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Stapled Versus Handsewn Intestinal Anastomosis in Emergency Laparotomy: a Systemic Review and Meta-Analysis

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Stapled Versus Handsewn Intestinal Anastomosis in Emergency Laparotomy: a Systemic Review and Meta-Analysis Clinical Review Stapled versus handsewn intestinal anastomosis in emergency laparotomy: A systemic review and meta-analysis David N. Naumann, MRCS,a,b Aneel Bhangu, PhD,a Michael Kelly, MBChB,a and Douglas M. Bowley, FRCS,a,b Birmingham, UK Background. The optimal technique for gastrointestinal anastomosis remains controversial in emergency laparotomy. The aim of this meta-analysis was to compare outcomes of stapled versus handsewn anastomosis after emergency bowel resection. Methods. A systematic review was performed for studies comparing outcomes after emergency laparotomy using stapled versus handsewn anastomosis until July 2014 (PROSPERO registry number: CRD42013006183). The primary endpoint was anastomotic failure, a composite measure of leak, abscess and fistula. Odds ratio (OR; with 95% CI) and weighted mean differences were calculated using meta-analytical techniques. Subgroup analysis was conducted for trauma surgery (TS) and emergency general surgery (EGS) cohorts. Risk of bias for each study was calculated using the Newcastle– Ottawa scale for cohort studies, and Cochrane Collaboration’s tool for randomized trials. Results. The final analysis included 7 studies of 1,120 patients, with a total of 1,205 anastomoses. There were 5 TS studies and 2 EGS studies. There were no differences in anastomotic failure between handsewn and stapled techniques on an individual anastomosis level (OR, 1.53; 95% CI, 0.97–2.43; P = .070), or on an individual patient level (OR, 1.44; 95% CI, 0.92–2.25; P = .110). There were no differences in the individual rates of anastomotic leak, abscess, fistulae, or postoperative deaths between techniques. Subgroup analysis of EGS and TS studies demonstrated no superior operative technique. Conclusion. Available evidence is sparse and at high risk of bias, and neither stapling nor handsewing is justifiably favored in emergency laparotomy. Surgeons might therefore select the technique of their own choice with caution owing to unresolved uncertainty. (Surgery 2015;157:609-18.) From the Department of General Surgery,a Heart of England NHS Foundation Trust, Bordesley Green East; and Royal Centre for Defence Medicine,b Birmingham, UK THE RECENT COCHRANE REVIEW that compared elective none of the individual studies favored handsewn stapled and handsewn colorectal anastomosis or stapled techniques, meta-analysis favored the sta- showed no differences in outcome between tech- pled technique in the cancer resection subgroup niques, but commented that during higher risk but not the Crohn’s disease resection subgroup.2 emergency laparotomy, this question remains unan- Such a finding suggests that there may be unique cir- swered.1 Another recent Cochrane review analyzing cumstances in which even small differences in out- elective ileocolic anastomosis found that, although comes between techniques have the potential to make a difference in specific populations. Choice Conflict of interests: None declared. of operative technique also depends on differences Presented at the Tripartite Colorectal Meeting 2014, Birming- in opinion, interpretation of evidence, as well as ham, UK both personal and institutional practice, making Accepted for publication September 26, 2014. this a topic of debate and controversy. There have Reprint requests: Aneel Bhangu, PhD, Heart of England NHS been no randomized clinical trials (RCTs) in the Foundation Trust, Bordesley Green East, Birmingham B9 5SS, last 10 years regarding elective handsewn versus sta- UK. E-mail: [email protected]. pled colorectal anastomoses, leading the Cochrane 0039-6060/$ - see front matter reviewers to stipulate that the research question has Ó 2015 Elsevier Inc. All rights reserved. lost its strength.1 However, emergency surgery dif- http://dx.doi.org/10.1016/j.surg.2014.09.030 fers from elective surgery in terms of pathology, SURGERY 609 610 Naumann et al Surgery April 2015 perioperative physiology, and general management well as whether there were any differences among principles, which may mean that technical success in trauma and EGS study subgroups. the elective setting may not be transferable to emer- gency patients, and that these situations must be METHODS considered separately. There is particular concern Data sources and search strategy. This review was that edematous bowel is less suited to stapled anasto- performed according to a prespecified protocol, mosis than handsewn in an emergency situation.3-6 which was registered with the International Bowel becomes edematous after splanchnic hypo- Prospective Register of Systematic Reviews (PROS- perfusion and subsequent reperfusion; in addition, PERO, ID number: CRD42013006183). A systematic the inflammatory host response may be initiated in search of the OVID SP and PubMed versions of response to sepsis or trauma. We hypothesized that Medline, the Cochrane Database of Systematic Re- there would be a favorable trend toward handsewn views, Current Controlled Trials, and ClinicalTrials. anastomosis in an emergency setting, because this gov was performed for published studies comparing technique might be more suitable than stapling stapled and handsewn anastomoses for emergency for technical ‘‘finetuning’’by the operating surgeon bowel surgery. Only studies published after 1990 in to compensate for the more hostile conditions of English were included. The search was performed bowel. independently by 2 authors (M.K., A.B.). Medical We also hypothesized that there may be addi- subject heading terms were used to search Medline, tional differences between trauma surgery (TS) combining domains of the operation, anastomosis and emergency general surgery (EGS) patients, type and randomization, using the AND function because the physiologic conditions are typically (Supplementary Table I). A manual search of refer- dominated by hemodynamic instability from hem- ence lists in relevant review articles was undertaken orrhage in the former, whereas the latter is pre- to further identify studies of potential interest. Ab- dominantly complicated by sepsis. The 2 groups stracts and conference proceedings were excluded may also have different patient demographics, with because of the high probability of incomplete TS patients being younger and more likely to be data. Citations were collated with EndNote Refer- male than EGS patients. There have been no ence Manager (Version X4, Thomson Reuters), systematic reviews comparing handsewn and sta- and duplicates removed. The last search was per- pled anastomosis in the emergency laparotomy formed on July 25, 2014. setting; neither have there been any analyses of the Inclusion and exclusion criteria. RCTs, as well as subgroups of TS and EGS. We therefore sought to both prospective and retrospective cohort studies address this gap in the literature with a summation comparing $1 outcome of stapled versus hand- of the best available evidence. sewn anastomosis after emergency bowel resection RCTs in the emergency surgical context remain were included. All gastrointestinal anastomoses, challenging. Because there is no preoperative for any emergency indication, were eligible for certainty that anastomosis will be required, gaining inclusion. Studies with only elective patients or informed consent is difficult. Furthermore, insti- unclear anastomosis technique were excluded. tutional review boards may prohibit RCTs that seek Where there was overlap in the same patients to predetermine operative techniques among sur- between studies, the older study was excluded. geons, because it may not be ethical or practical to Patients who underwent concurrent handsewn and ‘‘force’’ surgeons to use techniques they are not stapled anastomoses during multiple anastomoses accustomed to, or do not wish to use. Therefore, were excluded from further analysis, because it when conducting this systematic review and meta- would be impossible to identify which outcome was analysis, we were aware that RCT data might be attributable to which anastomosis. sparse, and that a pragmatic approach of utilizing Data extraction. Two authors extracted data all other retrospective and cohort study data would independently (D.N.N., M.K.). Discrepancies in likely have to suffice. Summation of these data, outcome extraction were resolved by reexamination although less than scientifically ideal, will provide of the relevant study until consensus was achieved. the largest and most generalizable evidence to date Data extracted on study design included: Indication on this topic, which may help to assess the need for (TS or EGS), randomization technique, interven- more specifically targeted trials if potential tion arms, mechanism of anastomosis (using a avenues of investigation were to be highlighted. stapling device or handsewn). Details relating to We aimed to determine whether there was a the included patients were number, age, gender, difference in outcome between stapled and hand- mechanism of injury, injury severity score, and sewn anastomosis after emergency laparotomy, as anatomic level of bowel resection and anastomosis. Surgery Naumann et al 611 Volume 157, Number 4 Details relating to the operation were policy for blood product requirement, surgical site infec- anastomosis technique and type of stapler or sutures tions, and duration of operating time. used. Subgroup analysis. As well as meta-analysis for all Definitions. ‘‘Stapled’’ was defined as an anasto- emergency studies, the subgroups of trauma and mosis fashioned using a stapling device of any kind, EGS were also separately analyzed using the same with or without
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