4, 31.2) 0.044

Covariates OR (95% CI) P

Duration of stay ≤4 days Stapled vs. hand-sewn

Total

- univariate - 1.44 (1.12-1.87) 0.005

Charlson, Age 1.43 (1.09-1.86) 0.009 Ch. Age. DoS 1.65 (1.24-2.21) 0.001 Ch., Age, Lap. 1.03 (0.78-1.38) 0.83

Ch, Age, Lap, DoS 1.24 (0.91-1.68) 0.17

2008-2011 - univariate - 3.17 (1.91-5.25) <0.001

Ch., Age, Lap. 2.28 (1.33-3.91) 0.003 Ch., Age, Lap, DoS 2.28 (1.23-3.92) 0.003

AJCC: American Joint Committee on Cancer staging (7th edition);

Charlson/Ch: The Charlson comorbidity score, adjusted for colon cancer. DoS: Date of Surgery;

Conclusions

In our colon cancer surgery cohort:•Stapled anastomosis had similar complication rates (if not better)•Stapled anastomosis are associated with faster discharges•Time-related changes were an important factor to account for when comparing outcomes and complications

Questions?

Disclosures: None.

Contact:E: ramzi_amri@harvard.eduW: hsph.me/ramri