Kirstie S Van Ry, MD, Thomas D Martin, MD, Timothy Kuwada, MD. Carolinas Medical Center, Charlotte North Carolina
Introduction: Most surgeons utilize a circular stapler (EEA) for construction of a colorectal anastomosis (CRA). Leakage and bleeding at this anastomosis carries significant morbidity. Recent studies have reported that the rate of anastomotic leakage in colorectal surgery with use of an EEA is around 3% to 7%. The reported rate of major bleeding from a colorectal anastomosis following use of an EEA ranges in most studies from 1.5% to 3.4%. Staple line reinforcement (SLR) is associated with increased staple line burst pressure and lower bleeding. However, there is a paucity of data examining the use of SLR with the EEA for the CRA. Our objective was to review the outcomes of CRA/EEA with SLR.
Methods: Retrospective review of prospectively collected data of consecutive sigmoid colectomy and colostomy takedown (single surgeon) between 2010 and 2014. Lighted ureteral stents were used for all cases. OR time includes this procedure. Covidien (Dublin, Ireland) EEA stapler was used for all cases. All CRA were constructed with an EEA (28 or 25mm) with SLR (Seamguard; GORE, Flagstaff, AZ). Leak test with flexible sigmoidoscopy was routinely performed post CRA and the appearance of the staple line was noted (bleeding). Patient demographics, LOS, anastomotic configuration, technical difficulties with CRA, positive leak test and postop CRA complications were all recorded.
Results: 49 patients met inclusion criteria. 66% were female. There were no leaks and no significant anastomotic bleeds. Procedures include 43 laparoscopic sigmoid colectomies, 5 colostomy takedowns, and 1 revision of anastomosis. Included within these cases were 4 colovaginal fistulas, 3 colovesical fistulas, and 2 diverting loop ileostomies. Indications were diverticulitis ± colovaginal or colovesical fistula (N=38), colon cancer (N=5), ostomy takedown (N=5), emergent GI bleed (N=1). Configurations of anastomoses were end to end (36), side colon to end rectum (8), end colon to side rectum (3), side to side (2). One patient had bleeding at the anastomosis seen on intra-op endoscopy. This did not lead to complications or transfusion. 11 patients had a 25mm stapler used. Only one of these patient was found to have a stricture on post-op endoscopy that needed dilatation. There were no injuries attributed to the insertion of the stapler.
| Patient information | N | Mean |
|---|---|---|
| Age | 49 | 60.1±12.3 |
| Day of Surgery BMI | 49 | 28.7±5.2 |
| OR time (min) | 25 | 270.8±49.8 |
| Pre Op Hb | 49 | 13.4±1.6 |
| Hb POD 1 | 49 | 11.0±1.6 |
| EBL (mL) | 49 | 118.2±96.5 |
| Size of EEA (mm) | 49 | 27.3±1.3 |
| LOS | 49 | 5.6±3.2 |
| PO clears (days) | 49 | 2.5±1.6 |
Conclusion: SLR is a safe adjunct to EEA anastomosis. Compared to historical data, SLR seems to lower the risk of CRA bleed and leak. Further studies are required to clarify the benefits using SLR with the CRA.