Randomized prospective evaluation of the EEA stapler for colorectal anastomoses. Staples or sutures for low colorectal anastomoses: a prospective randomized trial. [Technic of rectum anastomoses in rectum resection. A controlled study: instrumental suture versus hand suture]. [The best anastomoses after colonic resection].
A randomized, prospective study should be done to evaluate any new procedure or instrument. Our experience with the end-to-end anastomosis (EEA) stapler suggests that an anastomosis can be created in a shorter time than is required for the traditional hand-sewn technique. This difference is even greater when the anastomosis is technically difficult and located deep within the pelvis. There appears to be little difference in the security of a hand-sewn anastomosis compared with that of stapled anastomosis. Postoperative complications appear similar. With the stapler, however, there is an increased risk of intraoperative complications that are not apparent with the traditional hand-sewn technique. These include rectal tears and anastomotic defects. It appears that the EEA stapler can save as many as 12 percent of rectums that otherwise might have to be removed because of technical inability to perform an anastomosis. One hundred and eighteen patients undergoing low colorectal anastomoses were randomly allocated to reconstitution by either single layer interrupted extramucosal sutures or circular staple gun. In the 60 patients undergoing sutured anastomosis there were 2 (3 per cent) clinical leaks and 4 (7 per cent) radiological leaks, and no failures. Of the 58 patients who underwent stapled anastomosis there were 4 failures, 7 (12 per cent) clinical leaks, 14 (24 per cent) radiological leaks and 1 death. Stapled anastomoses were more than ten times as expensive as sutured anastomoses and there were no savings in time or numbers of associated colostomies. An interrupted extramucosal suture technique remains the ultimate standard for low colorectal anastomosis. Stapler and manual sutures in rectal end-to-end anastomoses were compared in a controlled trial. The following results were obtained: For the analysis the cases naturally separated into three groups, A (manual suture), B (planned stapler suture) and WD ("withdrawn" cases, from both groups, in which continence could be maintained only with a stapler suture). The distribution of the WD cases in dependence on localization and sex varied significantly from groups A and B, while A and B remained comparable, in spite of the WD cases. The analysis of the date showed no, or only slight, clinical differences. In a comparison of the two stapler groups B and WD, significantly more suture dehiscences, colocutaneous fistulae and post-operative disturbances in bladder function were found in group WD. As a general conclusion we can state that: In comparable anastomosis localizations it is possible to achieve almost the same clinical results with both suture techniques. With a circular stapler it is, however, technically possible to perform rectum resections in cases in which this was not previously possible, particularly in men with a narrow pelvis and a stale pelvic floor. To what extent this still is an advantage after the local recurrences are taken into consideration remains to be seen. Among the numerous anastomotic techniques after colonic resection, the mechanical sutures using staplers have been credited with a lower incidence of anastomotic leakage than hand-sewn anastomoses. This hypothesis has been tested in two multicentre, prospective, randomized trials after right hemicolectomy for carcinoma and after left colectomy with colorectal anastomosis. After right hemicolectomy, the stapled anastomosis using the GIA and TA staplers appeared to be superior to all hand-sewn anastomoses. This superiority was not apparent after left colectomy followed by colorectal anastomosis. Although the leakage rate of stapled anastomoses was similar to hand-sewn anastomoses, they carry a high rate of intra-operative mishaps. Furthermore, the stapler does not permit a lower anastomosis in this study. Finally, the overall cost of a stapled anastomosis is superior to the cost of an hand-sewn anastomosis.
The evidence found was insufficient to demonstrate any superiority of stapled over handsewn techniques in colorectal anastomosis surgery, regardless of the level of anastomosis. There were no randomised clinical trials comparing these two types of anastomosis in elective conditions in the last decade. The relevance of this research question has possibly lost its strength where elective surgery is concerned. However, in risk situations, such as emergency surgery, trauma and inflammatory bowel disease, new clinical trials are needed.