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Single-layer anastomosis of the colon
Single-Layer Anastomosis of the Colon A Review of 165 Cases GBsta Jgnsell, MD, Stockholm, Gllles Edelmann,
Sweden
MD, Paris, France
Recent clinical and experimental investigations have drawn attention to the importance of suture technic in the etiology of colonic anastomotic leaks [l-7]. In international papers, the two-layer inverting anastomosis is usually referred to as the conventional technic and the use of an alternative method has so far had few defenders. In most surgical centers in France, however, the two-layer technic has been replaced by a one-layer anastomosis using a fine interrupted nonabsorbable suture. This technic is adopted for all esophagogastrointestinal suturing. As this one-layer anastomosis has been our conventional method for more than twenty years, we regard it to be of general interest to present the frequency of suture line dehiscence in a consecutive series of colon anastomoses. Material
and Methods
From January 1,197l to October 1,1976,165 consecutive patients underwent elective resection of the rectum and/or colon. A routine for bowel preparation consisting of dietary restriction, mechanical cleansing, and orally administered neomycin sulfate or phthalylsulfathiazole for 48 hours preceding the operation was used. The standard operations were right hemicolectomy, transverse colectomy, left hemicolectomy, and anterior resections. Segmental resections of the transverse and ascending colon have been included in either the group of right hemicolectomies or transverse colectomies, depending on the site of the anastomosis. Segmental resections of the sigmoid colon have been referred to as high anterior resections, or as left hemicolectomies, not differentiating between high rectal,’ low sigmoid, or high sigmoid lesions. High anterior resections signify a colorectal anastomosis above the level of the pelvic
From the Service de Chirurgie de I’appareil digestif. Hbpital Bichat. Paris, France. Reprint requests should be addressed to Wsta Jonsell. MD, Clinic of Surgery II, Sabbatsbergs Hospital, Box 6401. S-l 13 62 Stockholm, Sweden.
630
peritoneal floor. Lesions at or below the peritoneal reflection were usually removed by abdominoperineal resection with end colostomy. When it was possible to achieve a safe 5 cm margin below these lesions, the anastomosis was made between the colon and the extraperitoneal rectal stump. This operation is referred to as low anterior resection. The intestinal sutures were made between open segments and these were irrigated with a macromolecular solution to reduce the contamination and the risk of implantation of cancer in the suture line. The operations were made by different senior or consultant surgeons. All anastomoses were made end-to-end and performed with single layer sutures using interrupted stitches of 4-O Ethiflexe (Ethicon). Two or three sutures were first placed horizontally at each end followed by vertical sutures through all layers except the mucosa. Great attention was paid to assure that the entire submucosal layer was taken in every stitch. The stitches were placed at intervals of 3 to 4 mm and mucosal eversion was strictly avoided. The splenic flexure was mobilized when suturing without tension required added length. Postoperative anal dilatation was generally performed. Drainage of the anastomotic site was provided in all cases. Preoperatively diagnosed diseases with possible influence on the incidence of leakage are referred to as com-
TABLE I
Anastomotlc Leakage and Mortality after Elective Resectlons of Colon and Rectum Anasto-
Type of Operation
No. of Patients
RI-I
43
TC
5
LH HAR LAR Total
38 72 7 165
motic Leakage 1 1 1 8 1: (8.5%)
Resulting Deaths
Total Postoperative Deaths
0 1 0 0 0 1 (0.6%)
2 1 0 1 0 4 (2.4%)
Note: RH = right hemicolectomy; TC = transverse colectomy; LH = left h8mico~8ctomy; HAR = high anterior resection; LAR = low anterior resection.
The American Journal of Surgery
Single-LayerColon Anastomosis
plicating disorders in the following text. Among these disorders, the anemias and electrolyte disturbances were in all cases corrected before operation. Cardiopulmonary disease indicates that the patient was regarded as risk group 3 to 4 by the anesthetist because of recent or present syndrome. Metabolic disease includes insulin-treated diabetes mellitus, liver cirrhosis with collateral circulation, and patients under steroid treatment. The terms overweight and underweight are defined as 20 per cent more or less than the estimated normal weight. A weight loss greater than 10 per cent within the past preoperative six months is referred to as underweight. The mortality was based on sixty days postoperative observation. Anastomotic leakage was documented by reoperation, fecals in drain, or appearance of fistula or was strongly suggested by the clinical course. Routine radiographic examinations
tion, frequency of anastomotic leakage, resulting deaths, and total postoperative deaths. Table II presents the incidence of complicating disorders in the 14 patients with fistulization, 63.4 per cent of whom suffered from one or several complicating disorders compared with 36.4 per cent of the patients without clinical manifestation of anastomotic leakage. In 13 patients a right-sided defunctioning colostomy was made and none of these patients had fistulization. Comments
In 1887 Halsted [8] recognized that collagen was primarily situated in a dense submucosal layer and that this layer is the only part of the bowel wall with enough substantial strength to hold anastomotic stitches. He considered one row of sutures as safe, and regarded a second row as a factor that could disturb the proper healing of the anastomosis. The suture technic adopted by us is in accordance with these statements. This has been the standard anastomotic technic in France since the late 1950s beginning with Pierre Jourdan’s presentation of 300 cases in 1953 [9]. Several other studies have shown that a two-layer anastomosis is associated with a higher frequency of complications than the one-layer technic [IO-131. Nevertheless, the standard method of most American, British, German, and Scandinavian surgeons is still the two-layer technic. Series of colonic and colorectal one-layer anastomoses with excellent results have been published [14-161. Goligher’s review [ 71 of visceral suture problems in 1976 presents a controlled trial of one-layer versus twolayer inverting sutures concluding that the one-layer technic is slightly superior in low anterior resections but equal in high anastomoses. Irvin, Goligher, and
or sigmoidoscopes were not made postoperatively. Results
The conditions requiring operation in the 165 patients (76 male, 89 female; age range, 19 to 85 years) were carcinoma in 110, diverticular disease in 27, polyps in 16, Crohn’s disease in 6, and miscellanous conditions in 6. The latter group includes 2 patients with degenerated villous adenoma, 1 with tuberculosis of the right colon, 1 with chronic ischemic colitis, 1 with fistulization after appendectomy (but with no signs of Crohn’s disease), and 1 operated on for a cyst of the pancreas and who accidentally developed a lesion of the middle colic artery and required transverse colectomy. The overall mortality was 2.4 per cent, and 25 per cent of the deaths were due to anastomotic leakage. The mortality in patients with anastomotic dehiscence was 7.1 per cent compared with 1.9 per cent in patients with no clinically manifest leakage. Table I shows the proportions of different types of opera-
TABLE II
lncldence of Complicating Dlsorders in 14 Patients with Anastomotic Dehlscence
Type of Operation RH TC LH, CD HAR HAR HAR HAR HAR HAR HAR HAR LAR LAR LAR
Cardiopulmonary
Metabolic
Overweight
.
. . .
Hypoproteinemia . .
Anemia Electra . .
. . . . .
.
.
Note: RH = right hemicolectomy; TC = transverse colectomy; resection: LAR = low anterior resection.
Vofumo 135, May 1978
Underweight
.
.
LH = left hemicolectomy;
. .
CD = Crohn’s disease;
HAR = high anterior
631
Jonsell and Edelmann
Johnston [5] in 1973 in a randomized trial of the two technics found no significant difference. The incidence of anastomotic leakage varies considerably from series to series, and as shown by Goligher et al [1] in 1970, this is very much a question of which diagnostic methods are applied to find the dehiscence. The total mortality and overall frequency of complications in these series are comparable to other studies presenting one-layer colonic anastomosis [15,16]. The number of patients with dehiscences in the small group of low anterior resections is important (3 of 7), but of these three, one was considerably underweight and had hypoproteinemia, and another had a long operation with important blood loss (left hepatectomy in a 31 year old male with solitary liver metastasis). In all these cases the fistula healed spontaneously. The influence of complicating disorders on the frequency of anastomotic dehiscence is in accordance with earlier reports [17-201. The one-layer technic is made with less tissue trauma and less disturbance of circulation than the two-layer technic [12,21]. It can be performed in an anatomically more precise manner and in less time. It is easier to make than the two-layer technic, especially in low anastomoses. Considering that there was only one death after anastomotic leakage in the whole series, we find it justifiable to conclude that this one-layer anastomotic technic is a safe method, avoiding as much as possible the incidence of severe life-threatening dehiscences.
References 1. Goligher JC, Morris C, McAdam WAF, De Dombal FT, Johnston
2. 3. 4.
5.
6. 7. 8. 9. 10.
11. 12. 13.
14.
15. 16.
17.
Summary
One hundred sixty-five patients undergoing elective colorectal or colonic anastomoses with a onelayer technic are presented. One death from suture line dehiscence was noted, and the overall mortality was 2.4 per cent. The usual technic for esophagogastrointestinal suturing in French surgical centers is described and the importance of suture technic in the etiology of anastomotic leaks is discussed,
632
18.
19.
20.
21.
D: A controlled trial of inverting versus everting intestinal suture in clinical large bowel surgery. Br J Sufg 57: 817, 1970. I&Adam AJ, Meikle AG, Taylor JO: One layer or two layer colonic anastomoses? Am J Surg 120: 546, 1970. Zollinger RM, Sheppard Ml-i: Carcinoma of the rectum and the rectosigmoid. 729 cases. Arch Surg 102: 335, 197 1. Irvin TT, Edwards JP: Comparison of single layer everting, two layer inverting and everting anastomoses in the rabbit colon. Br J Surg 60: 453, 1973. Irvin IT, Goligher JC, Johnston D: A randomized prospective clinical trial of single layer and two layer inverting intestinal anastomoses. Br J Surg 60: 457, 1973. Barnes JP: The techniques for end-to-end intestinal anastomoses. Surg Gynecof Obstet 138: 433, 1974. Goligher JC: Visceral and parietal suture in abdominal surgery. Am JSurg 131: 130, 1976. Halsted WS: Circular suture of the intestine-an experimental study. Am J Med Sci 94: 436, 1887. Jourdan P: Sutures en un plan des tuniques digestives. Paris, VignB, 1953. Buchin R, Van Geertruyden J: Valeur comparBe des sutures intestinales en un plan et en deux plans. Etude exp&imentale et clinique. Acta Chir Be/g 59: 461, 1960. Hamilton JE: Reappraisal of open intestinal anastomoses. Ann Surg 165: 917, 1967. Orr NWM: A single layer of intestinal anastomosis. Br J Surg 56: 771, 1969. Everett WG: A comparison of one layer and two layer techniques for colorectal anastomoses. Br J Surg 62: 135, 1975. Peters HE, Stanten A: Aseptic single layer anastomosis of the bowel. A review of 175 cases. Am J Surg 122: 159, 1971. Matheson NA, Irving AD: Single layer anastomosis after rectosiamoid resection. Br J Sure 62: 239, 1975. Hell KYRossetti M. Allgiiwer M: 700 konsekutive Kolonresektionen mit einreihiger Allschichtnaht und radiologischer FrDhkontrolle. He/v Chir Acta 43: 225, 1976. Morgenstern L, Yamakawa T. Ben-Shoshan M, Lippman H: Anastomotic leakage after low colonic anastomosis. Am J Surg 123: 104. 19j2. Schrock TR. Devenev CW. Dunohv JE: Factors contributino to leakage of color& aiasto&ses. Ann Surg 177: 5-13, 1973. Hgijer-Madsen K, Beth Hansen J, Lindenberg J: Anastomotic leakage following resection for cancer of the colon and rectum. Acta Chir Stand 141: 304, 1975. Manson PN, Corman ML, Caller JA, Veidenheimer MC: Anterior resection for adanocarcinoma. Lahey Clinic experience from 1963 to 1969. Am JSurg 131: 434. 1976. Langer St: Klinische und tierexperimentelle Studien zur Anastomosentechnik in der Darmchirurgie. Langenbecks Arch Chir 335: 309, 1974.
The American Journal of Surgery
Sweden
MD, Paris, France
Recent clinical and experimental investigations have drawn attention to the importance of suture technic in the etiology of colonic anastomotic leaks [l-7]. In international papers, the two-layer inverting anastomosis is usually referred to as the conventional technic and the use of an alternative method has so far had few defenders. In most surgical centers in France, however, the two-layer technic has been replaced by a one-layer anastomosis using a fine interrupted nonabsorbable suture. This technic is adopted for all esophagogastrointestinal suturing. As this one-layer anastomosis has been our conventional method for more than twenty years, we regard it to be of general interest to present the frequency of suture line dehiscence in a consecutive series of colon anastomoses. Material
and Methods
From January 1,197l to October 1,1976,165 consecutive patients underwent elective resection of the rectum and/or colon. A routine for bowel preparation consisting of dietary restriction, mechanical cleansing, and orally administered neomycin sulfate or phthalylsulfathiazole for 48 hours preceding the operation was used. The standard operations were right hemicolectomy, transverse colectomy, left hemicolectomy, and anterior resections. Segmental resections of the transverse and ascending colon have been included in either the group of right hemicolectomies or transverse colectomies, depending on the site of the anastomosis. Segmental resections of the sigmoid colon have been referred to as high anterior resections, or as left hemicolectomies, not differentiating between high rectal,’ low sigmoid, or high sigmoid lesions. High anterior resections signify a colorectal anastomosis above the level of the pelvic
From the Service de Chirurgie de I’appareil digestif. Hbpital Bichat. Paris, France. Reprint requests should be addressed to Wsta Jonsell. MD, Clinic of Surgery II, Sabbatsbergs Hospital, Box 6401. S-l 13 62 Stockholm, Sweden.
630
peritoneal floor. Lesions at or below the peritoneal reflection were usually removed by abdominoperineal resection with end colostomy. When it was possible to achieve a safe 5 cm margin below these lesions, the anastomosis was made between the colon and the extraperitoneal rectal stump. This operation is referred to as low anterior resection. The intestinal sutures were made between open segments and these were irrigated with a macromolecular solution to reduce the contamination and the risk of implantation of cancer in the suture line. The operations were made by different senior or consultant surgeons. All anastomoses were made end-to-end and performed with single layer sutures using interrupted stitches of 4-O Ethiflexe (Ethicon). Two or three sutures were first placed horizontally at each end followed by vertical sutures through all layers except the mucosa. Great attention was paid to assure that the entire submucosal layer was taken in every stitch. The stitches were placed at intervals of 3 to 4 mm and mucosal eversion was strictly avoided. The splenic flexure was mobilized when suturing without tension required added length. Postoperative anal dilatation was generally performed. Drainage of the anastomotic site was provided in all cases. Preoperatively diagnosed diseases with possible influence on the incidence of leakage are referred to as com-
TABLE I
Anastomotlc Leakage and Mortality after Elective Resectlons of Colon and Rectum Anasto-
Type of Operation
No. of Patients
RI-I
43
TC
5
LH HAR LAR Total
38 72 7 165
motic Leakage 1 1 1 8 1: (8.5%)
Resulting Deaths
Total Postoperative Deaths
0 1 0 0 0 1 (0.6%)
2 1 0 1 0 4 (2.4%)
Note: RH = right hemicolectomy; TC = transverse colectomy; LH = left h8mico~8ctomy; HAR = high anterior resection; LAR = low anterior resection.
The American Journal of Surgery
Single-LayerColon Anastomosis
plicating disorders in the following text. Among these disorders, the anemias and electrolyte disturbances were in all cases corrected before operation. Cardiopulmonary disease indicates that the patient was regarded as risk group 3 to 4 by the anesthetist because of recent or present syndrome. Metabolic disease includes insulin-treated diabetes mellitus, liver cirrhosis with collateral circulation, and patients under steroid treatment. The terms overweight and underweight are defined as 20 per cent more or less than the estimated normal weight. A weight loss greater than 10 per cent within the past preoperative six months is referred to as underweight. The mortality was based on sixty days postoperative observation. Anastomotic leakage was documented by reoperation, fecals in drain, or appearance of fistula or was strongly suggested by the clinical course. Routine radiographic examinations
tion, frequency of anastomotic leakage, resulting deaths, and total postoperative deaths. Table II presents the incidence of complicating disorders in the 14 patients with fistulization, 63.4 per cent of whom suffered from one or several complicating disorders compared with 36.4 per cent of the patients without clinical manifestation of anastomotic leakage. In 13 patients a right-sided defunctioning colostomy was made and none of these patients had fistulization. Comments
In 1887 Halsted [8] recognized that collagen was primarily situated in a dense submucosal layer and that this layer is the only part of the bowel wall with enough substantial strength to hold anastomotic stitches. He considered one row of sutures as safe, and regarded a second row as a factor that could disturb the proper healing of the anastomosis. The suture technic adopted by us is in accordance with these statements. This has been the standard anastomotic technic in France since the late 1950s beginning with Pierre Jourdan’s presentation of 300 cases in 1953 [9]. Several other studies have shown that a two-layer anastomosis is associated with a higher frequency of complications than the one-layer technic [IO-131. Nevertheless, the standard method of most American, British, German, and Scandinavian surgeons is still the two-layer technic. Series of colonic and colorectal one-layer anastomoses with excellent results have been published [14-161. Goligher’s review [ 71 of visceral suture problems in 1976 presents a controlled trial of one-layer versus twolayer inverting sutures concluding that the one-layer technic is slightly superior in low anterior resections but equal in high anastomoses. Irvin, Goligher, and
or sigmoidoscopes were not made postoperatively. Results
The conditions requiring operation in the 165 patients (76 male, 89 female; age range, 19 to 85 years) were carcinoma in 110, diverticular disease in 27, polyps in 16, Crohn’s disease in 6, and miscellanous conditions in 6. The latter group includes 2 patients with degenerated villous adenoma, 1 with tuberculosis of the right colon, 1 with chronic ischemic colitis, 1 with fistulization after appendectomy (but with no signs of Crohn’s disease), and 1 operated on for a cyst of the pancreas and who accidentally developed a lesion of the middle colic artery and required transverse colectomy. The overall mortality was 2.4 per cent, and 25 per cent of the deaths were due to anastomotic leakage. The mortality in patients with anastomotic dehiscence was 7.1 per cent compared with 1.9 per cent in patients with no clinically manifest leakage. Table I shows the proportions of different types of opera-
TABLE II
lncldence of Complicating Dlsorders in 14 Patients with Anastomotic Dehlscence
Type of Operation RH TC LH, CD HAR HAR HAR HAR HAR HAR HAR HAR LAR LAR LAR
Cardiopulmonary
Metabolic
Overweight
.
. . .
Hypoproteinemia . .
Anemia Electra . .
. . . . .
.
.
Note: RH = right hemicolectomy; TC = transverse colectomy; resection: LAR = low anterior resection.
Vofumo 135, May 1978
Underweight
.
.
LH = left hemicolectomy;
. .
CD = Crohn’s disease;
HAR = high anterior
631
Jonsell and Edelmann
Johnston [5] in 1973 in a randomized trial of the two technics found no significant difference. The incidence of anastomotic leakage varies considerably from series to series, and as shown by Goligher et al [1] in 1970, this is very much a question of which diagnostic methods are applied to find the dehiscence. The total mortality and overall frequency of complications in these series are comparable to other studies presenting one-layer colonic anastomosis [15,16]. The number of patients with dehiscences in the small group of low anterior resections is important (3 of 7), but of these three, one was considerably underweight and had hypoproteinemia, and another had a long operation with important blood loss (left hepatectomy in a 31 year old male with solitary liver metastasis). In all these cases the fistula healed spontaneously. The influence of complicating disorders on the frequency of anastomotic dehiscence is in accordance with earlier reports [17-201. The one-layer technic is made with less tissue trauma and less disturbance of circulation than the two-layer technic [12,21]. It can be performed in an anatomically more precise manner and in less time. It is easier to make than the two-layer technic, especially in low anastomoses. Considering that there was only one death after anastomotic leakage in the whole series, we find it justifiable to conclude that this one-layer anastomotic technic is a safe method, avoiding as much as possible the incidence of severe life-threatening dehiscences.
References 1. Goligher JC, Morris C, McAdam WAF, De Dombal FT, Johnston
2. 3. 4.
5.
6. 7. 8. 9. 10.
11. 12. 13.
14.
15. 16.
17.
Summary
One hundred sixty-five patients undergoing elective colorectal or colonic anastomoses with a onelayer technic are presented. One death from suture line dehiscence was noted, and the overall mortality was 2.4 per cent. The usual technic for esophagogastrointestinal suturing in French surgical centers is described and the importance of suture technic in the etiology of anastomotic leaks is discussed,
632
18.
19.
20.
21.
D: A controlled trial of inverting versus everting intestinal suture in clinical large bowel surgery. Br J Sufg 57: 817, 1970. I&Adam AJ, Meikle AG, Taylor JO: One layer or two layer colonic anastomoses? Am J Surg 120: 546, 1970. Zollinger RM, Sheppard Ml-i: Carcinoma of the rectum and the rectosigmoid. 729 cases. Arch Surg 102: 335, 197 1. Irvin TT, Edwards JP: Comparison of single layer everting, two layer inverting and everting anastomoses in the rabbit colon. Br J Surg 60: 453, 1973. Irvin IT, Goligher JC, Johnston D: A randomized prospective clinical trial of single layer and two layer inverting intestinal anastomoses. Br J Surg 60: 457, 1973. Barnes JP: The techniques for end-to-end intestinal anastomoses. Surg Gynecof Obstet 138: 433, 1974. Goligher JC: Visceral and parietal suture in abdominal surgery. Am JSurg 131: 130, 1976. Halsted WS: Circular suture of the intestine-an experimental study. Am J Med Sci 94: 436, 1887. Jourdan P: Sutures en un plan des tuniques digestives. Paris, VignB, 1953. Buchin R, Van Geertruyden J: Valeur comparBe des sutures intestinales en un plan et en deux plans. Etude exp&imentale et clinique. Acta Chir Be/g 59: 461, 1960. Hamilton JE: Reappraisal of open intestinal anastomoses. Ann Surg 165: 917, 1967. Orr NWM: A single layer of intestinal anastomosis. Br J Surg 56: 771, 1969. Everett WG: A comparison of one layer and two layer techniques for colorectal anastomoses. Br J Surg 62: 135, 1975. Peters HE, Stanten A: Aseptic single layer anastomosis of the bowel. A review of 175 cases. Am J Surg 122: 159, 1971. Matheson NA, Irving AD: Single layer anastomosis after rectosiamoid resection. Br J Sure 62: 239, 1975. Hell KYRossetti M. Allgiiwer M: 700 konsekutive Kolonresektionen mit einreihiger Allschichtnaht und radiologischer FrDhkontrolle. He/v Chir Acta 43: 225, 1976. Morgenstern L, Yamakawa T. Ben-Shoshan M, Lippman H: Anastomotic leakage after low colonic anastomosis. Am J Surg 123: 104. 19j2. Schrock TR. Devenev CW. Dunohv JE: Factors contributino to leakage of color& aiasto&ses. Ann Surg 177: 5-13, 1973. Hgijer-Madsen K, Beth Hansen J, Lindenberg J: Anastomotic leakage following resection for cancer of the colon and rectum. Acta Chir Stand 141: 304, 1975. Manson PN, Corman ML, Caller JA, Veidenheimer MC: Anterior resection for adanocarcinoma. Lahey Clinic experience from 1963 to 1969. Am JSurg 131: 434. 1976. Langer St: Klinische und tierexperimentelle Studien zur Anastomosentechnik in der Darmchirurgie. Langenbecks Arch Chir 335: 309, 1974.
The American Journal of Surgery