Comparative Study Between Hand-Sewn Loop Ileostomy Closure Versus Side-To-Side Stapler Anastomosis Closure Of Loop Ileostomy In A Teaching Institute Of India
F Shah, B Prajapati, M Gandhi, D Vasavada
hand-sewn anastomosis closure, loop ileostomy, postoperative complications., side-to-side stapler anastomosis closure
F Shah, B Prajapati, M Gandhi, D Vasavada. Comparative Study Between Hand-Sewn Loop Ileostomy Closure Versus Side-To-Side Stapler Anastomosis Closure Of Loop Ileostomy In A Teaching Institute Of India. The Internet Journal of Surgery. 2012 Volume 28 Number 2.
Loop ileostomy is a commonly performed procedure for various surgical operations and is now gaining on conventional loop colostomy. There are different methods of loop ileostomy closure. This study was carried out to compare hand-sewn loop ileostomy closure and stapler anastomosis side-to-side closure
Loop ileostomy is becoming increasingly popular among colorectal surgeons because it is simpler to form and close than loop colostomy.(1,2) Both ileostomy construction and subsequent closure are relatively straightforward safe procedures but are also associated with some morbidity and mortality.(3)(4) Many options exist for optimum methods of performing closure like hand sewn end-to-end anastomosis or side-to-side stapler anastomosis closure with proponents of different methods claiming their advantages in terms of diminishing risk of anastomotic leakage and small bowel obstruction, operative time and cost. So this study aimed to compare both methods of closure in terms of operative time, postoperative complications, postoperative hospital stay and cost effectiveness.
Materials And Methods
This comparative study of stapler versus hand-sewn anastomosis of loop ileostomy closure was performed between June 2008 to June 2010 in GURU GOBINDSINGH Hospital, M.P.Shah Medical College, Jamnagar, Gujarat, India. Fifty patients of loop ileostomy of all ages and genders, who were fit for anesthesia and did not show any obvious distal pathology, both clinically as well as on investigation, were randomized either to the stapler or to the hand-sewn group (25 each). Informed consent was obtained and the procedure and it outcomes were well explained. In both techniques, the loop ileostomy was adequately mobilized from skin and deeper layers and then both loops of the ileum were separated protecting its blood supply and the anastomosis was done.
1$=45 Rupees (approx.)
The observations in our study of 50 cases of loop ileostomy closure which includes both stapler and hand-sewn ileostomy anastomosis are being analyzed and discussed. All patients were operated by senior consultants so that the parameters like duration of operation, operative techniques etc. can be compared with uniformity. The mean operative time in the hand-sewn group was 51 minutes while for the stapler group it was 42 minutes, which was significantly less. Anastomotic leak or fistula formation occurred in 4% and small-bowel obstruction occurred in 8 % of patients in the hand-sewn group and in none in the stapler group. Small-bowel obstruction was diagnosed clinically and confirmed radiologically. So complications were statistically higher in the hand-sewn group. The average duration of hospital stay for the stapler group was 8 days and for the hand-sewn group it was 9 days, which was not significantly different. Cost of stapler anastomosis was Rs 8317 (184$), which was significantly higher than in the hand-sewn group (Rs 428; 9.5$).
The results of our study are comparable to other studies done as shown in the tables below.
The operative time was less in the stapler group than in the hand-sewn group in our study and the same was concluded by a meta-analysis done by Leung et al.(11) and Horisberger et al.(9); however, the studies of Bain(3) and Hasegawa(6) did not show significant differences.
In our study, small-bowel obstruction did not occur in any patient in the stapler group whereas 8% (2) in the hand sewn group had small bowel obstruction. Both patients were re-admitted, one of them was cured conservatively and the other one went for laparotomy with resection and anastomosis for anastomotic stricture. One patient with anastomosis leak underwent laparotomy. Studies have shown that stapler anastomosis is of larger diameter and thus has less chance of postoperative stricture or narrowing leading to small bowel obstruction.(9) (10) (11) and chances of anastomosis leak are also lower.
There was no significant difference in hospital stay between the two groups of our study; however, Balik et al.(12) showed that postoperative stay was significantly shorter in the stapler group and patients showed better postoperative compliance.
Summary And Conclusion
From this study it was evident that stapler closure is more effective than hand-sewn loop ileostomy closure in terms of operative time reduction, ease of performance and no major postoperative complications. There was no difference in hospital stay. Only cost is a negative factor in stapler closure9), especially in a developing country like India. Though the result of the study is influenced by its smaller size, stapler anastomosis should be the preferred choice as studies have proved that stapler anastomosis is easy to perform, as it is less dependent on surgical skills compared to precise suturing in hand-sewn anastomosis. Postoperative obstruction is less frequent in stapler anastomosis due to its larger diameter(10)(11). The results of the HASTA trial(13), a randomized multicentric controlled trial in Germany, are awaited to throw more light on the issue.