comparitive study of stapler versus handsewen anastomosis

1. Journal club:
Presenter :- Dr. v.veeranath reddy.
Moderator :- Dr Gopinath Pai.
Professor,
Department of General
Surgery.

2. 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

3. 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.

4. • 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.

5. • The two most commonly used anastomotic
techniques are
1. handsewn anastomosis and
2.stapled anastomosis.

6. 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.

7. • 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.

8. 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.”

9. • 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.

10. • 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.

11. • 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.

12. • 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.

13. 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.

14. Inclusion criteria:
• All patients undergoing handsewn or stapled
anastomosis for lower gastrointestinal tract
malignancy will be included in the study.

15. 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.

16. 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.

17. 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.

18. • 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.

19. 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.

20. 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.

21. 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.

22. 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.

23. 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).

24. 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

25. 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.

26. • 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.

27. • 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.

28. 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.

29. THANK YOU