A We present a technique to perform this anastomosis linear stapled duodeno-jejunal side-to-side anasto- easily, based on the application of the linear endo- mosis is performed. The technique is easy and rapid to perform, avoids passing an anvil through the scopic stapling device. Key words: Duodenal switch, stapled anastomosis, side- Surgical Technique to-side anastomosis, morbid obesity After devascularization and resection of the greater curvature of the stomach, the first portion of the duo- denum is dissected. The continuation of the greater Introduction curvature of the stomach is devascularized from the pylorus down to the division line, which is placed Duodenal switch is a bariatric procedure with some approximately 4 cm from the pylorus. The right side advantages for selected patients when compared to or the lesser curvature of the duodenum is scarcely gastric bypass. It provides excellent weight loss touched, aiming to preserve its whole vascularization.
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Open in a separate window PRACTICE The choice of anastomotic technique may be influenced by the diameter of the bowel ends, oedema, accessibility and site of anastomosis, contamination, available time and equipment and underlying pathology. Anastomoses can be described as follows: sutured: 1 interrupted or continuous; 2 single or 2-layer; 3 end-to-end or side-to-side or any combination ; 4 various suture materials; 5 extramucosal or full-thickness sutures; and 6 size of and spacing between each suture; and stapled: 1 side-to-side or end-to-end or any combination ; 2 staple lines oversewn, buried or not; and 3 Various stapling devices.
Between and several case series and small randomised controlled trials RCTs showed no significant difference in anastomotic leak rates, morbidity or mortality between sutured and stapled anastomoses throughout the gastrointestinal tract[ 8 - 11 ]. This study included elective and emergency anastomoses performed anywhere from the oesophagus to the low rectum, with patients randomised to a sutured or stapled technique intra-operatively.
One thousand four patients under the care of 13 general surgeons in five hospitals were included. Overall clinical leak rate, morbidity and mortality were not significantly different[ 12 ]. It was concluded, following these studies, that both suturing and stapling could be performed safely throughout the gastrointestinal tract[ 8 - 12 ]. More recently, however, numerous studies have investigated the benefits of particular techniques in specific situations, and meta-analyses of RCTs have demonstrated differences not previously detected.
Ileocolic anastomoses A right hemicolectomy and ileocolic anastomosis is a common procedure in the elective and emergency setting. Case series have suggested that both stapled and sutured anastomoses can be performed with a very low risk of anastomotic leak[ 13 ].
A large RCT was published in regarding elective right hemicolectomy for colonic adenocarcinoma. In the Cochrane Collaboration published a meta-analysis of RCTs regarding ileocolic anastomoses[ 15 ]. Trials comparing stapled side-to-side anastomoses with any suturing technique were included. This produced patients of whom had stapled and had sutured anastomoses. Stapled anastomoses were associated with significantly fewer anastomotic leaks than hand-sewn anastomoses odds ratio 0.
Subgroup analysis revealed the same result in patients operated on for colonic cancer odds ratio 0. There was no significant difference in other complications, mortality or length of hospital stay[ 15 ]. A stapled side-to-side anastomosis is recommended following a right hemicolectomy, particularly if this operation is performed for a colonic adenocarcinoma[ 15 ].
Crohns disease There are several factors to consider in the surgical management of Crohns disease: In addition to anastomotic healing the risk of Crohns recurrence and the need for re-operation must also be considered. This may also be influenced by anastomotic technique[ 16 - 20 ]. Whilst one randomised study showed anastomotic leak rates to be equivalent in the stapled and sutured groups[ 21 ], several subsequent randomised and non-randomised studies have shown a reduced risk of anastomotic leak[ 16 , 22 ] and a reduced risk of overall complications[ 17 , 19 ] with a stapled anastomosis.
A reduced risk of reoperation or a delayed reoperation rate for recurrent Crohns following a stapled anastomosis has also been demonstrated in several studies[ 17 - 19 ]. A meta-analysis comparing sutured end-to-end anastomoses with other anastomoic configurations following Crohns resection was published in [ 23 ]. Two RCTs and six non-randomised studies were included, giving a total of patients. The leak rate of end-to-end anastomoses was 6.
One hundred and seventy-one patients were randomised to a sutured end-to-end or stapled side-to-side anastomosis. Symptomatic recurrence rates were also similar sutured Long-term follow-up data is awaited with interest. No evidence favours a sutured end-to-end anastomosis. Colorectal anastomoses The circular stapled anastomosis in both high and low anterior resections has been extensively studied. Multiple small RCTs and several larger retrospective studies have been published with conflicting results.
Some have suggested that the anastomotic leak rates are similar[ 25 - 29 ]; some that stapling is preferable to suturing[ 30 ], and vice versa[ 31 ]. One large RCT reported that while in experienced hands the anastomotic leak rates were equivalent, when performed by a trainee the sutured anastomosis resulted in a higher leak rate[ 32 ]. A further large RCT involving colorectal anastomoses subgroup analysis of a larger trial including all GI tract anastomoses reported a statistically significant increase in the radiological leak rate in the sutured colorectal anastomosis group, a trend towards a reduced clinical leak rate in this group, and no difference in the overall leak rate[ 33 , 34 ].
A meta-analysis of RCTs was published in to clarify these results[ 35 ]. Nine trials were included in which patients were randomised to a sutured or stapled elective colorectal anastomosis.
No patient had to be re-operated on for this complication[ 35 ]. The authors concluded that there was no demonstrable superiority of one technique over the other, regardless of the level of the anastomosis.
They advised that the decision regarding whether to perform a stapled or a sutured colorectal anastomosis remains a matter of surgical judgement[ 35 ].
Recent studies regarding the stapled colorectal anastomosis have suggested routine mobilisation of the splenic flexure and a stapled colo-pouch or end-to-side anastomosis. Splenic flexure mobilisation allows the better-perfused descending colon to be anastomosed to the rectum and the use of an end-to-side anastomosis or a colo-pouch tends to fill the pelvis, reducing dead space in which a haematoma or collection could develop[ 5 ].
Trauma In , a retrospective study of 84 trauma patients, who underwent gastrointestinal anastomoses in a single United States trauma centre over a four-year period was published[ 36 ]. This included small bowel and 17 large bowel anastomoses, of which 58 were stapled and 60 hand-sewn. Another retrospective study countered this[ 37 ], showing that of small bowel anastomoses stapled; 34 sutured there was no significant difference in anastomotic leak rate or other intra-abdominal complication.
It did, however, show that enterotomies which did not require resection were best treated by sutured repair[ 37 ]. In a multi-centre retrospective study which included patients from the study compared the incidence of complications following emergency bowel resection and anastomosis in trauma[ 38 ]. Data over a four-year period from five US Level 1 trauma centres was included, producing a total of patients with anastomoses stapled; sutured.
The injury severity score and the distribution of small bowel and large bowel anastomoses in the two groups were not significantly different.
A recent study compared stapled with sutured colonic anastomoses following penetrating trauma[ 39 ]. This was a prospective, multi-centre non-randomised study including patients. They found no significant difference in anastomotic leak rate or other abdominal complications between the two groups, concluding that sutured and stapled colonic anastomoses are equally valid. These results should be interpreted with caution, however, as the stapled and sutured groups were not well matched: patients who had a sutured anastomosis were significantly more likely to have waited over six hours from time of injury to operation, and patients who had a stapled anastomosis were significantly more likely to have required a massive blood transfusion[ 39 ].
The problem with all of these studies is that they are not randomised, so results are subject to bias[ 36 - 39 ]. However this currently remains our best available evidence, and suggests that stapled small bowel anastomoses may be best avoided in trauma[ 36 , 38 ]. The question of the stapled colonic anastomosis remains uncertain. Reversal of loop ileostomy Several studies have compared methods of small bowel anastomosis in elective reversal of loop ileostomy.
Randomised and non-randomised studies have not previously shown any significant difference in anastomotic leak rate[ 40 - 43 ], however the rate of post-operative bowel obstruction can be affected by anastomotic technique[ 44 , 45 ]. Mobilising the ileostomy spout and closing the enterotomy, rather than resecting the spout and performing an anastomosis can reduce the risk of small bowel obstruction[ 44 ], as can performing a stapled side-to-side anastomosis rather than a sutured end-to-end anastomosis[ 45 ].
A meta-analysis of six previous studies two RCTs and four non-randomised studies including participants was published in [ 46 ]. This showed no statistically significant difference in complications between stapled and sutured anastomoses. There was, however, a non-significant trend favouring stapled anastomoses with regard to lower small bowel obstruction rates, anastomotic leaks and shorter operating times[ 46 ].
Following mobilisation of a loop ileostomy either excision of the spout and a stapled side-to-side anastomosis or mobilisation of the spout and sutured closure of the enterotomy are reasonable options[ 6 , 44 - 46 ].
Resection and sutured anastomosis is not the preferred technique, although the evidence for this is mainly from retrospective, non-randomised studies[ 6 , 44 - 46 ].
CONCLUSION The theory behind a good bowel anastomosis remains consistent, whether a stapled or sutured technique is employed: the bowel ends must have a good blood supply, be under no tension, and be anastomosed with meticulous technique. Either stapled or sutured techniques are suitable in most situations.
In recent years, however, evidence has shown particular anastomotic techniques to be advantageous in specific settings - in this article the available literature is reviewed to provide the on-call general surgeon with the information required to make an evidence-based decision regarding anastomotic technique.
Latero-lateral end anastomosis for right hemicolectomy using staplers
Open in a separate window PRACTICE The choice of anastomotic technique may be influenced by the diameter of the bowel ends, oedema, accessibility and site of anastomosis, contamination, available time and equipment and underlying pathology. Anastomoses can be described as follows: sutured: 1 interrupted or continuous; 2 single or 2-layer; 3 end-to-end or side-to-side or any combination ; 4 various suture materials; 5 extramucosal or full-thickness sutures; and 6 size of and spacing between each suture; and stapled: 1 side-to-side or end-to-end or any combination ; 2 staple lines oversewn, buried or not; and 3 Various stapling devices. Between and several case series and small randomised controlled trials RCTs showed no significant difference in anastomotic leak rates, morbidity or mortality between sutured and stapled anastomoses throughout the gastrointestinal tract[ 8 - 11 ]. This study included elective and emergency anastomoses performed anywhere from the oesophagus to the low rectum, with patients randomised to a sutured or stapled technique intra-operatively.
Bowel anastomoses: The theory, the practice and the evidence base
Dot In summary, the One Anastomosis Gastric Bypass is, as is also the original Mini Gastric Bypass, a quick to perform and low risk procedure with minimal postoperative complications experienced by the patients. Randomized prospective evaluation of the EEA stapler for colorectal anastomoses. The postoperative complications associated with laparoscopic colorectal surgery are essentially the same as those for open surgery. Mason EE, Ito C: We performed a right hemicolectomy using a 4 port approach with the patient in modified lithotomy position.