Introduction

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.

Figure 1

Fig. 1: Dissection of loop ileostomy through circumferential incision

Figure 2

Fig. 2: Insertion of the linear cutting stapler (TL 55 mm) into proximal and distal limb of the ileum

Figure 3

Fig. 3: Completed side-to-side stapler anastomosis of the loop ileostomy with closure of entertomy with linear stapler 60 mm

Figure 4

Fig. 4: Proximal and distal limb of loop ileostomy in case of hand-sewn anastomosis. Double-layer anastomosis was done with vicryl 3-0 continuous locking sutures followed by 3-0 blacksilk Lambert sutures.

Figure 5

Fig. 5: Closure of posterior wall in continuous locking manner starting from the anti-mesenteric border

Figure 6

Fig. 6: Closure of loop ileostomy in continuous locking manner

Figure 7

Fig. 7: Completed hand-sewn end-to-end anastomosis

Observations

Figure 8

Table 1: Operative time

Figure 9

Table 2: Postoperative complications

Figure 10

Table 3: Postoperative hospital stay

Figure 11

Table 4: Cost of stapler technique

Figure 12

Table 5: Cost of hand-sewn technique

1$=45 Rupees (approx.)

Discussion

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.

Figure 13

Table 6: Operative time

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.

Figure 14

Table 7: Postoperative complications I

Figure 15

Table 8: Postoperative complications II

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.

Figure 16

Table 9: Postoperative hospital stay

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.