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5427
DOI:http://dx.doi.org/10.7314/APJCP.2014.15.13.5427
Stapled Versus Hand-Sewn Techniques for Colo-Rectal Anastomosis: A Study on 50 Patients.
Asian Pac J Cancer Prev, 15 (13), 5427-5431
Introduction
Following resections of the parts of the gut for any
benign or malignant condition, anastomosis is necessary
to restore the continuity of the gut. Intestinal anastomosis
can be preformed in a variety of ways Goulder (2012).
Currently, the two most commonly used anastomotic
techniques are: (A) hand-sewn sutured anastomosis
and (B) stapled anastomosis. Although both are well
established, they are not without their faults. Neither
provides an immediately “sealed” anastomosis and both
are prone to uncommon but serious complications such
as anastomotic bleeding, infection or leaks. However,
controversy remains regarding which of the two methods
of creating an anastomosis yields better clinical outcomes
(Buchberg et al., 2011).
The theory behind creating a safe, healthy bowel
anastomosis remains constant, irrespective of the
technique chosen. Unfortunately, however, despite the
“perfect patient”, healthy bowel and meticulous technique
Department of Surgical Oncology, National Cancer Institute, Cairo University, Egypt *For correspondence: drihab74@hotmail.com
Abstract
Aim: To evaluate the outcome of stapled versus sutured colo-rectal anastomosis after low anterior resection
of mid-rectal carcinoma. Patients and Methods
anastomosis following low anterior resection (LAR) of T2 mid-rectal cancers at the Egyptian National Cancer
a stapled anastomosis group I (25 patients) and a hand-sewn anastomosis group II (25 patients). All operations
are evaluated regarding intra-operative complications such as anastomotic line bleeding, visceral injuries or
major blood loss. The anastomotic time and operative time are documented for each operation. All patients are
evaluated post-operatively for anastomotic leakage (AL), wound infection and ileus. Results: The distance of the
tumor from the anal verge was 9.6±2.0 cm in group I and 9.9±2.4 cm in group II. The mean operative time was
191.5±16.2 min in the stapled group and 208±18.6 min in the sutured group (p=0.002). The mean anastomotic
times were 9.0±1.9 min and 19.7±12.2 min (p=0.001).Anastomotic leakage developed in three (12.0%) patients in
the stapled group and in four (16.0%) patients in the sutured group (p=1.000). Post-operative ileus was observed
in 3 patients in group I and one patient in group II. Wound infection developed in three (12.0%) patients in the
stapled group and four (16.0%) patients in the sutured group (p=1.000). Conclusion: Colo-rectal anastomosis
after low anterior resection for mid rectal carcinoma can be conducted safely either by stapling or hand-sewn
advantages regarding intra- or post-operative complications or hospital stay.
Keywords: Stapled - hand-sewn - colo-rectal anastomosis - rectal cancer
RESEARCH ARTICLE
Evaluation of Stapled versus Hand-Sewn Techniques for Colo-
RectalAnastomosis afterLowAnteriorResection of Mid-Rectal
Carcinoma: a Study on 50 Patients
Ihab Samy Fayek
morbidity and mortality (Phillips and Steele, 2009).
Prospective, randomized trials have not demonstrated
any differences between stapled and hand-sewn
anastomosis in terms of leakage rates, length of hospital
stay, or overall morbidity (Docherty et al., 1995; Chen,
2012). Comparing local recurrence, 3 - and 5-year survival
rates after anal preserving surgery and abdominoperineal
resection of Miles for rectal cancer, it showed no
(Yu et al.,
2012).
After colorectal resection, the incidence of anastomotic
leak ranges from 2.9% to 15.3%. These complications
may require further surgical intervention and can lead to
Yang et al., 2014). In colorectal surgery, the advantages of
the stapled technique are said to be a lower percentage of
complications, such as leaks, better blood supply, reduced
tissue manipulation, less edema, uniformity of sutures and
shorter hospital stay and operation time Korolija (2008).
Meta-analysis was performed to compare the safety
and effectiveness of stapled versus hand-sewn colorectal
Ihab Samy Fayek
5428
anastomosis surgery. Outcome measures were mortality,
anastomotic bleeding, leak, wound infection, anastomotic
duration (time taken to perform the anastomosis) and
found except that time taken to perform the anastomosis
was longer with handsewn techniques (p<0.05) (Neutzling
et al., 2012).
The time taken to perform the anastomosis may, when
analyzed in isolation, have some importance. It may
hospitalization of the patient. The other variables analyzed
did not demonstrate any advantage of one technique over
the other (Neutzling et al., 2012).
This study aims to re-evaluate the outcome of stapled
versus sutured colo-rectal anastomosis after low anterior
resection of mid-rectal carcinoma.
Patients and Methods
This is a prospective study of fifty patients who
underwent colo-rectal anastomosis following low anterior
resection (LAR) of T2 mid-rectal cancer at the Egyptian
National Cancer Institute during the time period from
stapled anastomosis group I (25 patients) and Hand-sewn
anastomosis group II (25 patients). No neoadjuvant
chemoradiation was given to any of the patients in the
study and no diverting colostomies were done intra-
operatively. All patients had either normal or corrected
to near normal laboratory investigations pre-operatively
controlled diabetes….etc.) and thorough metastatic work-
up was free. Colonoscopy was performed to all patients
to rule out synchronous lesions, to localize the lesion and
for tissue sampling for histopathology and assess distance
of the tumor from the anal verge.
Pre-operative preparation
Allpatientshadreceivedmechanicalbowelpreparation.
Two days before surgery: metronidazole 500mg, two
tablets of neomycin 500mg and rectal enema every eight
hours, castor oil extract orally at night or picolax 15
The day before surgery: the same regimen + NPO plus
mannitol orally.
Preoperative antibiotic prophylaxis on the induction
of anesthesia. Each patient received a single dose of
cephalosporin 2 g. for prophylaxis. Antibiotics were
continued for three to five days postoperatively in
addition to Metronidazole 500 mg bid. for three days
postoperatively was also used.
Intra-operative evaluation and technique
All operations are evaluated regarding intra-operative
complications as anastomotic line bleeding, visceral
injuries or major blood loss. The anastomotic time and
operative time are documented in each operation.
End-to-end hand-sewn colo-rectal anastomosis
The two bowel ends with right-angled clamps in
situ were brought close by applying lateral two corner
seromuscular traction sutures using Vicryl 3-0; Each was
then tied and tagged with a straight clamp. The needle and
suture is transected distal to the clamps.Anastomosis was
performed in a double layer using Vicryl 3-0. Posterior
interrupted sero-muscular sutures were taken from the
distal rectum to the proximal sigmoid colon (Five to seven
interrupted Lembert stitches were placed between the
corner sutures). Sutures were not tied but were held long
with artery forceps. This ensures accurate placement of
full-thickness (seromuscular) sutures. The sutures are then
tied (three knots) so that the knots will be “outside” the
anastomosis.After completing the posterior layer, sutures
were tied in order (three knots) so that the knots will be
“outside” the anastomosis starting from one corner. While
tying one suture, the next suture had been held taut by an
assistant to ensure that there was no abnormal gap between
two sutures.All except the two corner sutures are then cut,
leaving the tied corner sutures tagged with straight clamps.
The inner posterior layer was performed starting in the
middle, two continuous sutures were started to form the
inner layer of the anastomosis. Each suture goes towards
each corner incorporating the mucosal and submucosal
layers of each lumen. We used a Connell stitch to invert
the corner, which allows inversion of the bowel edges. The
Connell stitch was achieved by passing the suture from
the outside in, then inside out, on one end in the form of a
continuous U-shape. In a similar fashion, the second stitch
was taken in the opposite direction and a Connell stitch
inserted into the opposite corner. On the anterior surface
over-and-over stitches was done. The inner anterior layer;
the continuous suture is continued around the corners, one
after the other, coming together in the middle and tying the
two ends after cutting the needles of each. After the inner
layer of the anastomosis has been completed, the non-
crushing bowel clamps are removed. Next, the anterior
interrupted layer; seromuscular interrupted anterior-layer
sutures were taken as the posterior layer (seromuscular)
Lembert sutures are placed. Sutures were then tied at the
end (3 knots) and cut 5 mm. distal to the knots to complete
the anastomosis.
Stapled colo-rectal anastomosis
Utilizing the contour and ILS circular curved stapling
devices for anastomosis in LAR of the rectum was
performed in an end-to-end double-stapled colorectal
anastomosis. Laparotomy was performed through a low
midline incision with the patient in Supine position. The
rectum and sigmoid colon was mobilized and inferior
mesenteric vessels ligated and divided. Total mesorectal
excision was performed.After mobilization of the splenic
junction of the sigmoid and descending colon. Bowel
division had been performed by using a 55-mm linear
transverse anastomosis stapler or cutting with a knife after
applying a bowel clamp. After complete mobilization of
the rectum, a right-angled clamp was applied distal to the
tumor and the distal rectum was divided using a 45-mm
contour device applied distal to the right-angled clamp
(Figure 1). An adequate distal mural margin (2 cm) was
necessary to prevent recurrence. The distal rectal stumps
5429
DOI:http://dx.doi.org/10.7314/APJCP.2014.15.13.5427
Stapled Versus Hand-Sewn Techniques for Colo-Rectal Anastomosis: A Study on 50 Patients.
had been washed with saline or dilute povidone-iodine to
destroy exfoliated tumor cells shed in the distal rectum
before applying a clamp or stapler. After division of the
distal rectum, the bowel ends were prepared for double-
stapled anastomosis using a circular stapler (31-mm or
33-mm end-to-end anastomosis stapler). The proximal
bowel was prepared by applying full-thickness purse-
string stitches using polypropylene 3-0 after introducing a
well-lubricated anvil (Figure 2).The anvil head was placed
in the proximal colon and the purse-string suture was tied
above the tying notch. After gentle dilatation of anus, the
shaft of the circular stapler was advanced through the anal
canal and placed close to the staple line with the trocar
fully retracted inside. The trocar was then fully extended
to pierce the tissue so that the trocar advances through
the rectal wall, either anterior or posterior to the staple
line. The detachable head assembly had been reattached
by sliding the anvil shaft over the trocar and pushing until
the detachable head assembly snaps with the trocar into
its fully seated position. Both ends of the circular stapler
had been closed, with care taken that there was no twist
in the mesentery of the proximal colon. The stapler had
and then gently removed by rotating it counterclockwise
for half a turn before removal. The tissue doughnuts
were inspected for completeness before being sent for
pathologic examination. The integrity of the anastomosis
air in the distal rectum, and looking for air bubbles. If
doughnuts are not complete, additional sutures had been
made.
Post-operative evaluation
All patients are evaluated post-operatively for
anastomotic leakage (AL), wound infection and ileus.
The International Study Group of Rectal Cancer (ISREC)
extraluminal compartments due to a defect of the integrity
of the intestinal wall at the anastomosis between two parts
of the GIT. The extent or severity ofAL should be graded
according to the impact on clinical management. GradeA
does not require active therapeutic intervention; grade B
requires active therapeutic intervention, but is manageable
without re-laparotomy; and grade C requires re-laparotomy
(Morks et al., 2011). Hospital stay is documented. All
specimens are evaluated histopathologically.
Statistical methods
Data was analyzed using IBM SPSS advanced statistics
version 20 (SPSS Inc., Chicago, IL). Numerical data were
expressed as mean and standard deviation or median and
range as appropriate. Qualitative data were expressed
as frequency and percentage. Chi-square test (Fisher’s
exact test) was used to examine the relation between
qualitative variables. For quantitative data, comparison
between two groups was done using Mann-Whitney test
(non-parametric t-test). A p-value<0.05 was considered
Results
In this study there were 33 (66.0%) male and 17
(34.0%) female patients. Group I included 17 M and 8 F
patients with a mean age of 53.3±12.5 years while Group
II included 16 male and 9 female patients with a mean age
of 50.8±13.0 years, while (p=1.000 for sex and p=0.495
for age) (Table 1).
The distance of the tumor from the anal verge was
9.6±2.0 cm in group I and 9.9±2.4 cm in group II.
The mean operation time was 191.5±16.2 min in the
Stapled group and 208±18.6 min in the Sutured group
(p=0.002). The mean anastomotic time was 9.0±1.9 min in
the Stapled group and 19.7±12.2 min in the Sutured group
(p=0.001). The mean hospital stay was 10.2±1.3 days in
the Stapled group and 10.1±1.6 days in the Sutured group
(p=0.703). Intra-operative anastomotic line bleeding was
observed in two (8.0%) patients in the Stapled group and
in two patients (8.0%) in the Sutured group (p=1.000) and
was controlled by taking under-running sutures (Table 2).
Anastomotic leakage developed in three (12.0%)
patients in the Stapled group and in four (16.0%) patients
in the Sutured group (p=1.000). Two patients with leakage
in the Stapled group and three patients in the Sutured
group (p=1.000) were minor leakages (Grade B) treated
therapy, whereas one patient (4.0%) in the Stapled group
Figure 1. Insertinon of Contour Stapler to Divide the
Rectum
Figure 2. Fixation of the Anvil by Applying Full-
thickness Polypropylene Purse-string Stitches
0
25.0
50.0
75.0
100.0
Newlydiagnosedwithouttreatment
Newlydiagnosedwithtreatment
Persistenceorrecurrence
Remission
None
0
25.0
50.0
75.0
100.0
Newlydiagnosedwithouttreatment
Newlydiagnosedwithtreatment
Persistenceorrecurrence
Remission
None
Table 1. Clinicopathological Features (n=25)
Demographic data Stapled Suture p value
Age (years) 53.3±12.5 50.8±13.0 0.495
Gender 1
Male 17 (68.0%) 16 (64.0%)
Female 8 (32%) 9 (36.0%)
Comorbidity
Diabetus mellitus 3 (12.0%) 1 (4%) 0.609
Hypertension 4 (16.0%) 1 (4%) 0.349
Liver disease 2 (8.0%) 3 (12.0%) 0.49
Laboratory investigation
Tumor size (median) 4 3.5 0.381
Resection margin
R0 (Negative margin) 24 (96.0%) 24 (96.0%)
R1 (microscopic residual) 1 (4.0%) 1 (4.0%)
Ihab Samy Fayek
5430
on the 6th post-operative day and another patient in the
sutured group on the 8th post-operative day developed
re-operated and underwent a proximal defunctioning
transverse colostomy.
Post-operative ileus was observed in 3 patients in group
I and one patient in group II; all patients were treated
conservatively without any remarkable complications.
Wound infection developed in three (12.0%) patients in
the Stapled group and four (16.0%) patients in the Sutured
group (p=1.000) between the 4th
and 7th
post-operative
treated successfully by conservative measures in the form
of drainage, frequent dressings and proper antibiotics.
All specimens were examined histopathologically
margin by malignant cells in one specimen of the stapled
group and another one in the sutured group. All other
specimens revealed negative safety margins (distal,
1).
Discussion
The interest in the results from comparisons between
hand-sewing and stapling has been progressively growing.
However, the majority of the results come from studies of
inadequate methodological quality. Looking only at the
conclusions from randomized studies, it can be seen that
the results are not uniform (Angelca et al., 2002). This
study was designed to re-evaluate and compare the results
of both techniques in a non-biased manner.
Inspite Choy et al. (2011) stated that anastomotic
bleeding, anastomotic time, mortality, intra-abdominal
abscess, wound infection, length of stay, showed no
anastomotic and operative time with the stapled group.
The type of intestinal anastomosis one performs
depends on personnel preference but irrespective to
the technique used, principles that ensure a successful
outcome include: good vascular supply to segments
being approximated, no distal obstruction and a tension
free repair. Ideally the cut edges of the bowel segments
should bleed freely. Dusky, cyanosed, bowel ends indicate
an inadequate arterial supply and the affected Segment
important for anastomosis and stoma formation involving
the large bowel (Joyce et al., 2002; Goulder et al., 2012).
In this study, all the preceding factors for anastomotic
integrity were considered and applied by the surgeon
intra-operatively, and since irradiated bowel or previous
chemotherapy are contributing factors in anastomotic
failure and leakage (Trencheva et al., 2013; Yang et al.,
2013), all patients in this study didn’t receive neoadjuvant
chemoradiation regarding the early stage (T2) and
relatively the high distance from the anal verge 9.6±2.0
cm in group I and 9.9±2.4 cm in group II.
In general, complications can be divided into intra-
operative and post-operative complications. Occurrence
of intra-operative complications such as bleeding, bowel
injury, ureteral injuries and bladder injuries are caused
by intra-abdominal adhesions, anatomic problems, the
experience of the surgeon and many other factors. Major
post-operative complications include wound infection,
anastomotic leakage, ileus and bleeding (Artinyan et
al., 2008). In this study, two patients in each group had
anastomotic line bleeding detected intra-operatively and
controlled safely by under-running sutures. No major
wound infections were detected post-operatively, ileus
was observed in four patients (8%) and all were managed
conservatively by the use of nasogastric decompression
and correction of electrolyte imbalances (Kirchhoff et
al., 2010).
The frequency of anastomotic leakage (AL) ranges
from 1 to 24%. The consequences of postoperative
dehiscence are bad and include peritonitis, blood stream
infection, further surgery, creation of a defunctioning
stoma and different complications (Matthiessen et al.,
2007). In this study, anastomotic leakage (Grade B - C)
was detected collectively in 7 patients (14%) within
difference between the 2 groups studied, and only 2
patients required a diverting colostomy.
In a study by Yang et al., 2013 they reported an AL of
7.6%, inspite that this rate seems lower than in this study,
however they included the whole rectum (including upper
rectum), they excluded hand-sewn anastomoses and an
acquired infection in the postoperative period other than
leakage.
Yang et al. (2014) demonstrated an anastomotic
leakage in anterior resection with a double stapling
technique of 7.6% between the 6th
and 12th
postoperative
days compared to 12% in the stapled group of this study,
and this difference may be due the small sample size
(n=25) in this study compared to (n=753), while leakage
in this study was diagnosed between the 6th
and 8th
postoperative days.
In a study done by Singha et al. (2013) to find
out whether stapled anastomosis is safer than hand-
sewn anastomosis in colon and rectal cancer surgery,
they operated 100 patients were selected. 48 patients
underwent ‘Stapled’ and 52 underwent ‘Hand-sewn’
anastomosis. The outcome variables were ‘time required
for anastomoses, ‘postoperative hospital stay’ and early
and late ‘complications’ in postoperative and follow-up
period. They found that the time required for anastomosis
26.85 min; p=0.000) in favor of stapling group, almost
Table 2. Intra and Post-operative Outcomes (n=25)
Variable Stapled Suture p value
Time
Intra-operative complications
Anastomotic line bleeding 2 (8.0%) 2 (8.0 %) 1.000
Postoperative complications
Leakage 3 (12.0%) 4 (16.0%) 1.000
Wound infection 3 (12.0%) 4 (16.0%) 1.000
Ileus 3 (12.0%) 1 (4.0%) 0.609
5431
DOI:http://dx.doi.org/10.7314/APJCP.2014.15.13.5427
Stapled Versus Hand-Sewn Techniques for Colo-Rectal Anastomosis: A Study on 50 Patients.
similar to this study The mean anastomotic time was
(9.0±1.9 min and 19.7±12.2 min; p=0.001) in favor of
the stapling group too. No statistical difference was found
between the two groups regarding hospital stay (p=0.821)
as in this study where (p=0.703). Inspite the similarity
only one type of anastomosis (colo-rectal for mid rectal
carcinoma); both studies demand statistical strengthening
on a large scale patients’ number.
Another study by Jeelani, et al. (2013) on 58 patients
divided randomly into two groups 29 each showed that
anastomotic leak was more in hand sewn technique
min vs 180±20 min, p=0.0001) and this is comparable to
this study (191.5±16.2 min vs 208±18.6 min in p=0.002).
No stastical significant difference in mortality and
recurrence rate.
In conclusion, Colo-rectal anastomosis after low
anterior resection for mid rectal carcinoma can be done
safely either by stapling or hand-sewn techniques; however
the stapling technique showed shorter anastomotic and
intra-or post-operative complications or hospital stay.
References
Angelca S, Delico M, Alvaro N, Aldemar A (2002). Stapled
versus hand-sewn methods for colorectal anastomosis
surgery: a systematic review of randomized controlled trials.
Sao Paulo Med J, 120, 132-6.
Artinyan A, Nunoo-Mensah JW, Balasubramaniam S, et al
and predictors after surgery. World J Surg. 32, 1495-500.
Buchberg B, Masoomi H, Bergman H, Mills S, Stamos M (2011).
The use of a compression device as an alternative to hand-
sewn and stapled colorectal anastomoses, is three a crowd?
J Gastrointest Surg 15, 304-10.
Chen C (2012). The art of bowel anastomosis. Scan J Surg,
101, 238-40.
Choy P, Bissett I, Docherty J, et al (2011). Stapled versus
hand-sewn methods for ileo-colic anastomoses. Cochrane
Database of Systematic Reviews, Issue 9.
Docherty J, Mcgregor J, Akyol AM (1995). Comparison of
manually constructed and stapled anastomoses in colorectal
surgery. West of Scotland and HighlandAnastomosis Study
group. Ann Surg, 221, 176-84.
Goulder F (2012). Bowel anastomoses; the theory, the practice
and the evidence base. World J Gastrointest Surg; 4, 208-13.
stapled anastomosis and hand sewn anastomosis in low
anterior resection. Int J Advanced Res 1, 21-4.
Joyce M, Sweeneny K, Johnston S, Greaghty J (2002).
Techniques of bowel resection and anastomosis. CME J
Gyneacologic Oncol, 7, 284-9.
Kirchhoff P, Clavien P, Hahnloser D (2010). Complications in
colorectal surgery, risk factors and preventive strategies.
Patient Saf Surg, 4, 5.
Korolija D (2008). The current evidence on stapled versus
handsewn anastomoses in the digestive tract. Minimally
Invasive Therapy & Allied Technologies, 17, 151-4.
Matthiessen P, Hallbook O, Rutegard J (2007). Defunctioning
stoma reduces symptomatic anastmotic leakage after low
anterior resection of rectum for cancer, a randomized
multicenter trial. Ann Sur, 246, 207-12.
MorksA, Havenga K, Ploeg R (2011). Can intraluminal devices
prevent or reduce colorectal anastomotic leakage, a review.
World J Gastroenterol, 17, 4461-9.
Neutzling C, Lustosa S, Proenca I, Da Silva E, Matos D
(2012). Stapled versus hand-sewn methods for colorectal
anastomosis surgery. Cochrane Database of Systematic
Reviews.
Phillips R, Steele R (2009).ACompanion to Specialist Surgical
Practice: Colorectal Surgery. Philadelphia Elsevier
Saunders, 58-59, 304-10.
Singha J, Haq Z, Majid M (2013). Stapled Versus Hand-Sewn
Anastomosis in Colorectal Cancer Surgery : A comparative
study. Chattagram Maa-O-Shishu Hospital Med Coll J,
12, 56-61.
Trencheva K, Morrissey KP, Wells M, et al (2013). Identifying
important predictors for anastomotic leak after colon and
rectal resection: prospective study on 616 patients. Ann
Surg, 257, 108-13.
Yang L, Huang X, Xu L, et al (2013). Acidic pelvic drainage
as a predictive factor for anastomotic leakage after surgery
for patients with rectal cancer. Asian Pac J Cancer Prev,
14, 5441-47.
Yang L, Huang X, Zhou J (2014). Risk assessment on
anastomotic leakage after rectal cancer surgery: an analysis
of 753 patients. Asian Pac J Cancer Prev, 14, 4447-53.
Yu D, Huang X, Zhou J (2012). Comparative study on the value
of anal preserving surgery for aged people with low rectal
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Evaluation of Stapled versus Hand-Sewn Techniques for Colo- Rectal Anastomosis after Low Anterior Resection of Mid-Rectal Carcinoma: a Study on 50 Patients.

  • 1. 5427 DOI:http://dx.doi.org/10.7314/APJCP.2014.15.13.5427 Stapled Versus Hand-Sewn Techniques for Colo-Rectal Anastomosis: A Study on 50 Patients. Asian Pac J Cancer Prev, 15 (13), 5427-5431 Introduction Following resections of the parts of the gut for any benign or malignant condition, anastomosis is necessary to restore the continuity of the gut. Intestinal anastomosis can be preformed in a variety of ways Goulder (2012). Currently, the two most commonly used anastomotic techniques are: (A) hand-sewn sutured anastomosis and (B) stapled anastomosis. Although both are well established, they are not without their faults. Neither provides an immediately “sealed” anastomosis and both are prone to uncommon but serious complications such as anastomotic bleeding, infection or leaks. However, controversy remains regarding which of the two methods of creating an anastomosis yields better clinical outcomes (Buchberg et al., 2011). The theory behind creating a safe, healthy bowel anastomosis remains constant, irrespective of the technique chosen. Unfortunately, however, despite the “perfect patient”, healthy bowel and meticulous technique Department of Surgical Oncology, National Cancer Institute, Cairo University, Egypt *For correspondence: drihab74@hotmail.com Abstract Aim: To evaluate the outcome of stapled versus sutured colo-rectal anastomosis after low anterior resection of mid-rectal carcinoma. Patients and Methods anastomosis following low anterior resection (LAR) of T2 mid-rectal cancers at the Egyptian National Cancer a stapled anastomosis group I (25 patients) and a hand-sewn anastomosis group II (25 patients). All operations are evaluated regarding intra-operative complications such as anastomotic line bleeding, visceral injuries or major blood loss. The anastomotic time and operative time are documented for each operation. All patients are evaluated post-operatively for anastomotic leakage (AL), wound infection and ileus. Results: The distance of the tumor from the anal verge was 9.6±2.0 cm in group I and 9.9±2.4 cm in group II. The mean operative time was 191.5±16.2 min in the stapled group and 208±18.6 min in the sutured group (p=0.002). The mean anastomotic times were 9.0±1.9 min and 19.7±12.2 min (p=0.001).Anastomotic leakage developed in three (12.0%) patients in the stapled group and in four (16.0%) patients in the sutured group (p=1.000). Post-operative ileus was observed in 3 patients in group I and one patient in group II. Wound infection developed in three (12.0%) patients in the stapled group and four (16.0%) patients in the sutured group (p=1.000). Conclusion: Colo-rectal anastomosis after low anterior resection for mid rectal carcinoma can be conducted safely either by stapling or hand-sewn advantages regarding intra- or post-operative complications or hospital stay. Keywords: Stapled - hand-sewn - colo-rectal anastomosis - rectal cancer RESEARCH ARTICLE Evaluation of Stapled versus Hand-Sewn Techniques for Colo- RectalAnastomosis afterLowAnteriorResection of Mid-Rectal Carcinoma: a Study on 50 Patients Ihab Samy Fayek morbidity and mortality (Phillips and Steele, 2009). Prospective, randomized trials have not demonstrated any differences between stapled and hand-sewn anastomosis in terms of leakage rates, length of hospital stay, or overall morbidity (Docherty et al., 1995; Chen, 2012). Comparing local recurrence, 3 - and 5-year survival rates after anal preserving surgery and abdominoperineal resection of Miles for rectal cancer, it showed no (Yu et al., 2012). After colorectal resection, the incidence of anastomotic leak ranges from 2.9% to 15.3%. These complications may require further surgical intervention and can lead to Yang et al., 2014). In colorectal surgery, the advantages of the stapled technique are said to be a lower percentage of complications, such as leaks, better blood supply, reduced tissue manipulation, less edema, uniformity of sutures and shorter hospital stay and operation time Korolija (2008). Meta-analysis was performed to compare the safety and effectiveness of stapled versus hand-sewn colorectal
  • 2. Ihab Samy Fayek 5428 anastomosis surgery. Outcome measures were mortality, anastomotic bleeding, leak, wound infection, anastomotic duration (time taken to perform the anastomosis) and found except that time taken to perform the anastomosis was longer with handsewn techniques (p<0.05) (Neutzling et al., 2012). The time taken to perform the anastomosis may, when analyzed in isolation, have some importance. It may hospitalization of the patient. The other variables analyzed did not demonstrate any advantage of one technique over the other (Neutzling et al., 2012). This study aims to re-evaluate the outcome of stapled versus sutured colo-rectal anastomosis after low anterior resection of mid-rectal carcinoma. Patients and Methods This is a prospective study of fifty patients who underwent colo-rectal anastomosis following low anterior resection (LAR) of T2 mid-rectal cancer at the Egyptian National Cancer Institute during the time period from stapled anastomosis group I (25 patients) and Hand-sewn anastomosis group II (25 patients). No neoadjuvant chemoradiation was given to any of the patients in the study and no diverting colostomies were done intra- operatively. All patients had either normal or corrected to near normal laboratory investigations pre-operatively controlled diabetes….etc.) and thorough metastatic work- up was free. Colonoscopy was performed to all patients to rule out synchronous lesions, to localize the lesion and for tissue sampling for histopathology and assess distance of the tumor from the anal verge. Pre-operative preparation Allpatientshadreceivedmechanicalbowelpreparation. Two days before surgery: metronidazole 500mg, two tablets of neomycin 500mg and rectal enema every eight hours, castor oil extract orally at night or picolax 15 The day before surgery: the same regimen + NPO plus mannitol orally. Preoperative antibiotic prophylaxis on the induction of anesthesia. Each patient received a single dose of cephalosporin 2 g. for prophylaxis. Antibiotics were continued for three to five days postoperatively in addition to Metronidazole 500 mg bid. for three days postoperatively was also used. Intra-operative evaluation and technique All operations are evaluated regarding intra-operative complications as anastomotic line bleeding, visceral injuries or major blood loss. The anastomotic time and operative time are documented in each operation. End-to-end hand-sewn colo-rectal anastomosis The two bowel ends with right-angled clamps in situ were brought close by applying lateral two corner seromuscular traction sutures using Vicryl 3-0; Each was then tied and tagged with a straight clamp. The needle and suture is transected distal to the clamps.Anastomosis was performed in a double layer using Vicryl 3-0. Posterior interrupted sero-muscular sutures were taken from the distal rectum to the proximal sigmoid colon (Five to seven interrupted Lembert stitches were placed between the corner sutures). Sutures were not tied but were held long with artery forceps. This ensures accurate placement of full-thickness (seromuscular) sutures. The sutures are then tied (three knots) so that the knots will be “outside” the anastomosis.After completing the posterior layer, sutures were tied in order (three knots) so that the knots will be “outside” the anastomosis starting from one corner. While tying one suture, the next suture had been held taut by an assistant to ensure that there was no abnormal gap between two sutures.All except the two corner sutures are then cut, leaving the tied corner sutures tagged with straight clamps. The inner posterior layer was performed starting in the middle, two continuous sutures were started to form the inner layer of the anastomosis. Each suture goes towards each corner incorporating the mucosal and submucosal layers of each lumen. We used a Connell stitch to invert the corner, which allows inversion of the bowel edges. The Connell stitch was achieved by passing the suture from the outside in, then inside out, on one end in the form of a continuous U-shape. In a similar fashion, the second stitch was taken in the opposite direction and a Connell stitch inserted into the opposite corner. On the anterior surface over-and-over stitches was done. The inner anterior layer; the continuous suture is continued around the corners, one after the other, coming together in the middle and tying the two ends after cutting the needles of each. After the inner layer of the anastomosis has been completed, the non- crushing bowel clamps are removed. Next, the anterior interrupted layer; seromuscular interrupted anterior-layer sutures were taken as the posterior layer (seromuscular) Lembert sutures are placed. Sutures were then tied at the end (3 knots) and cut 5 mm. distal to the knots to complete the anastomosis. Stapled colo-rectal anastomosis Utilizing the contour and ILS circular curved stapling devices for anastomosis in LAR of the rectum was performed in an end-to-end double-stapled colorectal anastomosis. Laparotomy was performed through a low midline incision with the patient in Supine position. The rectum and sigmoid colon was mobilized and inferior mesenteric vessels ligated and divided. Total mesorectal excision was performed.After mobilization of the splenic junction of the sigmoid and descending colon. Bowel division had been performed by using a 55-mm linear transverse anastomosis stapler or cutting with a knife after applying a bowel clamp. After complete mobilization of the rectum, a right-angled clamp was applied distal to the tumor and the distal rectum was divided using a 45-mm contour device applied distal to the right-angled clamp (Figure 1). An adequate distal mural margin (2 cm) was necessary to prevent recurrence. The distal rectal stumps
  • 3. 5429 DOI:http://dx.doi.org/10.7314/APJCP.2014.15.13.5427 Stapled Versus Hand-Sewn Techniques for Colo-Rectal Anastomosis: A Study on 50 Patients. had been washed with saline or dilute povidone-iodine to destroy exfoliated tumor cells shed in the distal rectum before applying a clamp or stapler. After division of the distal rectum, the bowel ends were prepared for double- stapled anastomosis using a circular stapler (31-mm or 33-mm end-to-end anastomosis stapler). The proximal bowel was prepared by applying full-thickness purse- string stitches using polypropylene 3-0 after introducing a well-lubricated anvil (Figure 2).The anvil head was placed in the proximal colon and the purse-string suture was tied above the tying notch. After gentle dilatation of anus, the shaft of the circular stapler was advanced through the anal canal and placed close to the staple line with the trocar fully retracted inside. The trocar was then fully extended to pierce the tissue so that the trocar advances through the rectal wall, either anterior or posterior to the staple line. The detachable head assembly had been reattached by sliding the anvil shaft over the trocar and pushing until the detachable head assembly snaps with the trocar into its fully seated position. Both ends of the circular stapler had been closed, with care taken that there was no twist in the mesentery of the proximal colon. The stapler had and then gently removed by rotating it counterclockwise for half a turn before removal. The tissue doughnuts were inspected for completeness before being sent for pathologic examination. The integrity of the anastomosis air in the distal rectum, and looking for air bubbles. If doughnuts are not complete, additional sutures had been made. Post-operative evaluation All patients are evaluated post-operatively for anastomotic leakage (AL), wound infection and ileus. The International Study Group of Rectal Cancer (ISREC) extraluminal compartments due to a defect of the integrity of the intestinal wall at the anastomosis between two parts of the GIT. The extent or severity ofAL should be graded according to the impact on clinical management. GradeA does not require active therapeutic intervention; grade B requires active therapeutic intervention, but is manageable without re-laparotomy; and grade C requires re-laparotomy (Morks et al., 2011). Hospital stay is documented. All specimens are evaluated histopathologically. Statistical methods Data was analyzed using IBM SPSS advanced statistics version 20 (SPSS Inc., Chicago, IL). Numerical data were expressed as mean and standard deviation or median and range as appropriate. Qualitative data were expressed as frequency and percentage. Chi-square test (Fisher’s exact test) was used to examine the relation between qualitative variables. For quantitative data, comparison between two groups was done using Mann-Whitney test (non-parametric t-test). A p-value<0.05 was considered Results In this study there were 33 (66.0%) male and 17 (34.0%) female patients. Group I included 17 M and 8 F patients with a mean age of 53.3±12.5 years while Group II included 16 male and 9 female patients with a mean age of 50.8±13.0 years, while (p=1.000 for sex and p=0.495 for age) (Table 1). The distance of the tumor from the anal verge was 9.6±2.0 cm in group I and 9.9±2.4 cm in group II. The mean operation time was 191.5±16.2 min in the Stapled group and 208±18.6 min in the Sutured group (p=0.002). The mean anastomotic time was 9.0±1.9 min in the Stapled group and 19.7±12.2 min in the Sutured group (p=0.001). The mean hospital stay was 10.2±1.3 days in the Stapled group and 10.1±1.6 days in the Sutured group (p=0.703). Intra-operative anastomotic line bleeding was observed in two (8.0%) patients in the Stapled group and in two patients (8.0%) in the Sutured group (p=1.000) and was controlled by taking under-running sutures (Table 2). Anastomotic leakage developed in three (12.0%) patients in the Stapled group and in four (16.0%) patients in the Sutured group (p=1.000). Two patients with leakage in the Stapled group and three patients in the Sutured group (p=1.000) were minor leakages (Grade B) treated therapy, whereas one patient (4.0%) in the Stapled group Figure 1. Insertinon of Contour Stapler to Divide the Rectum Figure 2. Fixation of the Anvil by Applying Full- thickness Polypropylene Purse-string Stitches 0 25.0 50.0 75.0 100.0 Newlydiagnosedwithouttreatment Newlydiagnosedwithtreatment Persistenceorrecurrence Remission None 0 25.0 50.0 75.0 100.0 Newlydiagnosedwithouttreatment Newlydiagnosedwithtreatment Persistenceorrecurrence Remission None Table 1. Clinicopathological Features (n=25) Demographic data Stapled Suture p value Age (years) 53.3±12.5 50.8±13.0 0.495 Gender 1 Male 17 (68.0%) 16 (64.0%) Female 8 (32%) 9 (36.0%) Comorbidity Diabetus mellitus 3 (12.0%) 1 (4%) 0.609 Hypertension 4 (16.0%) 1 (4%) 0.349 Liver disease 2 (8.0%) 3 (12.0%) 0.49 Laboratory investigation Tumor size (median) 4 3.5 0.381 Resection margin R0 (Negative margin) 24 (96.0%) 24 (96.0%) R1 (microscopic residual) 1 (4.0%) 1 (4.0%)
  • 4. Ihab Samy Fayek 5430 on the 6th post-operative day and another patient in the sutured group on the 8th post-operative day developed re-operated and underwent a proximal defunctioning transverse colostomy. Post-operative ileus was observed in 3 patients in group I and one patient in group II; all patients were treated conservatively without any remarkable complications. Wound infection developed in three (12.0%) patients in the Stapled group and four (16.0%) patients in the Sutured group (p=1.000) between the 4th and 7th post-operative treated successfully by conservative measures in the form of drainage, frequent dressings and proper antibiotics. All specimens were examined histopathologically margin by malignant cells in one specimen of the stapled group and another one in the sutured group. All other specimens revealed negative safety margins (distal, 1). Discussion The interest in the results from comparisons between hand-sewing and stapling has been progressively growing. However, the majority of the results come from studies of inadequate methodological quality. Looking only at the conclusions from randomized studies, it can be seen that the results are not uniform (Angelca et al., 2002). This study was designed to re-evaluate and compare the results of both techniques in a non-biased manner. Inspite Choy et al. (2011) stated that anastomotic bleeding, anastomotic time, mortality, intra-abdominal abscess, wound infection, length of stay, showed no anastomotic and operative time with the stapled group. The type of intestinal anastomosis one performs depends on personnel preference but irrespective to the technique used, principles that ensure a successful outcome include: good vascular supply to segments being approximated, no distal obstruction and a tension free repair. Ideally the cut edges of the bowel segments should bleed freely. Dusky, cyanosed, bowel ends indicate an inadequate arterial supply and the affected Segment important for anastomosis and stoma formation involving the large bowel (Joyce et al., 2002; Goulder et al., 2012). In this study, all the preceding factors for anastomotic integrity were considered and applied by the surgeon intra-operatively, and since irradiated bowel or previous chemotherapy are contributing factors in anastomotic failure and leakage (Trencheva et al., 2013; Yang et al., 2013), all patients in this study didn’t receive neoadjuvant chemoradiation regarding the early stage (T2) and relatively the high distance from the anal verge 9.6±2.0 cm in group I and 9.9±2.4 cm in group II. In general, complications can be divided into intra- operative and post-operative complications. Occurrence of intra-operative complications such as bleeding, bowel injury, ureteral injuries and bladder injuries are caused by intra-abdominal adhesions, anatomic problems, the experience of the surgeon and many other factors. Major post-operative complications include wound infection, anastomotic leakage, ileus and bleeding (Artinyan et al., 2008). In this study, two patients in each group had anastomotic line bleeding detected intra-operatively and controlled safely by under-running sutures. No major wound infections were detected post-operatively, ileus was observed in four patients (8%) and all were managed conservatively by the use of nasogastric decompression and correction of electrolyte imbalances (Kirchhoff et al., 2010). The frequency of anastomotic leakage (AL) ranges from 1 to 24%. The consequences of postoperative dehiscence are bad and include peritonitis, blood stream infection, further surgery, creation of a defunctioning stoma and different complications (Matthiessen et al., 2007). In this study, anastomotic leakage (Grade B - C) was detected collectively in 7 patients (14%) within difference between the 2 groups studied, and only 2 patients required a diverting colostomy. In a study by Yang et al., 2013 they reported an AL of 7.6%, inspite that this rate seems lower than in this study, however they included the whole rectum (including upper rectum), they excluded hand-sewn anastomoses and an acquired infection in the postoperative period other than leakage. Yang et al. (2014) demonstrated an anastomotic leakage in anterior resection with a double stapling technique of 7.6% between the 6th and 12th postoperative days compared to 12% in the stapled group of this study, and this difference may be due the small sample size (n=25) in this study compared to (n=753), while leakage in this study was diagnosed between the 6th and 8th postoperative days. In a study done by Singha et al. (2013) to find out whether stapled anastomosis is safer than hand- sewn anastomosis in colon and rectal cancer surgery, they operated 100 patients were selected. 48 patients underwent ‘Stapled’ and 52 underwent ‘Hand-sewn’ anastomosis. The outcome variables were ‘time required for anastomoses, ‘postoperative hospital stay’ and early and late ‘complications’ in postoperative and follow-up period. They found that the time required for anastomosis 26.85 min; p=0.000) in favor of stapling group, almost Table 2. Intra and Post-operative Outcomes (n=25) Variable Stapled Suture p value Time Intra-operative complications Anastomotic line bleeding 2 (8.0%) 2 (8.0 %) 1.000 Postoperative complications Leakage 3 (12.0%) 4 (16.0%) 1.000 Wound infection 3 (12.0%) 4 (16.0%) 1.000 Ileus 3 (12.0%) 1 (4.0%) 0.609
  • 5. 5431 DOI:http://dx.doi.org/10.7314/APJCP.2014.15.13.5427 Stapled Versus Hand-Sewn Techniques for Colo-Rectal Anastomosis: A Study on 50 Patients. similar to this study The mean anastomotic time was (9.0±1.9 min and 19.7±12.2 min; p=0.001) in favor of the stapling group too. No statistical difference was found between the two groups regarding hospital stay (p=0.821) as in this study where (p=0.703). Inspite the similarity only one type of anastomosis (colo-rectal for mid rectal carcinoma); both studies demand statistical strengthening on a large scale patients’ number. Another study by Jeelani, et al. (2013) on 58 patients divided randomly into two groups 29 each showed that anastomotic leak was more in hand sewn technique min vs 180±20 min, p=0.0001) and this is comparable to this study (191.5±16.2 min vs 208±18.6 min in p=0.002). No stastical significant difference in mortality and recurrence rate. In conclusion, Colo-rectal anastomosis after low anterior resection for mid rectal carcinoma can be done safely either by stapling or hand-sewn techniques; however the stapling technique showed shorter anastomotic and intra-or post-operative complications or hospital stay. References Angelca S, Delico M, Alvaro N, Aldemar A (2002). Stapled versus hand-sewn methods for colorectal anastomosis surgery: a systematic review of randomized controlled trials. Sao Paulo Med J, 120, 132-6. Artinyan A, Nunoo-Mensah JW, Balasubramaniam S, et al and predictors after surgery. World J Surg. 32, 1495-500. Buchberg B, Masoomi H, Bergman H, Mills S, Stamos M (2011). The use of a compression device as an alternative to hand- sewn and stapled colorectal anastomoses, is three a crowd? J Gastrointest Surg 15, 304-10. Chen C (2012). The art of bowel anastomosis. Scan J Surg, 101, 238-40. Choy P, Bissett I, Docherty J, et al (2011). Stapled versus hand-sewn methods for ileo-colic anastomoses. Cochrane Database of Systematic Reviews, Issue 9. Docherty J, Mcgregor J, Akyol AM (1995). Comparison of manually constructed and stapled anastomoses in colorectal surgery. West of Scotland and HighlandAnastomosis Study group. Ann Surg, 221, 176-84. Goulder F (2012). Bowel anastomoses; the theory, the practice and the evidence base. World J Gastrointest Surg; 4, 208-13. stapled anastomosis and hand sewn anastomosis in low anterior resection. Int J Advanced Res 1, 21-4. Joyce M, Sweeneny K, Johnston S, Greaghty J (2002). Techniques of bowel resection and anastomosis. CME J Gyneacologic Oncol, 7, 284-9. Kirchhoff P, Clavien P, Hahnloser D (2010). Complications in colorectal surgery, risk factors and preventive strategies. Patient Saf Surg, 4, 5. Korolija D (2008). The current evidence on stapled versus handsewn anastomoses in the digestive tract. Minimally Invasive Therapy & Allied Technologies, 17, 151-4. Matthiessen P, Hallbook O, Rutegard J (2007). Defunctioning stoma reduces symptomatic anastmotic leakage after low anterior resection of rectum for cancer, a randomized multicenter trial. Ann Sur, 246, 207-12. MorksA, Havenga K, Ploeg R (2011). Can intraluminal devices prevent or reduce colorectal anastomotic leakage, a review. World J Gastroenterol, 17, 4461-9. Neutzling C, Lustosa S, Proenca I, Da Silva E, Matos D (2012). Stapled versus hand-sewn methods for colorectal anastomosis surgery. Cochrane Database of Systematic Reviews. Phillips R, Steele R (2009).ACompanion to Specialist Surgical Practice: Colorectal Surgery. Philadelphia Elsevier Saunders, 58-59, 304-10. Singha J, Haq Z, Majid M (2013). Stapled Versus Hand-Sewn Anastomosis in Colorectal Cancer Surgery : A comparative study. Chattagram Maa-O-Shishu Hospital Med Coll J, 12, 56-61. Trencheva K, Morrissey KP, Wells M, et al (2013). Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients. Ann Surg, 257, 108-13. Yang L, Huang X, Xu L, et al (2013). Acidic pelvic drainage as a predictive factor for anastomotic leakage after surgery for patients with rectal cancer. Asian Pac J Cancer Prev, 14, 5441-47. Yang L, Huang X, Zhou J (2014). Risk assessment on anastomotic leakage after rectal cancer surgery: an analysis of 753 patients. Asian Pac J Cancer Prev, 14, 4447-53. Yu D, Huang X, Zhou J (2012). Comparative study on the value of anal preserving surgery for aged people with low rectal carcinoma in Jiangsu, China. Asian Pac J Cancer Prev, 13, 2339-40.