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Intestinal anastomoses
ABDOMINAL SURGERY
Intestinal anastomoses
Factors in intestinal anastomotic healing
Aileen J McKinley
Positive • Healthy supply of blood • Maintenance of apposition • Appropriate alignment • Lack of tension
Z H Krukowski
Negative • Distal obstruction • Peri-anastomotic sepsis • Peri-anastomotic haematoma • Hypotension • Hypoxia • Malnutrition • Jaundice • Corticosteroids • Uraemia
Healing Primary healing by accurate apposition is considered the ‘ideal’ for epithelial wounds (see Enoch, CROSS REFERENCES) and the same applies to intestinal anastomoses. Most anastomotic techniques do not aspire to accurate realignment and consequently depend on secondary healing. Most intestinal anastomoses heal uneventfully because: • of the relatively profuse supply of blood to the bowel • healing is hidden within the abdomen.
Table 1
Healing phases: intestinal anastomoses heal in a series of overlapping phases: • lag phase (days 0–4), in which the acute inflammatory response clears the wound of debris • fibroplasia phase (days 3–14), in which fibroblasts proliferate and immature collagen is laid down • maturation phase (day 10 onwards), in which remodeling of collagen occurs. Intestinal anastomoses have little intrinsic resistance to distension, and longitudinal distraction is weak until collagen deposition is established. Extrinsic support is required during the lag phase to maintain tissue continuity.
Techniques for intestinal anastomosis Conventional methods • Sutured single layer (interrupted or continuous) two layer • Stapled Unconventional methods • Compression rings biodegradable anastomosis ring—BAR (‘Valtrac’) non-degradable (AKA2) • Tissue glue • Laser welding
The surgeon’s role is to provide support (usually by inserting sutures or staples) and to ensure optimal conditions for subsequent healing. Anastomotic technique is the most important determinant of outcome, but a number of other factors affect healing (Table 1); the wisdom of carrying out an anastomosis should be questioned if these combine to make the risk of anastomotic failure high.
Table 2
• incorporate the minimum amount of foreign material • not implant malignant cells at the anastomosis.
Anastomotic technique A number of anastomotic techniques are available (Table 2) but none are perfect because all compromise healing. The optimal method of intestinal anastomoses would: • promote primary healing by achieving accurate alignment of the divided bowel • cause minimal disruption of local vasculature
Hand-sewn anastomoses Traditionally, anastomoses were hand-sewn, with two layers of sutures to achieve mucosal inversion and serosal apposition —a continuous absorbable suture incorporated all layers of the bowel, and serosal apposition was achieved by an outer layer of interrupted seromuscular sutures which inverted the inner layer. The sense of security generated by the two-layer technique does not withstand critical scrutiny and single-layer anastomoses are now preferred. Single-layer anastomoses heal faster because they achieve more accurate realignment of muscle and mucosa, and cause less reduction in lumen size and less tissue strangulation than two-layer methods. Interrupted single-layer serosubmucosal suture is the ‘gold
Aileen J McKinley FRCS(Ed) is a Consultant General and Colorectal Surgeon at Aberdeen Royal Infirmary, Aberdeen, UK. Z H Krukowski FRCS(Ed) FRCS(Glas) FRCP(Ed) is a Consultant Surgeon and Professor of Clinical Surgery at Aberdeen Royal Infirmary, Aberdeen, UK. He is also Surgeon to the Queen in Scotland.
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ABDOMINAL SURGERY
standard’ for intestinal anastomoses and is the preferred handsewn technique. Interrupted serosubmucosal sutures: • allow accurate tissue apposition, using the strongest layer of the gut (submucosa; Figure 1) • cause minimal damage to the submucosal vascular plexus • minimize the risk of implantation of malignant cells. Continuous single-layer serosubmucosal suture – a continuous serosubmucosal suture method is equally effective if access is good and the anastomosis technically straightforward. This is particularly useful in the upper gastrointestinal tract (e.g. gastrojejunostomy and bilioenteric anastomoses) and can be quicker than the interrupted single-layer technique.
Idealized end-to-end anastomosis using a single-layer interrupted serosubmucosal (extramucosal) technique Serosa
Muscle layers Mucosa
Submucosa
Open end-to-end single-layer anastomosis is a universally applicable technique for open end-to-end anastomoses in accessible sites in the gastrointestinal tract (Figure 2). A modified technique (Figure 3) is required if access is limited (e.g. in oesophago-jejunal or colorectal anastomoses). Minimal cleaning of bowel is required for appositional anastomoses, and proportionately placed interrupted sutures can accommodate luminal disparities of up to 50% without recourse to an anti-mesenteric slit. • In the authors’ view, individual braided nylon sutures (3/0) supplied on controlled-release needles are preferable because of the combination of knotting and good handling with low reactivity of tissue. • Other synthetic suture material (e.g. polypropylene, polydioxanone sulphate, polyglycolic acid) can be used satisfactorily. • Silk and linen produce too brisk a tissue reaction. Inserting an excessive number of sutures must be avoided because this compromises the blood supply at the anastomoses. Individual sutures should be inserted at least 5 mm apart and 5–6 mm from the cut edge.
Figure 1
Side-to-side anastomoses are used for gastro-jejunostomy and occasionally to bypass obstruction. A continuous suture technique is satisfactory in this situation. End-to-side anastomoses are most commonly used in fashioning Roux loops and if there is significant disparity between the two ends. Colorectal anastomoses are facilitated if the posterior row of sutures is inserted with the proximal colon and rectal stump held some distance apart. Individual sutures are held in a series of artery forceps or, more conveniently, are placed in a disposable proprietary suture holder.
End-to-end anastomosis in accessible sites
a
c
e
b
d
f
a The first sutures are inserted at the mesenteric and anti-mesenteric borders, entering about 5–6 mm from the cut edge of the bowel and exiting in the submucosal plane. The suture then enters the opposing bowel en face in the same plane. The second suture is placed in similar fashion diagonally opposite the first. These sutures are knotted and held while the anterior sutures are inserted sequentially b. A mid-point marking suture aids accurate tissue apposition. Once the anterior sutures are tied and cut c, the anastomosis is turned through 180˚ d and the mesentery rotated to achieve a satisfactory lie. The posterior sutures are inserted e, working away from the mesenteric edge, thus ending on the anti-mesenteric border. All remaining sutures are tied and cut, and the mesenteric defect is closed f. Figure 2
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Modified end-to-end anastomosis for sites with limited access
Sutured colorectal anastomosis using a disposable sutureholding device B
A
b
a
c
a The posterior row of sutures is inserted with the bowel ends held apart. The individual sutures are knotted on the mucosal aspect of the apposed bowel. The anterior row of sutures is inserted b and the anastomosis is completed c. Figure 3
Intraperitoneal anastomoses do not have to be drained; experimental evidence (though weak) suggests that anastomoses with drains placed next to them are more likely to leak. A drain may prevent haematoma formation after low pelvic surgery.
• Linear stapling devices are used for side-to-side (Figure 4) and functional and triangulated end-to-end anastomoses. • Circular stapling devices (Figure 5) are required for end-to-end anastomoses. Neither the device nor the staples should crush the tissue. The bowel must be cleaned of mesentery and fat to reduce bulk before stapling. Extra care is required if the bowel wall is thickened; it may be safer to suture the anastomosis than to risk tissue necrosis or bleeding at a staple line. Intestinal staplers are not haemostatic and haemostasis may require a suture after stapling. Diathermy (see Hay, CROSS REFERENCES) should not be applied directly to staple lines because this is likely to result in tissue necrosis because of the electroconductivity of metal staples.
Stapled anastomoses Staplers have a certain appeal because they: • are easy to use • may be quicker than some sutured anastomoses • are helpful in situations where suture placement is difficult (e.g. low colorectal anastomoses). Indications for use are relative and may be considered optimal if: • multiple anastomoses are required at the end of a lengthy procedure • there is a marked discrepancy in the diameter of the two ends of bowel when the functional end-to-end anastomoses can be used. The anatomy of the stapled intestinal anastomosis resembles that of the traditional two-layer hand-sewn anastomosis. The bowel ends are inverted and the serosal surfaces are held in apposition by staples while healing occurs. Some stapled anastomoses (e.g. triangulated end-to-end anastomoses) produce an everted anastomosis over two-thirds of the circumference. Stapled anastomoses require the same attention to detail as sutured anastomoses, and reliance on stapling devices to overcome technical inadequacy is unlikely to prevent failure. Anastomoses can be made with linear or circular stapling devices, used alone or in combination.
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Sutureless anastomoses Sutureless anastomoses have been in use since Murphy’s button in 1892. Modern equivalents include: • compression rings (the two components of a hollow circular device are clipped together, compressing the two adjacent ends or sides of bowel) • tissue glue • laser anastomoses using neodymium–yttrium-aluminium-garnet to weld tissue.
Choice of technique Sutureless anastomoses remain, for practical purposes, experimental; the choice of anastomotic technique is between 226
© 2006 Elsevier Ltd
ABDOMINAL SURGERY
Stapled side-to-side anastomosis
a
b
c e
d
a The anti-mesenteric borders of the bowel to be anastomosed are approximated with traction sutures. Small (1 cm) enterotomies are made with a blade or cutting diathermy. b One limb of the linear stapler is inserted into each lumen and tissue is aligned evenly on each side so that the full length of the stapler is used. The instrument is closed, ensuring that the mesentery is excluded from the staple line. The gun is ‘fired’ (c, d and e). The residual enterotomy is closed using staples or sutures.
Figure 4
High stapled colorectal anastomosis
b d
a
c
e
a After mobilization to the desired level, the rectum is cross-clamped and the distal segment is lavaged per anum. A linear stapler is applied at the level of transection. The rectum is stapled and divided, and the surgical specimen is excised. b A pursestring is inserted around the end of the proximal colon, taking 3 mm full-thickness bites spaced 7 mm apart. The anvil of the circular stapler is inserted into the proximal colon and the pursestring is drawn and secured. The circular stapling cartridge is placed per anum and the trocar is advanced through the middle of the existing staple line. c The anvil shaft and the instrument shaft are engaged. The gap between them is then closed, thereby apposing the colon and rectum. Care is taken to exclude extraneous tissue. d The staples are fired, the anvil is disengaged and the instrument is withdrawn. e The anastomosis is air-tested and the ‘doughnuts’ of tissue excised by the stapler are inspected to ensure that they are complete. Figure 5A
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Low stapled colorectal anastomosis with colonic J-pouch a
b
c
Stay suture
‘Gusset stitch’
Pursestring-inserted suture 4 cm
Ensure mesentery is excluded from the stapler on closing
d
a A short colonic J-pouch may be fashioned to improve initial function for low rectal anastomoses. The distal colon is folded to create a J-shape and stay sutures placed. b The apex of the J is opened and the pouch created using a liner cutting stapler. c The anvil of a circular stapling gun is secured with a pursestring suture and the anastomosis fashioned and tested as in c–e above. Low rectal anastomoses are often covered by a defunctioning loop ileostomy. Figure 5B
sutures and staples. The selection of technique remains contentious and is often made on the grounds of convenience, cost and personal experience. Objective evidence has failed to show an outstanding benefit that would favour the universal use of staples over sutures. A recent meta-analysis of prospective randomized trials comparing a variety of suture techniques with staples did not confirm advantage of stapled anastomoses in terms of leaks, mortality or cancer recurrence. Optimal (i.e. single-layer) sutured techniques were not always the comparator in randomized trials and the issue may be further clouded by the variability of outcome between suture techniques. The potential saving in operating time when staples are used is small and may not offset the substantial cost of stapling instruments. Technical problems are much more likely to be encountered with stapling. Difficult anastomoses in less accessible sites (e.g. very low colorectal, coloanal or oesophagojejunal anastomoses) can be achieved by hand suturing, but most surgeons find stapling safer and easier in such situations. The increased propensity of stapled anastomoses to stenose is well documented, but only a few strictures require treatment, usually by dilation or endoluminal incision/resection. Trainee surgeons should adopt an anastomotic method that is
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suitable (with minor modifications) for all situations in the gut; this allows them to develop familiarity, sensitivity and selectivity in fashioning anastomoses. A single-layer technique (continuous or interrupted) should be mastered before relying on stapling devices, allowing the surgeon to take remedial action if technical problems occur with stapling.
CROSS REFERENCES Enoch S, Leaper D J. Basic science of wound healing. Surgery 2005; 23(2): 37–42. Hay D J. Electrosurgery. Surgery 2005; 23(2): 73–5. FURTHER READING Brundage S I, Jurkovich G J, Hayt D B et al. Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial. J Trauma 2001; 51: 1054–61. Burch J M, Franciose R J, Moore E et al. Single layer continuous versus two layer interrupted intestinal anastomosis: a prospective randomized trial. Ann Surg 2000; 231: 832–7. Feil W, Lippert P, Lozac’H P, Palazzini G (Editors). Atlas of surgical stapling. Heidelberg: Barth, 2000.
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© 2006 Elsevier Ltd
Intestinal anastomoses
Factors in intestinal anastomotic healing
Aileen J McKinley
Positive • Healthy supply of blood • Maintenance of apposition • Appropriate alignment • Lack of tension
Z H Krukowski
Negative • Distal obstruction • Peri-anastomotic sepsis • Peri-anastomotic haematoma • Hypotension • Hypoxia • Malnutrition • Jaundice • Corticosteroids • Uraemia
Healing Primary healing by accurate apposition is considered the ‘ideal’ for epithelial wounds (see Enoch, CROSS REFERENCES) and the same applies to intestinal anastomoses. Most anastomotic techniques do not aspire to accurate realignment and consequently depend on secondary healing. Most intestinal anastomoses heal uneventfully because: • of the relatively profuse supply of blood to the bowel • healing is hidden within the abdomen.
Table 1
Healing phases: intestinal anastomoses heal in a series of overlapping phases: • lag phase (days 0–4), in which the acute inflammatory response clears the wound of debris • fibroplasia phase (days 3–14), in which fibroblasts proliferate and immature collagen is laid down • maturation phase (day 10 onwards), in which remodeling of collagen occurs. Intestinal anastomoses have little intrinsic resistance to distension, and longitudinal distraction is weak until collagen deposition is established. Extrinsic support is required during the lag phase to maintain tissue continuity.
Techniques for intestinal anastomosis Conventional methods • Sutured single layer (interrupted or continuous) two layer • Stapled Unconventional methods • Compression rings biodegradable anastomosis ring—BAR (‘Valtrac’) non-degradable (AKA2) • Tissue glue • Laser welding
The surgeon’s role is to provide support (usually by inserting sutures or staples) and to ensure optimal conditions for subsequent healing. Anastomotic technique is the most important determinant of outcome, but a number of other factors affect healing (Table 1); the wisdom of carrying out an anastomosis should be questioned if these combine to make the risk of anastomotic failure high.
Table 2
• incorporate the minimum amount of foreign material • not implant malignant cells at the anastomosis.
Anastomotic technique A number of anastomotic techniques are available (Table 2) but none are perfect because all compromise healing. The optimal method of intestinal anastomoses would: • promote primary healing by achieving accurate alignment of the divided bowel • cause minimal disruption of local vasculature
Hand-sewn anastomoses Traditionally, anastomoses were hand-sewn, with two layers of sutures to achieve mucosal inversion and serosal apposition —a continuous absorbable suture incorporated all layers of the bowel, and serosal apposition was achieved by an outer layer of interrupted seromuscular sutures which inverted the inner layer. The sense of security generated by the two-layer technique does not withstand critical scrutiny and single-layer anastomoses are now preferred. Single-layer anastomoses heal faster because they achieve more accurate realignment of muscle and mucosa, and cause less reduction in lumen size and less tissue strangulation than two-layer methods. Interrupted single-layer serosubmucosal suture is the ‘gold
Aileen J McKinley FRCS(Ed) is a Consultant General and Colorectal Surgeon at Aberdeen Royal Infirmary, Aberdeen, UK. Z H Krukowski FRCS(Ed) FRCS(Glas) FRCP(Ed) is a Consultant Surgeon and Professor of Clinical Surgery at Aberdeen Royal Infirmary, Aberdeen, UK. He is also Surgeon to the Queen in Scotland.
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standard’ for intestinal anastomoses and is the preferred handsewn technique. Interrupted serosubmucosal sutures: • allow accurate tissue apposition, using the strongest layer of the gut (submucosa; Figure 1) • cause minimal damage to the submucosal vascular plexus • minimize the risk of implantation of malignant cells. Continuous single-layer serosubmucosal suture – a continuous serosubmucosal suture method is equally effective if access is good and the anastomosis technically straightforward. This is particularly useful in the upper gastrointestinal tract (e.g. gastrojejunostomy and bilioenteric anastomoses) and can be quicker than the interrupted single-layer technique.
Idealized end-to-end anastomosis using a single-layer interrupted serosubmucosal (extramucosal) technique Serosa
Muscle layers Mucosa
Submucosa
Open end-to-end single-layer anastomosis is a universally applicable technique for open end-to-end anastomoses in accessible sites in the gastrointestinal tract (Figure 2). A modified technique (Figure 3) is required if access is limited (e.g. in oesophago-jejunal or colorectal anastomoses). Minimal cleaning of bowel is required for appositional anastomoses, and proportionately placed interrupted sutures can accommodate luminal disparities of up to 50% without recourse to an anti-mesenteric slit. • In the authors’ view, individual braided nylon sutures (3/0) supplied on controlled-release needles are preferable because of the combination of knotting and good handling with low reactivity of tissue. • Other synthetic suture material (e.g. polypropylene, polydioxanone sulphate, polyglycolic acid) can be used satisfactorily. • Silk and linen produce too brisk a tissue reaction. Inserting an excessive number of sutures must be avoided because this compromises the blood supply at the anastomoses. Individual sutures should be inserted at least 5 mm apart and 5–6 mm from the cut edge.
Figure 1
Side-to-side anastomoses are used for gastro-jejunostomy and occasionally to bypass obstruction. A continuous suture technique is satisfactory in this situation. End-to-side anastomoses are most commonly used in fashioning Roux loops and if there is significant disparity between the two ends. Colorectal anastomoses are facilitated if the posterior row of sutures is inserted with the proximal colon and rectal stump held some distance apart. Individual sutures are held in a series of artery forceps or, more conveniently, are placed in a disposable proprietary suture holder.
End-to-end anastomosis in accessible sites
a
c
e
b
d
f
a The first sutures are inserted at the mesenteric and anti-mesenteric borders, entering about 5–6 mm from the cut edge of the bowel and exiting in the submucosal plane. The suture then enters the opposing bowel en face in the same plane. The second suture is placed in similar fashion diagonally opposite the first. These sutures are knotted and held while the anterior sutures are inserted sequentially b. A mid-point marking suture aids accurate tissue apposition. Once the anterior sutures are tied and cut c, the anastomosis is turned through 180˚ d and the mesentery rotated to achieve a satisfactory lie. The posterior sutures are inserted e, working away from the mesenteric edge, thus ending on the anti-mesenteric border. All remaining sutures are tied and cut, and the mesenteric defect is closed f. Figure 2
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Modified end-to-end anastomosis for sites with limited access
Sutured colorectal anastomosis using a disposable sutureholding device B
A
b
a
c
a The posterior row of sutures is inserted with the bowel ends held apart. The individual sutures are knotted on the mucosal aspect of the apposed bowel. The anterior row of sutures is inserted b and the anastomosis is completed c. Figure 3
Intraperitoneal anastomoses do not have to be drained; experimental evidence (though weak) suggests that anastomoses with drains placed next to them are more likely to leak. A drain may prevent haematoma formation after low pelvic surgery.
• Linear stapling devices are used for side-to-side (Figure 4) and functional and triangulated end-to-end anastomoses. • Circular stapling devices (Figure 5) are required for end-to-end anastomoses. Neither the device nor the staples should crush the tissue. The bowel must be cleaned of mesentery and fat to reduce bulk before stapling. Extra care is required if the bowel wall is thickened; it may be safer to suture the anastomosis than to risk tissue necrosis or bleeding at a staple line. Intestinal staplers are not haemostatic and haemostasis may require a suture after stapling. Diathermy (see Hay, CROSS REFERENCES) should not be applied directly to staple lines because this is likely to result in tissue necrosis because of the electroconductivity of metal staples.
Stapled anastomoses Staplers have a certain appeal because they: • are easy to use • may be quicker than some sutured anastomoses • are helpful in situations where suture placement is difficult (e.g. low colorectal anastomoses). Indications for use are relative and may be considered optimal if: • multiple anastomoses are required at the end of a lengthy procedure • there is a marked discrepancy in the diameter of the two ends of bowel when the functional end-to-end anastomoses can be used. The anatomy of the stapled intestinal anastomosis resembles that of the traditional two-layer hand-sewn anastomosis. The bowel ends are inverted and the serosal surfaces are held in apposition by staples while healing occurs. Some stapled anastomoses (e.g. triangulated end-to-end anastomoses) produce an everted anastomosis over two-thirds of the circumference. Stapled anastomoses require the same attention to detail as sutured anastomoses, and reliance on stapling devices to overcome technical inadequacy is unlikely to prevent failure. Anastomoses can be made with linear or circular stapling devices, used alone or in combination.
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Sutureless anastomoses Sutureless anastomoses have been in use since Murphy’s button in 1892. Modern equivalents include: • compression rings (the two components of a hollow circular device are clipped together, compressing the two adjacent ends or sides of bowel) • tissue glue • laser anastomoses using neodymium–yttrium-aluminium-garnet to weld tissue.
Choice of technique Sutureless anastomoses remain, for practical purposes, experimental; the choice of anastomotic technique is between 226
© 2006 Elsevier Ltd
ABDOMINAL SURGERY
Stapled side-to-side anastomosis
a
b
c e
d
a The anti-mesenteric borders of the bowel to be anastomosed are approximated with traction sutures. Small (1 cm) enterotomies are made with a blade or cutting diathermy. b One limb of the linear stapler is inserted into each lumen and tissue is aligned evenly on each side so that the full length of the stapler is used. The instrument is closed, ensuring that the mesentery is excluded from the staple line. The gun is ‘fired’ (c, d and e). The residual enterotomy is closed using staples or sutures.
Figure 4
High stapled colorectal anastomosis
b d
a
c
e
a After mobilization to the desired level, the rectum is cross-clamped and the distal segment is lavaged per anum. A linear stapler is applied at the level of transection. The rectum is stapled and divided, and the surgical specimen is excised. b A pursestring is inserted around the end of the proximal colon, taking 3 mm full-thickness bites spaced 7 mm apart. The anvil of the circular stapler is inserted into the proximal colon and the pursestring is drawn and secured. The circular stapling cartridge is placed per anum and the trocar is advanced through the middle of the existing staple line. c The anvil shaft and the instrument shaft are engaged. The gap between them is then closed, thereby apposing the colon and rectum. Care is taken to exclude extraneous tissue. d The staples are fired, the anvil is disengaged and the instrument is withdrawn. e The anastomosis is air-tested and the ‘doughnuts’ of tissue excised by the stapler are inspected to ensure that they are complete. Figure 5A
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ABDOMINAL SURGERY
Low stapled colorectal anastomosis with colonic J-pouch a
b
c
Stay suture
‘Gusset stitch’
Pursestring-inserted suture 4 cm
Ensure mesentery is excluded from the stapler on closing
d
a A short colonic J-pouch may be fashioned to improve initial function for low rectal anastomoses. The distal colon is folded to create a J-shape and stay sutures placed. b The apex of the J is opened and the pouch created using a liner cutting stapler. c The anvil of a circular stapling gun is secured with a pursestring suture and the anastomosis fashioned and tested as in c–e above. Low rectal anastomoses are often covered by a defunctioning loop ileostomy. Figure 5B
sutures and staples. The selection of technique remains contentious and is often made on the grounds of convenience, cost and personal experience. Objective evidence has failed to show an outstanding benefit that would favour the universal use of staples over sutures. A recent meta-analysis of prospective randomized trials comparing a variety of suture techniques with staples did not confirm advantage of stapled anastomoses in terms of leaks, mortality or cancer recurrence. Optimal (i.e. single-layer) sutured techniques were not always the comparator in randomized trials and the issue may be further clouded by the variability of outcome between suture techniques. The potential saving in operating time when staples are used is small and may not offset the substantial cost of stapling instruments. Technical problems are much more likely to be encountered with stapling. Difficult anastomoses in less accessible sites (e.g. very low colorectal, coloanal or oesophagojejunal anastomoses) can be achieved by hand suturing, but most surgeons find stapling safer and easier in such situations. The increased propensity of stapled anastomoses to stenose is well documented, but only a few strictures require treatment, usually by dilation or endoluminal incision/resection. Trainee surgeons should adopt an anastomotic method that is
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suitable (with minor modifications) for all situations in the gut; this allows them to develop familiarity, sensitivity and selectivity in fashioning anastomoses. A single-layer technique (continuous or interrupted) should be mastered before relying on stapling devices, allowing the surgeon to take remedial action if technical problems occur with stapling.
CROSS REFERENCES Enoch S, Leaper D J. Basic science of wound healing. Surgery 2005; 23(2): 37–42. Hay D J. Electrosurgery. Surgery 2005; 23(2): 73–5. FURTHER READING Brundage S I, Jurkovich G J, Hayt D B et al. Stapled versus sutured gastrointestinal anastomoses in the trauma patient: a multicenter trial. J Trauma 2001; 51: 1054–61. Burch J M, Franciose R J, Moore E et al. Single layer continuous versus two layer interrupted intestinal anastomosis: a prospective randomized trial. Ann Surg 2000; 231: 832–7. Feil W, Lippert P, Lozac’H P, Palazzini G (Editors). Atlas of surgical stapling. Heidelberg: Barth, 2000.
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© 2006 Elsevier Ltd