Revisiting stapled and handsewn loop ileostomy closures: a large retrospective series

OBJECTIVE: To compare the surgical outcomes of stapled and handsewn closures in loop ileostomies. METHODS: The data of 225 patients requiring loop ileostomies from 2002 to 2007 were retrospectively evaluated. The patients underwent partial small-bowel resections and either handsewn or stapled anastomoses for the ileostomy closures. They were followed up postoperatively with routine surgical examinations. RESULTS: The study group consisted of 124 men and 101 women with a mean age of 49.12 years. The ileostomy closure was performed with handsewn in 129 patients and with stapled in 96 patients. The mean time to the first postoperative flatus was 2.426 days in the handsewn group and 2.052 days in the stapled group (p <0.05). The mean time to the first postoperative defecation was 3.202 days in the handsewn group and 2.667 days in the stapled group (p <0.05). The mean duration of patient hospital stay was 8.581 days for the handsewn group and 6.063 days for the stapled group (p <0.05). CONCLUSIONS: Patients who underwent ileostomy closure with stapled recovered faster in the postoperative period and required shorter hospital stays than those whose closures were performed with handsewn. In our opinion, stapled should be considered the gold standard for loop ileostomy closures.

Short-term outcome of side-to-side stapled cervical esophagogastrostomy after esophagectomy / 中华消化外科杂志

Objective To evaluate the short-term outcome of side-to-side staple cervical esophagogastrostomy after esophagectomy. Methods The clinical data of 105 patients with esophageal cancer who were admitted to the Daping Hospital from January 2006 to March 2009 were retrospectively analyzed. Of the 105 patients, 97 received side-to-side stapled cervical esophagogastrostomy and eight received traditional hand-sewn end-to-end cervical esophagogastrostomy. Nine patients were selected from the 97 patients who received side-to-side stapled cervical esophagogastrostomy to conduct matched pair analysis. The efficacy of the two methods was analyzed using the t test. Results No postoperative death was observed. The mean operation time of side-to-side staple cervical esophagogastrostomy was (21 ± 3 )minutes (range, 15-30 minutes). Postoperative complications were observed in 16 patients, including pulmonary complications in seven patients, vocal cord paralysis in four patients, anastomotic leakage in three patients and anastomotic stricture in two patients. The mean anastomotic diameter of patients who received side-to-side staple cervical esophagogastrostomy was ( 3. 01 ± 0. 17 ) cm, which was significantly longer than ( 1.69 ± 0. 26) cm of patients who received traditional hand-sewn end-to-end cervical esophagogastrostomy (t =2. 093, P ＜0.05 ). Dysphagia occurred in two patients who received side-to-side stapled cervical esophagogastrostomy and in four patients who received traditional hand-sewn end-to-end cervical esophagogastrostomy.Conclusions Side-to-side stapled cervical esophagogastrostomy is simple, safe and effective for patients with esophageal cancer after esophagectomy. This technique could decrease the incidence of postoperative dysphagia and improve the pharyngo-esophageal motor function.

Application of a side-to-side stapled cervical esophagogastric anastomosis after three-incision esophagectomy for cancer / 中国癌症杂志

Background and purpose: Three-incision esophagectomy for patients with esophageal cancer has been increasingly used, but the incidence of either postoperative anastomotic leak or stricture is higher than that in intrathoracic gastroesophageal anastomosis. The purpose of this study was to investigate the clinical effects of the side-to-side stapled cervical gastroesophageal anastomosis in preventing anastomotic leak and stricture after three-incision esophagectomy. Methods: One hundred and twenty-seven patients undergoing three-incision esophagectomy for esophageal cancer with gastric replacement were reviewed. A side-to-side stapled cervical gastroesophageal anastomosis was performed in 71 cases and manually sewn anastomosis in 56 cases. The incidence of postoperative anastomotic leak and stricture was compared between these two groups and the results were statistically analyzed using SPSS11.0 soft.Results: Anastomotic leakage was noted in seven patients (9.9%) in the stapler group and fourteen patients (25.0%) in the manually sewn group (P=0.04). After the operation two patients (2.8%) in the stapler group and nine patients (16.1%) in the manually sewn group developed a benign esophageal stricture (P=0.02).The incidence of either postoperative anastomotic leak or stricture in cases of the stapler group was significantly lower than that in the manually sewn group (P<0.05). Conclusion: Construction of the cervical esophagogastric anastomosis with a side-to-side stapled technique provides a larger luminal diameter which significantly reduces the incidence of postoperative anastomotic strictures. The surgery also greatly reduces the incidence of anastomotic leaks and strictures, so it could be used as an alternative strategy for cervical esophagogastric anastomosis after esophagectomy for esophageal cancer

Controversies in Pouch Surgery for Ulcerative Colitis

Restorative proctocolectomy (RPC) has become a standard procedure over 30 yr in patients with ulcerative colitis and familial adenomatous polyposis. However, there are several controversies in surgical method and strategy. From oncological point of view, mucosal proctectomy and hand-sewn ileal pouch anal anastomosis has advantage because of relatively complete removal of columnar epithelium. However, long-term follow-up results after stapled anastomosis revealed extremely low incidence of dysplasia in the anal transitional zone (ATZ). Furthermore, recent publication of 26 cancer occurrence after RPC showed more prevalence in mucosectomy group. Risk factors of dysplasia after RPC are supervening cancer or dysplasia on the proximal colon, long duration of symptom, and history of primary sclerosing cholangitis. Preservation of ATZ by stapled anastomosis may have functional superiority, which is supported by some manometric and functional studies. However, two randomized controlled trials showed no difference between the groups. Although there are some surgeons who advocate one stage RPC, majority of centers prefer two stage RPC with ileostomy. According to meta-analysis one stage RPC revealed 2-3 times frequent anastomotic leakage or pelvic sepsis. Five to ten percent of ulcerative colitis has some pathologic characteristics of Crohn's disease, which is classified as indeterminate colitis (IC). Long-term results of RPC in patients with IC revealed similar results with ulcerative colitis and superior to Crohn's disease. So RPC may be justified in patients with IC. Conclusively, RPC should be tailored according to clinicopathologic details and operative findings.

Mid-term Outcomes of Side-to-Side Stapled Anastomosis in Cervical Esophagogastrostomy

This study was conducted to evaluate the mid-term results of cervical esophagogastric anastomosis using a side-to-side stapled anastomosis method for treatment of patients with malignant esophageal disease. A total of 13 patients were reviewed retrospectively from January 2001 to November 2005 who underwent total esophagectomy through a right thoracotomy, gastric tube formation through a midline laparotomy and finally a cervical esophagogastric anastomosis. Average patient age was 62.6 yr old and the male to female ratio was 11:2. The mean anastomosis time was measured to be about 32.5 min; all patients were followed for about 22.8+/-9.9 months postoperatively. There were no early or late mortalities. There were no complications of anastomosis site leakage or conduit necrosis. A mild anastomotic stricture was noted in one patient, and required two endoscopic bougination procedures at postoperative 4th month. Construction of a cervical esophagogastric anastomosis by side-to-side stapled anastomosis is relatively easy to apply and can be performed in a timely manner. Follow up outcomes are very good. We, therefore, suggest that the side-to-side stapled anastomosis could be used as a safe and effective option for cervical esophagogastric anastomosis.

Mid-term Outcomes of Side-to-Side Stapled Anastomosis in Cervical Esophagogastrostomy

This study was conducted to evaluate the mid-term results of cervical esophagogastric anastomosis using a side-to-side stapled anastomosis method for treatment of patients with malignant esophageal disease. A total of 13 patients were reviewed retrospectively from January 2001 to November 2005 who underwent total esophagectomy through a right thoracotomy, gastric tube formation through a midline laparotomy and finally a cervical esophagogastric anastomosis. Average patient age was 62.6 yr old and the male to female ratio was 11:2. The mean anastomosis time was measured to be about 32.5 min; all patients were followed for about 22.8+/-9.9 months postoperatively. There were no early or late mortalities. There were no complications of anastomosis site leakage or conduit necrosis. A mild anastomotic stricture was noted in one patient, and required two endoscopic bougination procedures at postoperative 4th month. Construction of a cervical esophagogastric anastomosis by side-to-side stapled anastomosis is relatively easy to apply and can be performed in a timely manner. Follow up outcomes are very good. We, therefore, suggest that the side-to-side stapled anastomosis could be used as a safe and effective option for cervical esophagogastric anastomosis.

Anastomotic Stricture after Colorectal Stapled Anastomosis

INTRODUCTION: Stapled anastomosis in the rectal cancer surgery has been already proven as a safe technique, maintaing secure suture and saving times compared to handsewn anastomosis. With the advancement of stapling device, the incidence of anastomotic leakage has decreased significantly. However, developement of anastomotic stricture has become a major postoperative complication. PURPOSE: An analysis of the clinical features and the predisposing factors of anastomotic stricture was made to identify its pathogenesis and to determine adequate procedure. METHODS: We analyzed 49 patients (8.1%) with the rectal stricture among 608 patients, undergone stapled anastomosis for the rectal cancer surgery at Asan Medical Center from Jan 1993 to Dec 1998. Rectal stricture was defined when index finger or colonoscope could not pass the anastomotic site (high grade), or could pass with difficulty(low grade). RESULTS: Underlying general diseases, e.g., DM, hypertension and cardiovascular disease was associated more frequently in patients with anastomotic stricture (20.4%) than patients without (10.8%) (P<0.05). The rate of postoperative major complications in patients with stricture was 22.4%, while that of anastomotic leakage was 6.1%. Development of anastomotic stricture was not associated with operative methods, age, anastomosis level, and postoperative radiotherapy. In patients with stricture, 34 patients (69.4%) were asymptomatic, and 15 patients were symptomatic. In treating symptomatic rectal stricture, only five patients performed dilation manually or by the Hegar dilator. CONCLUSIONS: Rectal stricture after stapled anastomosis might be associated with underlying diseases, and correlated with prolonged sanguinous drainage and ileus. Meticulous management of underlying disease and complete hemostasis during operation appear to be important to reduce the rate of rectal stricture.