Hand-sewn Bowel Anastomosis - University of Colorado Denver

Hand-sewn Bowel Anastomosis:
The Only Correct Choice
Ashok Babu, M.D.
Department of Surgery
University of Colorado

• History
Outline
• 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
Complication
• 13 PRCT comparing handsewn vs stapled
Leak
• No study independently showed significant
Mortality 1.27
0.55-2.93
difference in leak rate, stricture, cancer
Stricture 3.12
1.28-7.56
recurrence, or mortality
Tech Problem
Cancer rec.
Wound infection
15
1.3
1.02
MacRae et. al. Dis Colon Rectum 1998.
Odds Ratio
1.09
Conf. Interval
0.78-1.52
4.6-49
0.57-3.04
0.53-1.98
ODDS RATIO LESS THAN 1 FAVORS STAPLED ANASTOMOSIS

Colorectal—Meta-analysis
•Complication Cochrane Review—9 Stapled PRCT. Sewn 1233 patient CI
– 622 stapled
Leak
– 611 handsewn
6.3%
Mortality 2.4% 3.6% NS
• Indications included cancer, diverticulosis,
Stricture prolapse 8% 2% 1.2%-
8.1%
• Mostly EEA but some end to side
Wound infection
5.9% 4.3% NS
Lustosa et. al. Cochrane Database. 2001.
7.1%
NS

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 End to End
• Wide lumen side to side stapled (69) compared
to Handsewn end to end (69)
• Stricture/fistula
Hypothesis: wide lumen 26% leads to less 4% stasis, p=.017
pressure, and ischemia resulting in lower leak,
stricture , and recurrence rates
Recurrence
Munoz-Juarez. Dis Col Rectum. 2001
57%
Wide side/side
24% p=.04

• Retrospective study
Ileocolic—Crohn’s
• 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 anastomotic
configuration AND stapled vs. handsewn
technique 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
n
Leak
IAA
Fistula
Brundage et. al. JOT 1999
Stapled
58
4 (7%)
6 (10%)
1
Sewn
60
0
2 (3%)
1
p
.04
.13

Trauma Suture is better
• Retrospective multicenter
• Small bowel and large bowel, blunt and penet.
n
Leak
IAA
Fistula
Brundage et. al. JOT 2001
Stapled
175
7
19
3
Sewn
114
0
4
2
p
.04
.04
NS

Trauma No Difference
• Retrospective cohort—Minnesota group
• Small bowel injury only, blunt and penet.
• Compared resections with handsewn vs. stapled
reconstruction
n
Leak
IAA
Fistula
Witzke et. al. JOT 2000
Stapled
110
0
11
2
Sewn
34
3
15
0
p
NS
NS
NS

Trauma No Difference
• Prospective multicenter nonrandomized
• Penetrating colon injuries
• Leaks defined as req. draining or operation
n
Infection
IAA
Leak
Mortality
Stapled
79
26.6%
20.3%
6.3%
3.8%
Demetriades, Moore et. al. JOT 2002
Sewn
128
20.3%
15.6%
7.8%
3.1%
p
0.3
0.39
0.69
0.8

• Shape
• Technique
• Technical
• Location
• Indication
Heterogeneity
Stapled
Handsewn
End-to-End
End-to-Side
Side-to-Side
Circular
Linear
Continuous
Interrupted
Tension
Blood Supply
Technical execution
Esophagus
Stomach
Small bowel
Large bowel
Cancer
IBD
Trauma
Infection
2 nd layer
No reinforcement
Single Layer
Double Layer

1 st Author
George
Didolkar
McGinn
Scher
Adloff
Operative Time
Design
PRCT
PRCT
PRCT
PNRT
Retro
n
1004
88
118
242
51
Stapled
(min)
104
170
115
148
180
Sewn
(min)
116
154
122
163
176

Single surgeon experience
Bruno Cola, Bologna, Italy

Cola. It. J Coloproct. 2004
Cost Analysis (Euros)

Cola. It. J Coloproct. 2004
Cost Analysis (Euros)

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.)