Stapled versus hand-sewn pediatric intestinal anastomoses: A retrospective cohort study

doi:10.1016/j.jpedsurg.2018.02.021

Journal of Pediatric Surgery

Volume 53, Issue 5, May 2018, Pages 959-963

https://doi.org/10.1016/j.jpedsurg.2018.02.021 Get rights and content

Abstract

Background

Whereas the adult literature has demonstrated the acceptable safety profile of stapled anastomoses when compared to the hand-sewn alternative, the choice of intestinal anastomosis using sutures or staples remains inadequately investigated in children. The purpose of this study is to compare the anastomotic outcomes of both techniques in children under 5 years of age.

Methods

A retrospective analysis of patients undergoing intestinal anastomosis at a single tertiary centre (2012–2016) was undertaken. Demographics, diagnosis, anatomy, and complications were compared between the hand-sewn (HS) and stapled anastomosis (SA) groups. Primary outcomes were anastomotic leak and/or stricture requiring intervention.

Results

There were 72 patients with 90 intestinal anastomoses (67 HS, 23 SA). Baseline demographics between the two anastomotic groups were comparable. The overall anastomotic complication rate was 23.9% (HS) and 17.4% (SA). In the ileocolic subgroup, anastomotic complications occurred in 3/7 HS vs. 0/5 SA (ns). There were no statistically significant differences in primary outcomes between HS and SA. All SA complications occurred with 3.5 or 3.8 mm staples.

Conclusions

In our study population, no statistically significant difference between hand-sewn and stapled intestinal anastomosis outcomes was found. However, further investigation is warranted.

Level of Evidence

3 (Retrospective Comparative Treatment Study)

Section snippets

Materials and methods

A retrospective review of pediatric patients under 5 years of age undergoing an intra-abdominal intestinal anastomosis between 2012 and 2016 at a single large tertiary pediatric hospital was performed. Institutional ethics approval was obtained [#H16–01016]. Demographic data including gestational age at birth, gender, the presence of any congenital anomalies, underlying surgical diagnosis, age and weight at procedure, and the length of follow-up was collected. Characteristics of the anastomosis

Results

Over the four years reviewed, a total of 90 intestinal anastomoses were performed in 72 patients. 67 were hand-sewn, and 23 were stapled (Table 1). Both age and weight at the time of surgery were comparable between the anastomotic groups. In the HS group, the median age at the time of operation was 8.9 months, while it was 10.5 months in the SA group (p = 0.629). In the HS group, median weight was 8 kg, while it was 8.2 kg in the SA group (p = 0.848). A significant difference between anastomotic groups

Discussion

Stapled intestinal anastomoses have been widely studied in the adult population, and thus their safety and efficacy when compared to hand-sewn anastomoses is un-questioned [1], [2], [3]. In fact, there is evidence to suggest that, besides a decrease in operative time, a decreased rate of anastomotic leak may be seen in ileocolic anastomoses specifically, with the use of a stapled technique [4]. In children however, the evidence base is not nearly as strong. Despite stapling devices being first

Conclusions

We present, to our knowledge, one of the largest reported pediatric studies comparing outcomes of hand-sewn and stapled intestinal anastomoses, and we found no significant differences in anastomotic outcomes between the two groups. This suggests that, when permitted by intestinal size, a stapled anastomosis is a safe choice. Ultimately, as already carried out in the adult population, a prospective, multi-centre trial would be most helpful in comparing stapled to hand-sewn anastomotic techniques

Acknowledgements

Ms. Maryam Noparast for assistance with statistical analysis.

References (20)

M. Olguner et al.
Laparoscopic appendectomy in children performed using single endoscopic GIA stapler for both mesoappendix and base of appendix
J Pediatr Surg
(1998)
G. Mattioli et al.
Stapled restorative proctocolectomy in children with refractory ulcerative colitis
J Pediatr Surg
(2005)
L. Wrighton et al.
Stapled intestinal anastomoses in infants
J Pediatr Surg
(2008)
I.C. Mitchell et al.
Experience performing 64 consecutive stapled intestinal anastomoses in small children and infants
J Pediatr Surg
(2011)
R.W. Powell
Stapled intestinal anastomosis in neonates and infants: use of the endoscopic intestinal stapler
J Pediatr Surg
(1995)
Frances Goulder
Bowel anastomoses: The theory, the practice and the evidence base
World J Gastrointest Surg
(2012)
C.B. Neutzling et al.
Stapled versus handsewn methods for colorectal anastomosis surgery
Cochrane Database Syst Rev
(2012)
J.C. Slieker et al.
Systematic Review of the Technique of Colorectal Anastomosis
JAMA Surg
(2013)
P.Y. Choy et al.
Stapled versus handsewn methods for ileocolic anastomoses
Cochrane Database Syst Rev
(2011)
J.L. Talbert et al.
Evaluation of a modified Duhamel operation for correction of Hirschsprung's disease
Ann Surg
(1974)

There are more references available in the full text version of this article.

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^☆: This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

View full text

Stapled versus hand-sewn pediatric intestinal anastomoses: A retrospective cohort study☆

Abstract

Background

Methods

Results

Conclusions

Level of Evidence

Section snippets

Materials and methods

Results

Discussion

Conclusions

Acknowledgements

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

J Pediatr Surg

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World J Gastrointest Surg

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Cochrane Database Syst Rev

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JAMA Surg

Stapled versus handsewn methods for ileocolic anastomoses

Cochrane Database Syst Rev

Evaluation of a modified Duhamel operation for correction of Hirschsprung's disease

Ann Surg