Best evidence topic: Is ileocolic anastomotic leak rate higher in handsewn or stapler's anastomosis?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: is ileocolic anastomotic leak rate higher in handsewn or stapler's anastomosis? Using the reported search, 150 papers were found. 6 studies were deemed to be suitable to answer the question. The outcomes assessed were anastomotic leaks rate in hands Sewn and stapler's ileocolic anastomosis. The evidence does not provide an agreed consensus for which modalities of anastomosis have higher anastomotic leaks rate. Until a high quality randomized control trial is performed, the authors recommend an individual approach in a term of selection of which anastomotic modalities to be used.


Introduction
This BET was devised using a framework outlined by the International Journal of Surgery [1]. This format was used because a preliminary literature search suggested that the available evidence is of insufficient quality to perform a meaningful meta-analysis. A BET provides evidence-based answers to common clinical questions, using a systematic approach of reviewing the literature.

Clinical scenario
You are a general surgery trainee. Assisting in a case of right hemicolectomy for cecal cancer, the consultant is about to perform the ileocolic anastomosis and he is quite concern about the possibility of leak, you are wondering which is the better modality to reduce the leak rate, hands Sewn or stapler's anastomosis?

Three-part question
In [patients planned for ileocolic anastomosis] is [the anastomotic leaks rate] is higher in [hands sewn or stapler's anastomosis]?

Search strategy
A. Embase 1974 to October 2020 using the OVID interface: [ The results were limited to English articles and human studies.

Search outcome
A total of 197 papers were found using OVID and 159 using the PubMed interface. A total of 150 papers were identified after we removed duplicates. Out of these 141 papers were excluded because they were irrelevant based on titles and abstracts. 9 full-text articles were screened and assessed for eligibility. From these, six papers were identified that provided the best evidence to answer the question eligible articles were defined as those articles that compared the anastomotic leak rate among patients who underwent ileocolic anastomosis with handsewn or stapler's techniques regardless of the indications for surgery. Up to our knowledge there is no universal consensus of a practical definition of ileocolic anastomosis yet available in the literature, so we relied on what was described by the authors as anastomotic leaks.

Discussion
Puleo et al. [7], conducted a large retrospective study in 2012 they included 999 patients who underwent ileocolic anastomosis for cancer and inflammatory bowel disease. 46.4% (464) of the anastomoses were handsewn and 53.6% (535) were stapled. The author concluded that the rate of anastomotic leakage among cancer patients was higher in the hand sewn group compared to the stapled group. 22 (4.9%) leaks in Author handsewn group compared to 13 (2.5%) in stapled group (P = <0.05). The incidence of anastomotic leak among patients with inflammatory bowel disease was not statistically significant.
In contrast, Gustafson et al. [6] in 2015, conducted a large multicentre retrospective study included 3428 cohorts who were diagnosed with right sided colon cancer and therefore underwent ileocolic anastomosis after a right hemicolectomy or ileocolic resection. The author concluded that the stapled anastomosis group had a statistically significant higher leakage rate compared to the handsewn group (2.4% vs. 1.2% P value = 0.006). Furthermore, Nordholm-Carstensen et al. [3], in 2018 reached the same conclusion after they conducted a large nationwide retrospective study which included 1414 patients who had ileo-colic anastomosis after right hemicolectomy for adenocarcinoma in the right colon. The author stated a 2-fold increase in anastomotic leak among stapled group versus handsewn group. There were 21 leaks (5.4%) in the stapled group compared to 24 (2.4%) in handsewn group (p = 0.004).
Nevertheless, despite these contradicting findings, another three large sized trials including randomised control trials showed no statically significant difference in anastomotic leak rate between handsewn and stapled techniques used for ileocolic anastomosis.
Those are the study which were conducted by Zurbuchen et al. [2] In 2012, which was a multicentre randomized controlled trial that included 67 patients who had ileocolic resection for Crohn's disease and also, the retrospective study in 2018 by Jurowich et al. [4] which included 4062 patients who underwent ileocolic anastomosis after right hemicolectomy for colon cancer and recently in 2019 Golda et al. [5]. Performed a single centre retrospective study including 470 patients who underwent ileocolic anastomosis after right colectomy for cancer.

Limitations of this review
1. Relatively weak level of evidence as there is only one randomized controlled trial out of the six studies included. 2. Lack of heterogeneity in the diagnosis, as some studies included cancer and some included Crohn's disease. 3. Lack of an agreed unified technique between the trials. As some used end to end and some side to side with different suturing materials and techniques which made it hard to compare. 4. Some of the papers have mentioned a possibility of selection bias between different centres and surgeons.

Clinical bottom line
There is insufficient scientific evidence to provide an answer regarding which modalities of anastomosis (handsewn or stapler's anastomosis) has higher anastomotic leaks rate in ileocolic anastomosis. Although from the evidence we have got, it seems that handsewn technique is more promising, as two studies compared to one study concluded that handsewn technique is associated with statistically significant lower leaks rate in comparison to stapler's technique. Until a large volume, multicentre, high quality randomized control trials can be performed, the author's advice a case by case individual approach in a term of selection of the anastomotic modalities, based on the skills of the surgeon and the availability of resources.

Ethical approval
Not applicable.

Sources of funding
None.

Author contribution
SA: conducted the literature search and wrote the paper. AK: assisted in the literature search and. Writing of paper. TA: assisted in writing of paper. RI: assisted in the literature search, editing and Writing of paper.

Provenance and peer review
Not commissioned, externally peer reviewed.

Declaration of competing interest
None.