Keywords
stapled intestinal anastomosis - newborn - children
Introduction
The creation of a join between two bowel ends in newborns and infants is a central
surgical procedure in the life of the pediatric surgeons and has been usually performed
using hand-sewn techniques. Since the introduction of stapling in infants younger
than 4 months[1] only few articles reported usage of stapled technique in small patients. In this
work, we have described our experience with repair of bowel discontinuity by applying
stapled anastomosis. The aim of this study was to compare two basic intestinal anastomotic
techniques and to establish the feasibility of the stapled connection of bowel in
neonates and infants.
Methods
A retrospective review of the records of 44 infants younger than 3 months of age who
underwent intestinal anastomoses from August 2009 to December 2011 was performed.
The ethical committee of the Irkutsk Pediatric Hospital (Irkutsk, Russia) approved
this study.
The standard perioperative data and outcome variables included age and weight at operation,
operative time and time of full enteral nutrition, and length of hospital stays. Differences
between groups were assessed using the Mann–Whitney U Test. A p value of less than 0.05 was considered statistically significant.
In all cases of bowels join (group II), a stapled side-to-side functioning end-to-end
intestinal anastomosis was constructed using the Endopath ATW-35 Endoscopic Articulating
Linear Stapler with 2.5-mm staples (Ethicon Endo-Surgery, Cincinnati, Ohio, United
States). Standard double-stapled surgical techniques described in pediatric surgical
literature were used for creation of the intestinal anastomoses.[2]
[3]
In brief, after efferent bowel limbs were sutured in proximity, the stapled device
cannulated the bowel limbs. Before closing the stapler and completing the anastomosis,
the stapler was positioned onto the antimesenteric wall of the intestine. After being
inspected for intestinal lumens and patency, the stapler was again applied across
the joined bowel limbs, closing the bowel anastomosis ([Figs. 1] and [2]). Staple lines were not oversewn unless there was evidence of a leak at the time
of operation.
Figure 1 Creation of a first longitudinal line of stapled intestinal anastomosis (single stapled).
Figure 2 Complete formation of a stapled side-to-side functioning end-to-end intestinal anastomosis
(double stapled).
The minimum body weight of the patient in the “stapler” group was 1210 g. In the current
study, use of the suturing device was defined not by the weight of the patient, but
by the diameter of connected segments of intestines. The endoscopic stapler was used
for this manipulation because only this device can be inserted in a small-caliber
gut lumen of the neonate and premature children. The proximal intestinal limb having
the larger size was cannulated with larger end of the stapler. The smaller end of
the suturing device was inserted in other distal intestinal segment. Possibility of
application of the stapler was defined during operation by measurement of diameter
of the smallest segment of the gut. We calculated perimeter of cross-section of the
small end of the stapler and defined that the smallest diameter of a gut for anastomosis
will be 6 mm. Only in these cases we opened sterile box of the device and applied
the mechanical suture.
In the “hand-sewn” patients (group I), anastomoses were performed in an end-to-end
fashion by continuous two-layer absorbable suture material.
We have no selection criteria between groups. Choice of anastomotic technique was
determined by preference of the senior surgeon.
The length of the follow-up averaged 6 months. The patients were returned 1 month
to 1 year after surgery for repeated medical examination. The bowel function, body
weight, and gastrointestinal symptoms were recorded at surgical service of the pediatric
hospital.
Results
A total of 44 patients were identified during the study period. A total of 23 patients
of group I had two-layer hand-sewn anastomosis and 21 patients of the group II had
stapled side-to-side functional end-to-end intestinal anastomosis. The reasons for
the anastomoses in hand-sewn group included necrotizing enterocolitis (NEC) and isolated
ileal perforations (IIP) (60.9%), patent omphalomesenteric duct (17.4%), and congenital
and acquired bowel obstruction (21.7%). The most common diagnoses for patients undergoing
stapled anastomoses were NEC and IIP (52.4%), anal atresia (14.3%), bowel necrosis
in gastroschisis (9.5%), patent omphalomesenteric duct (9.5%), intestinal duplications
(9.5%), and total Hirschsprung disease (4.8%). The patient's data and outcome are
summarized in [Table 1].
Table 1
A comparison of preoperative and postoperative details in the groups
|
Parameters
|
Group I: hand-sewn anastomosis
|
Group II: stapled anastomosis
|
p Values
Mann–Whitney U test
|
|
Preoperative parameters
|
|
Age at operation (day)
|
19.7 (2.8[a])
|
23.2 (2.8)
|
0.095516
|
|
Body weight at operation (g)
|
2884.3 (240.3)
|
2716.0 (226.0)
|
0.692459
|
|
Postoperative parameters
|
|
Operative time (min)
|
77.4 (2.4)
|
56.4 (2.1)
|
<0.0001
|
|
Full enteral feeding (day)
|
6.7 (0.5)
|
6.7 (0.6)
|
0.92589
|
|
Length of hospital stay (day)
|
13.3 (1.0)
|
14.1 (1.5)
|
0.852406
|
a Values are expressed as mean (SEM).
There were no differences in the preoperative data between the two groups regarding
the age before surgery and body weight at surgery. The “hand” and “stapler” groups
had similar mean preoperative age (19.7 vs. 23.2 days; p = 0.096) and average weight (2884.3 vs. 2716.0 g; p = 0.692). The mean time to full enteral feeding for patients with stapled anastomosis
was isochronous for patients with standard hand-sewn technique (6.7 vs. 6.7 days;
p = 0.926). The statistical identical postoperative hospital stay was registered in
patients of both groups (13.3 vs. 14.1 days; p = 0.852).
The only statistically significant parameter was the operative time. The mean operative
time for the restoration of bowel continuity was 77.4 minutes in group I and 56.4
minutes in group II (p < 0.0001).
The postoperative course was routine in all patients of both groups. There were no
intra- and postoperative complications. We had no anastomotic leak and wound infections.
At follow-up, bowel function was perfect in all operated patients. The infants were
free from late postoperative complications such as stricture and failure in area of
anastomosis. Good intestinal transit and absorption were observed at these patients.
Discussion
Intestinal anastomosis is a surgical procedure to establish communication between
two portions of the intestine. In neonatal and pediatric patients, it may be required
for the management of many conditions. Some conditions may require resection of pathology
followed by primary anastomosis, whereas other conditions may necessitate delayed
anastomosis.
Intestinal anastomosis can be performed by a hand-sewn technique using absorbable
or nonabsorbable sutures or stapling devices. Although surgical stapling devices have
existed since the early 20th century, their use in routine gastrointestinal surgery
has not been widespread until ∼30 years ago when their design became much more efficient
and convenient.
Among the American and European surgeons who were trained in surgery at the end of
the 20th century, staplers were called as “Russian Gun.” The history of the origin
of this term is known.[4] The Russian Scientific Institute for Surgical Devices and Instruments studied and
then developed stapling instruments that served as the prototype of today's staplers.
An American Surgeon, Dr. Mark Ravitch, visited Soviet Union and observed Russian surgeons
who operated with a stapler. As a result, Dr. Ravitch studied this surgical product
and then designed a series of American instruments with reusable staplers and sterilized
cartridges. That is how the era of stapled anastomoses in surgery began. With modern
devices, the staple lines are of more consistent quality and anastomoses in difficult
locations are easier to construct.
The role of stapling devices in surgery has continued to expand. In adults, the safety
and efficacy of stapled intestinal anastomosis have been extensively documented since
1978.[5] Recent studies indicate that patients requiring mechanical anastomoses who are managed
with stapling have a similar rate of complications than do those in whom a hand-sewn
anastomosis is used. A Cochrane review of seven trials found fewer leaks after stapled
anastomosis with no differences in operative time or the incidence of stricture or
wound infection.[6] In addition, a meta-analysis studied 13 trials reported no differences in mortality
and leakage rate after stapling usage.[7]
In pediatric surgery, gastrointestinal staplers were applied traditionally and double-stapled
anastomotic technique was performed by anatomic side-by-side functioning and end-to-end
anastomosis was used. Several studies have described the use of staplers in children
for the treatment of Hirschsprung disease,[8] appendectomy,[9] Meckel diverticulectomy,[10] and intestinal lengthening procedures.[11]
There are four articles describing the use of intestinal stapler in infants for bowels
join.[1]
[2]
[3]
[12] In 1995, Powell[1] published a series of seven newborns with a mean age of 72 days and a mean weight
of 3.7 kg. In our study, mean age at operation in “stapler” group was 23 days and
mean weight was 2.7 kg. Patients in “stapler” group were also younger compared with
report of Wrighton et al[2] (mean age 105 days).
Although the superiority of stapled anastomosis in newborns is not proven yet over
hand-sewn anastomosis, it has definitely facilitated the ease of doing the procedure.
In 2011, Mitchell et al[3] reported a series of using staplers in 64 small children with phenomenal postoperative
results excluding leaks. Mitchell et al concluded that the stapled anastomosis is
an effective alternative for restoration of bowel discontinuity in newborns and small
babies when permitted by intestinal size.
Another benefit of stapler anastomosis, which has been shown in our results and support
previous reports, is clear decrease in operative time. This may be particularly important
in small, premature infants.
In modern literature, complications of mechanical method of join of bowel are described
rarely. There is only one report in the published articles of adverse outcomes after
stapled intestinal anastomoses in children presented with intestinal volvulus several
years after stapled anastomosis at 2 months and 3 years of age.[13] We have not found any complications in our groups in short-term follow-up.
In conclusion, we reported series of stapled intestinal anastomoses in infants and
compared outcomes with those who underwent hand-sewn bowel connection. Efficacy of
the stapled anastomosis was confirmed by the shorter operative time with saving equal
time to full enteral feeding and length of hospital stay. We did not observe complications
in both groups at operations and short-term follow-up. We concluded that the age and
size of patients are not the limiting factors for using gastrointestinal staplers.
Our study further validates the use of the stapled anastomosis in neonates, but investigation
is required to verify long-term follow-up.
