Stapled versus handsewn methods for ileocolic anastomoses

 

Abstract

Background

Ileocolic anastomoses are commonly performed for right-sided colon cancer and Crohn's disease. The anastomosis may be constructed using a linear cutter stapler or by suturing. Individual trials comparing stapled versus handsewn ileocolic anastomoses have found little difference in the complication rate but they have lacked adequate power to detect potential small difference. This is an update of a Cochrane review first published in 2007.

Objectives

To compare outcomes of ileocolic anastomoses performed using stapling and handsewn techniques. The hypothesis tested was that the stapling technique is associated with fewer complications.

Search methods

MEDLINE, EMBASE, Cochrane Colorectal Cancer Group specialised register SR-COLOCA, Cochrane Library were searched for randomised controlled trials comparing use of a linear cuter stapler with any type of suturing technique for ileocolic anastomoses in adults from 1970 to 2005 and were updated in December 2010. Abstracts presented to the following society meetings between 1970 and 2010 were handsearched: American Society of Colon and Rectal Surgeons, the Association of Coloproctology of Great Britain and Ireland, European Association of Coloproctology.

Selection criteria

Randomised controlled trials comparing use of linear cutter stapler (isoperistaltic side to side or functional end to end) with any type of suturing technique in adults.

Data collection and analysis

Eligible studies were selected and their methodological quality assessed. Relevant results were extracted and missing data sought from the authors. RevMan 5 was used to perform meta-analysis when there were sufficient data. Sub-group analyses for cancer inflammatory bowel disease as indication for ileocolic anastomoses were performed.

Main results

After obtaining individual data from authors for studies that include other anastomoses, seven trials (including one unpublished) with 1125 ileocolic participants (441 stapled, 684 handsewn) were included. The five largest trials had adequate allocation concealment.

Stapled anastomosis was associated with significantly fewer anastomotic leaks compared with handsewn (S=11/441, HS=42/684, OR 0.48 [0.24, 0.95] p=0.03). One study performed routine radiology to detect asymptomatic leaks. For the sub-group of 825 cancer patients in four studies, stapled anastomosis led to significantly fewer anastomotic leaks (S=4/300, HS=35/525, OR 0.28 [0.10, 0.75] p=0.01). In subgroup analysis of non-cancer patients (3 studies, 264 patients) there were no differences for any reported outcomes. All other outcomes: stricture, anastomotic haemorrhage, anastomotic time, re-operation, mortality, intra-abdominal abscess, wound infection, length of stay, showed no significant difference.

Authors' conclusions

Stapled functional end to end ileocolic anastomosis is associated with fewer leaks than handsewn anastomosis.

 

Plain language summary

A comparison of two methods to join small and large bowel together in surgery

Surgery for right-sided bowel cancer or Crohn's disease commonly involve removing a segment of bowel and re-joining the small and large bowel together. The join, or anastomosis, can be made by stapling or sewing.

This systematic review found seven randomised controlled trials with a total of 1125 participants (441 stapled, 684 handsewn) comparing these two methods. The leak rate from the bowel join for stapled anastomosis was 2.5%, significantly lower than handsewn (6%). For the sub-group of 825 cancer patients in four studies, stapled join again has fewer leaks compared with handsewn, being 1.3% and 6.7% respectively. For the sub-group of 264 non-cancer patients in three studies, there were no differences for the reported outcomes. This sub-group included patients with Crohn's disease. Overall, there was no significant difference in the other outcomes of stricture, bleeding from the join, time to perform the join, re-operation, mortality, intra-abdominal abscess, wound infection and length of stay, although these were not consistently reported.

The reason why a handsewn bowel join is more likely to leak is unclear. Possible explanations include less handling of the bowel, decreased spillage of bowel content during surgery, and uniform closure of all the staples using a stapler. This review did not compare different sewing materials or methods. The trials included in this review were performed from the early 1980's to 2009 involving six countries. The studies in Crohn's disease were more recent but the combined number of patients was too small to summarise outcomes. More randomised controlled trials comparing the two surgical techniques in Crohn's disease are needed.

 

摘要

背景

使用吻合器和手縫合手術對於迴腸結腸接合(Ileocolic anastomoses)治療的影響

迴腸結腸接合治療是一種普遍使用於右側大腸癌和克隆氏症的一種治療方式，通常接合的動作係透過一個線型切割吻合器或是縫合來加以達成，針對吻合器和縫合方式對於迴腸結腸接合效果比較的個別試驗顯示這2個方法對於併發症的出現率有些許的差異，但是這些證據仍缺乏適當的能力來檢測潛在的微小差異，在我們的認知中，本研究是針對迴腸結腸進行特別研究的第一篇系統性文獻

目標

本研究的主要目的在於比較使用吻合器或是手縫合技術對於迴腸結腸接合的效果，試驗中假設使用固定器較不容易引發併發症

搜尋策略

本研究檢索了MEDLINE、EMBASE、Cochrane Colorectal Cancer Group specialised register SRCOLOCA、Cochrane Library等資料庫來取得針對使用線型切割吻合器和任何縫合技術來進行成人患者迴腸結腸接合效果比較的隨機性對照試驗，檢索文獻的時間範圍為1970年至2005年，1970年至2002年間發表於下列期刊摘要的相關文獻也會納入本研究中：American Society of Colon and Rectal Surgeons、 Association of Coloproctology of Great Britain and Ireland和European Association of Coloproctology

選擇標準

針對使用線型切割吻合器(側邊對側邊吻合或是功能性尾端對尾端)和任何縫合技術來進行成人患者迴腸結腸接合效果比較的隨機性對照試驗都會納入本研究中

資料收集與分析

選取適合納入研究的試驗並且評估這些試驗的方法學品質，相關結果會被取出，並且向試驗作者索取遺漏的數據，在具有充分數據下，使用RevMan 4.2 分析軟體1.0.5版本來進行後設分析，對於癌症和發炎性大腸疾病進行子集分析可以作為迴腸結腸接合效果的指標

主要結論

由試驗作者處取得包含其他接合治療的個別患者數據後，有6個納入955迴腸結腸患者(357個患者使用固定器，598個患者接受縫合治療)的試驗(包括1個未公開試驗)被納入本研究中，有3個大型試驗適度的進行隱藏分組，相對於縫合治療來說，接受使用吻合器的患者明顯可以降低吻合處滲透的現象(吻合器組為5/357，縫合組為36/598，OR值為0.34[95％的信心區間介於0.14至0.82之間]，p = 0.02)，有1個試驗使用常態性放射線法來檢測無症狀的滲漏現象，有個試驗將825名癌症患者進行分組，使用固定器的小組也有明顯降低吻合處滲漏的效果((吻合器組為4/300，縫合組為32/525，OR值為0.284[95％的信心區間介於0.10至0.75之間]，p = 0.01)，在子分組中的克隆氏症患者人數太少，所有其他的治療成果，例如狹窄(stricture)，吻合處出血(anastomotic haemorrhage)，吻合時間，再手術，死亡率，腹內膿腫、傷口感染和住院時間等在各組間並沒有出現顯著差異

作者結論

功能性尾端對尾端使用吻合器來進行迴腸結腸接合比手縫合更可以降低滲漏現象

翻譯人

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌

總結

與使用手縫合技術相較，使用吻合器進行迴腸結腸接合可以降低吻合處滲漏現象，特別是在大腸癌手術中，在進行右側腸癌手術和克隆氏症手術後，腸的尾端可能會利用使用吻合器或手縫合的方式加以接合，本研究有系統的檢視了包含有955位受試者(357名患者使用吻合器，598名患者進行縫合治療)，並針對這兩種方法進行比較的6個試驗，結果顯示，使用吻合器接合的方法可以將低吻合處滲漏現象1.4％，明顯低於手縫合組的6％(p = 0.02)，其中個試驗將825名癌症患者細分為小組，也可以得到類似的結果，雖然缺乏一致性的報告，但是所有其他的治療成果，例如狹窄(stricture)，吻合處出血(anastomotic haemorrhage)，吻合時間，再手術，死亡率，腹內膿腫、傷口感染和住院時間等在各組間並沒有出現顯著差異