Single-fire Versus Double-fire Technique for Functional End-to-end Anastomosis: Does Size Matter?

Eric M Changchien, MD, Melinda Hawkins, MD, Nathan L Pace, MD, John A Griffin, MD. St Mark’s Hospital, Salt Lake City, Ut.

Background: Traditionally, stapled side-to-side functional end-to-end anastomoses are fashioned with a linear stapler between two bowel limbs and closure of the subsequent common enterotomy using a thoracoabdominal (TA) stapler. The combination of transverse closure of the anastomosis combined with physiologic postoperative bowel edema can narrow the anastomosis, leading to a delay in return of bowel function (ROBF) and as such, hospital length of stay (LOS). We hypothesized that the use of a double-fire technique (2 sequential fires of the linear stapler) would result in a wider anastomosis and thus more rapid ROBF and decreased LOS.

Methods: A retrospective chart review was performed on all stapled bowel anastomosis between small bowel (ileostomy reversal, small bowel resection) or small bowel and colon (right hemicolectomy, ileocolectomy) by a single colorectal surgeon between 2007-2013. A t-test analysis was used to assess differences in LOS and ROBF between single- and double-fire techniques. Contributing factors including patient diagnosis, laparoscopic versus open surgery, and type of anastomosis (small bowel to small bowel versus small bowel to large bowel) were also examined by a Poisson family generalized linear model.

Results: A total of 152 bowel anastomoses (41 double-fire, 111 single-fire) were reviewed. There was a non-statistically significant difference in length of stay (4.5 days double-fire vs 4.9 days single-fire, p=0.70) and return of bowel function (3.2 days double-fire vs 3.0 days single-fire, p=0.84). Patient diagnosis (p<0.001 ANOVA) affected LOS. The type of bowel involved (small bowel having shorter LOS than large bowel, p=0.003, ANOVA) was also a factor.

Conclusions: In this series, the underlying diagnosis and type of bowel involved in an anastomosis were the primary determinants of return of bowel function and length of stay. The technique of double-stapled anastomoses does not appear to significantly expedite this process and as such, cannot be a currently recommended practice without further study.

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