Double stapling can be hazardous
Steven D Wexner MD PhD(Hon)
Surgeon, Educator, Researcher, Author, Innovator, and Communications Leader; Past Vice Chair, Board of Regents at American College of Surgeons; Chair National Accreditation Program for Rectal Cancer
Anastomotic leaks are amongst the most vexing complications which follow intestinal anastomoses. The rates of leakage are highest at the proximal and distal ends of the intestinal tract. Many factors have been found to increase the rate of colonrectal or coloanal anastomotic leakage including male gender, obesity, prior radiation, and immunosuppression. Surgeons have employed many methods to try to decrease low pelvic anastomotic leakage including routine splenic flexure mobilization, routine high ligation of the inferior mesenteric artery and vein, and anastomotic assessment. This latter method of verification of anastomotic integrity can be performed in any one of several methods as we have previously published, our preferences quadruple assessment including inspection of donuts, direct endoscopic anastomotic visualization, air insufflation to assess circumferential anastomotic integrity, and indocyanine green fluorescence angiography. Double stapling during open surgery has evolved into a misnomer in minimally invasive surgery. Specifically, as opposed to using a single 30 millimeter stapler one or more firings of a linear cutting stapler are employed to facilitate distal rectal transection. Increasing attention has been paid to the potential hazards of this technique. Most recently, Balciscueta and coworkers performed a systematic review and meta-analysis in which they identified five studies detailing the data on 1,267 patients. The authors identified that the rate of anastomotic leakage increased from 3.5% in cases in which one stapler firing was employed to almost double at 6.7% in instances in which two stapler firings were employed. The authors calculated an odds ratio of 2.44 and a significance of p=0.003 as increased risks of anastomotic leak when two staple firings were utilized. I congratulate the authors from Spain on their critically important study. I agree with them that we should strive to avoid more than a single stapler firing. Perhaps carrying forward their clearly significant findings of multiple stapler firings increasing the risk of anastomotic leak we should strive to completely avoid any double stapling and perform end to end anastomoses such as may be routinely undertaken in patients in whom a coloanal anastomosis is formed.
Minimal Invasive and Oncology Surgery, Fine Arts lover
4 年I do thank Steven D Wexner for sharing his very interesting comments on the paper from Balciscueta. Avoiding multiple stapler firings should be a must in surgery of the lower rectum. This could be a further advantage of the transanal approach to TME (TaTME) and a field for future investigation
Libero professionista Medicina
4 年I completely agree with Prof Wexner and with the conclusion that we to try to avoid multiple staple firing performing low Colorectal anastomosis withouth intersepting staple line. I had the opportunity to present my technique of low Colorectal anastomosis with transanal control with CAD and PSA 14 years ago in a wonderful meeting in Fort Lauderdale organized by Prof Wexner. In that presentation the rectal stump suture line was resected avoiding dog ears formation , the low Colorectal anastomoses was realized without intersepting staple line and the anastomoses was evaluated in laparoscopic with the original technique of the reverse air leak test. Many thanks Prof Wexner for this very interesting post. #crafafrancesco #lowcolorectalanastomoseswithtransanalcontroll #reverseairleaktest #avoiddogears #TICRANTSTUDY #