The key point of digestive cancer surgery is reconstruction and anastomosis of the digestive tract. Traditional anastomoses involve double-layer interrupted suturing, manually or using a surgical stapler. In special anatomical locations, however, suturing may become increasingly difficult and the complication rate increases accordingly. In this study, we aimed to investigate the feasibility and safety of a new manual suturing method, the single-layer continuous suture in the posterior wall of the anastomosis. Between January, 2007 and August, 2012, 101 patients with digestive cancer underwent surgery in Xi’an Gaoxin Hospital. Of those patients, 27 underwent surgery with the new manual method and the remaining 74 underwent surgery using traditional methods of anastomosis of the digestive tract. Surgical time, intraoperative blood loss, drainage duration, complications, blood tests, postoperative quality of life (QOL) and overall expenditure were recorded and analyzed. No significant differences were observed in surgical time, intraoperative blood loss, temperature, blood tests and postoperative QOL between the two groups. However, compared with the control group, the new manual suture group exhibited a lower surgical complication rate (7.40 vs. 31.08%; P=0.018), lower blood transfusion volume (274.07±419.33 vs. 646.67±1,146.06 ml; P=0.053), shorter postoperative hospital stay (14.60±4.19 vs. 17.60±6.29 days; P=0.038) and lower overall expenditure (3,509.85±768.68 vs. 6,141.83±308.90 renminbi; P=0.001). Our results suggested that single-layer continuous suturing for the anastomosis of the digestive tract is feasible and safe and may contribute to the reduction of surgical complications and overall expenditure.
Gastric cancer is currently a leading cause of cancer-related mortality. Despite the overall decrease in morbidity over the last few years, gastric cancer remains the second leading cause of cancer-related mortality worldwide and the first in China (
Traditional manual suturing and surgical staples are commonly used in clinical practice. The main anastomotic complications include leakage, stricture and infection. It was reported that, in esophagogastric anastomosis, the incidence rate of leakage and stricture was 0–21.9 and 0–25.8%, respectively, with manual suturing and 0–19.5 and 0–32.8%, respectively, with surgical stapling (
Traditional manual anastomosis with double-layer interrupted suture is a complicated procedure, depending largely on the skill of the surgeon. Furthermore, in certain surgeries, such as esophagogastrostomy and colorectostomy, the anastomosis may be more difficult to perform, owing to the special anatomical location, and the complication rate increases accordingly.
Stapling devices are used for suturing in difficult anastomotic locations. With the use of staplers, an increasing number of proximal gastric cancers have become resectable through the abdominal cavity and the number of anal-preserving surgeries for rectal cancer is also on the increase. Stapling devices may decrease surgery time, surgical trauma and anastomotic complications (
Single-layer continuous suture is a method commonly used for vessel anastomosis in deep locations. The tightness and safety of the single-layer suture has been proven in anastomoses of the digestive tract (
In this study, we aimed to investigate a new manual method for difficult anastomotic locations, which is the single-layer continuous suture in the posterior wall of the anastomosis. We consider this method to be feasible and safe and it may help simplify procedures that are considered difficult due to special anatomical locations, solve the problem of instrument shortage for instrumental anastomosis and reduce expenditure.
Between January, 2007 and August, 2012, 350 consecutive patients with gastric or colorectal cancer underwent open surgery in the Department of General Surgery, Xi’an Jiaotong University, China. For this prospective cohort study, the patient inclusion criteria were as follows: i) adult patients (>18 years); ii) patients with gastric cancer who underwent proximal or total gastric resection with esophagogastric or esophagojejunal anastomosis, whereas those with distal gastric resection or palliative resection were excluded; and iii) patients with colorectal cancer who underwent low anterior resection of the rectum or left-side colostomy followed by colon-to-rectum anastomosis, whereas those undergoing local excision, Hartmann procedure, Miles procedure, palliative treatment or right-side colostomy were excluded.
Of the 101 patients who met the inclusion criteria and were enrolled in this cohort study, 65 underwent esophagogastric anastomosis and 36 underwent colorectal anastomosis. The patients were grouped according to the treatment received as follows: i) new manual suture, 27 patients; ii) traditional manual suture, 65 patients; and iii) stapling, 9 patients. The clinical and pathological details of all the cases were carefully recorded. The TNM clinical and pathological staging classification was used for gastric cancer and Dukes’ staging classification was used for rectal cancer.
This study was approved by the Ethics Committee of the Xi’an Jiaotong University. All patients received verbal and written information regarding the study and provided informed consent prior to their enrollment.
Demographic data, including gender, age, smoking status, alcohol consumption and disease history were collected. Preoperative data, including routine hematological and biochemical tests and X-rays were collected to enable a subsequent analysis of the comparability of the groups.
All surgeries were performed under general anaesthesia. Bowel preparation and antibiotic prophylaxis were standardized. An upper midline abdominal incision was performed, followed by spleen-preserving D2 lymphadenectomy.
The staple suturing was performed as follows: the distal esophagus was transected and a purse-string suture was placed on the proximal end. Subsequently, the anvil of a 28-mm diameter circular stapler was introduced into the distal esophageal end, the central shaft of the gun was thrust through the anterior wall of the distal greater curvature and was assembled with the anvil (outer ring). An end-to-side anastomosis was created with the button, the gun was withdrawn and the residual gastric end was closed.
In the traditional manual suture group, the lesser curvature lateral to the gastric end was closed and the greater curvature was prepared for end-to-end anastomosis. The double-layer interrupted suture with silk thread was used in the posterior and anterior wall of the anastomosis (total layer suture combined with embedding of the serosal and muscle layer).
The new manual suture was performed as follows: the single-layer continuous suture with 4-0 prolene thread (Ethicon, Inc., Somerville, NJ, USA) was used in the posterior wall of the anastomosis and the double-layer interrupted suture with silk thread was used in the anterior wall. Abdominal drains were inserted and the abdominal incision was closed to complete the surgery.
The new manual suture was performed as follows: the posterior wall of the anastomosis was sutured using the single-layer continuous suture with a 4-0 prolene thread and the anterior wall was sutured with the traditional manual technique.
The staple suture was performed with a 32-mm diameter circular stapler (Johnson & Johnson, New Brunswick, NJ, USA), with the anvil placed on the distal end of the colon. The central shaft of the gun was introduced into the residual rectum via the anal canal and assembled with the anvil. An end-to-end colon-to-rectum anastomosis was created with the button. The abdominal incision was closed in layers.
The volume of the drainage fluid was recorded at 1, 2, 3 and 7 days following the surgery. The surgical time was measured from the first skin incision to the last suture placement for all the techniques. The recovery time of gastrointestinal function, intraoperative blood loss, total amount of blood transfusion and the highest postoperative temperature were recorded. The surgical specimens, together with any separately harvested lymph nodes, were placed in formalin and transported to the laboratory for pathological examination. The histological subtype and pathological stage were recorded using the Union for International Cancer Control TNM classification for gastric cancer and the Dukes’ classification for rectal cancer.
Following the surgery, blood samples were collected and routine blood, liver and renal function tests were performed.
Radiological assessment of the anastomotic integrity for the esophagogastric and colorectal anastomoses was performed using a water-soluble contrast enema 4–14 days postoperatively. Any extravasation of the contrast medium detected on radiography was considered a radiological leak. A clinical leak was defined as the appearance of fecal material in the abdominal drains, development of a colocutaneous fistula, or the development of systemic sepsis associated with local peritoneal signs during the postoperative period. Clinically significant anastomotic strictures were defined as those requiring surgical dilation in patients who developed symptoms of outlet obstruction.
The European Organization for Research and Treatment of Cancer (EORTC) QLQ-C30 patient questionnaire was used, which is a recognized reliable and validated QOL evaluation tool (
The data were analyzed using SPSS software, version 11.5 (SPSS Inc., Chicago, IL, USA). The Student’s t-test and Chi-square test were used to analyze continual and categorical variables, respectively. To elucidate the risk factors for postoperative complications, a multivariate analysis was performed using the logistic regression model.
The average surgical time in the new manual technique group was 4.58±1.04 h and in the traditional manual and staple group was 4.57±1.47 h (P=0.965). There was no significant difference in the amount of intraoperative blood loss between the two groups.
Following the surgery, there were no significant differences between the two groups with regard to the highest recorded temperature, time until a regular diet was tolerated and time until the first bowel movement. However, the volume of abdominal drainage fluid at 1, 2, 3 and 7 days in the new manual technique group was significantly lower compared with that in the traditional group.
The blood transfusion volume in the new manual technique group was lower compared to that in the traditional technique group (274.07±419.33 vs. 646.67±1,146.06 ml, respectively; P=0.053). The postoperative hospital stay was shorter in the new manual compared to that in the traditional technique group (14.60±4.19 vs. 17.60±6.29 days, respectively; P=0.038). The total expenditure of the surgery was lower in the new manual compared to that in the staple group (3,509.85±768.68 vs. 6,141.83±308.90 renminbi, respectively; P=0.001) (
There were no significant differences in the routine blood, liver and renal function tests, or in glucose and electrolyte levels between the new manual and traditional technique groups (
The incidence rate of complications in the new manual technique group was 7.40%, which was statistically significantly lower compared to that in the traditional group, which was 31.08% (P=0.018). However, there were no differences regarding the complications of the anastomotic port (0 vs. 4.05%; P=0.288) (
The mean scores for all EORTC QLQ-30 questions in new manual and traditional technique groups were 18.46±6.59 vs. 16.13±6.03. There were no statistically significant differences between the two groups (P=0.31) (
In this study, we used the continuous single-layer suture in the posterior wall of the anastomosis of the digestive tract in 27 cases involving difficult surgical locations and demonstrated that this new manual anastomostic method is technically possible to perform and appears to be as efficient and safe as the traditional and stapling techniques. The complication rate was the same or lower compared to that observed with stapling and traditional anastomotic techniques. Moreover, the overall expenditure was significantly reduced.
Our results demonstrated that the total complication rate in the new manual technique group was 7.4% and the anastomotic complication rate was zero, which was lower than that recorded in the traditional technique group and previous studies (
The difficulty of the anastomosis lies with limited exposure, particularly of the posterior wall, in certain anatomical locations. The anastomosis may not be adequately visualized due to the surrounding tissues; even with the use of surgical staplers, the procedure is performed blindly. However, the continuous suture does not require a prior butt joint, which makes the exposure of the posterior wall easier and contributes to convenience and safety.
The first basic consideration regarding the surgical technique of gastrointestinal anastomosis is mechanical integrity. Undoubtedly, among various types of anastomosis, the continuous suture is the tightest, which explains the fact that it is commonly used for blood vessel sutures. Furthermore, it was demonstrated that single-layer anastomosis is as strong as double-layer suturing in the small intestine and colon and ensures mechanical integrity (
It was previously demonstrated that the surgical time may be reduced by ≤30 min for each stapled anastomosis (
The development of strictures is closely associated with the diameter of the anastomosis and the thickness of the wall. Staple and conventional manual sutures are double-layer sutures and, in certain cases, a strengthening suture may be required following stapling. The staple anastomosis ‘reinforced’ with sutures is a three-layered affair, leading to more tissue turning inwards and inducing stricture formation (
In conclusion, our results suggest that single-layer continuous suture in the posterior wall of the anastomosis of the digestive tract is a novel, feasible and safe method that may simplify the surgical procedure in anastomoses that present with difficulty due to special anatomical location, while reducing overall expenditure.
This study was supported by the Science Research and Technology Development Program of Shaanxi (grant no. 2010K15-07-03). The authors would like to thank Dr An Xin-Ming and Wang Na for their help with data collection and statistical analysis.
Characteristics of patients in new manual and traditional method groups.
Characteristics | Gastric cancer
|
Rectal cancer
| ||||
---|---|---|---|---|---|---|
New manual | Traditional | P-value | New manual | Traditional | P-value | |
Male/female | 15/4 | 31/15 | 0.550 | 3/5 | 14/14 | 0.695 |
Age, years (mean ± SD) | 58.89±11.31 | 63.50±11.68 | 0.207 | 48.14±25.61 | 61.70±15.44 | 0.133 |
Tumor size, cm | 4.48±2.01 | 5.89±3.25 | 0.165 | 5.17±2.79 | 5.67±2.33 | 0.668 |
Lymph node involvement | ||||||
Negative | 5 | 10 | 0.753 | 5 | 15 | 0.709 |
Positive | 14 | 35 | - | 3 | 13 | - |
Unknown | 0 | 1 | - | 0 | 0 | - |
Grade of differentiation | ||||||
High | 2 | 4 | 0.755 | 4 | 9 | 0.635 |
Moderate | 8 | 22 | - | 4 | 15 | - |
Poor | 9 | 18 | - | 0 | 2 | - |
Unknown | 0 | 2 | - | 0 | 2 | - |
Pathological type | ||||||
Adenocarcinoma | 12 | 28 | 0.990 | 5 | 22 | 0.384 |
Non-adenocarcinoma | 7 | 18 | - | 3 | 6 | - |
TNM stage | ||||||
I | 3 | 2 | 0.128 | |||
II | 0 | 6 | - | |||
III | 7 | 22 | - | |||
IV | 9 | 16 | - | |||
Dukes’ stage | ||||||
A | 3 | 3 | 0.297 | |||
B | 1 | 10 | - | |||
C | 2 | 6 | - | |||
D | 2 | 9 | - |
The Student’s t-test was used to analyze age and tumor size; the Chi-square test was used to analyze categorical variables. The traditional group involved double-layer manual and stapled suture. SD, standard deviation.
Comparison of preoperative data between patients undergoing anastomosis with the new manual and traditional techniques.
Variables | New manual (mean ± SD) | Traditional (mean ± SD) | P-value |
---|---|---|---|
Surgical time (h) | 4.58±1.04 | 4.57±1.47 | 0.965 |
Intraoperative blood loss (ml) | 215.78±141.47 | 262.50±182.27 | 0.343 |
Time until regular diet tolerated (days) | 6.31±1.57 | 7.00±1.71 | 0.093 |
Time until first bowel movement (days) | 4.88±1.07 | 5.24±1.32 | 0.255 |
Abdominal drainage (ml) | |||
Day 1 | 126.32±81.77 | 208.88±182.24 | 0.013 |
Day 2 | 59.42±62.39 | 93.70±114.76 | 0.036 |
Day 3 | 29.85±42.42 | 84.84±110.67 | 0.005 |
Day 7 | 15.38±36.66 | 45.70±94.5 | 0.064 |
Temperature (°C) | 37.79±0.70 | 37.58±0.47 | 0.182 |
Blood transfusion (ml) | 274.07±419.33 | 646.67±1,146.06 | 0.053 |
Expenditure of surgery (RMB) | 3,509.85±768.68 | 6,141.83±308.90 |
0.001 |
Hospital stay (days) | 14.60±4.19 | 17.60±6.29 | 0.038 |
The value was obtained from the group undergoing staple suture. The Student’s t-test was used to analyze all the variables. The traditional group involved double-layer manual and stapled suture. SD, standard deviation; RMB, renminbi.
Pre- and postoperative routine blood and liver function tests in patients undergoing anastomosis with the new manual and traditional techniques.
Variables | Preoperative
|
P-value | Postoperative
|
P-value | ||
---|---|---|---|---|---|---|
New manual (mean ± SD) | Traditional (mean ± SD) | New manual (mean ± SD) | Traditional (mean ± SD) | |||
Routine blood test | ||||||
WBC (109/l) | 5.88±2.62 | 6.56±2.86 | 0.415 | 9.18±3.13 | 9.12±7.08 | 0.966 |
GRA (%) | 62.86±15.54 | 67.49±8.58 | 0.264 | 75.23±8.32 | 74.37±12.25 | 0.797 |
RBC (1012/l) | 4.19±0.83 | 3.85±0.53 | 0.128 | 3.85±0.68 | 3.82±0.48 | 0.855 |
HGB (g/l) | 122.44±28.60 | 107.43±25.32 | 0.068 | 114.67±22.65 | 110.80±11.77 | 0.541 |
PLT (109/l) | 198.13±75.20 | 248.74±111.73 | 0.084 | 260.07±110.32 | 264.86±123.01 | 0.898 |
Liver function | ||||||
T.BIL ( |
14.12±6.89 | 14.10±5.96 | 0.992 | 16.23±7.80 | 10.08±3.11 | 0.116 |
ALT (U/l) | 23.48±16.75 | 27.31±20.14 | 0.553 | 48.93±49.21 | 47.33±30.86 | 0.931 |
TP (g/l) | 65.95±8.09 | 63.92±20.99 | 0.693 | 60.98±7.50 | 66.04±8.66 | 0.165 |
ALB (g/l) | 39.67±4.72 | 36.20±11.25 | 0.210 | 33.57±4.24 | 34.64±4.97 | 0.560 |
Renal function | ||||||
BUN (mmol/l) | 5.95±2.51 | 4.75±1.47 | 0.143 | 4.49±1.54 | 5.67±2.31 | 0.210 |
CR ( |
76.66±21.76 | 74.75±21.84 | 0.812 | 62.36±16.29 | 74.00±28.51 | 0.284 |
Glucose (mmol/l) | 5.32±1.66 | 5.42±0.82 | 0.872 | 6.85±2.63 | 7.83±2.82 | 0.654 |
Blood electrolytes | ||||||
Na (mmol/l) | 141.74±4.09 | 140.52±2.76 | 0.407 | 135.99±5.22 | 138.30±2.80 | 0.284 |
K (mmol/l) | 4.03±0.48 | 3.86±0.59 | 0.387 | 4.10±0.71 | 4.49±0.77 | 0.249 |
Cl (mmol/l) | 102.45±3.53 | 101.60±2.87 | 0.518 | 98.05±5.44 | 98.86±2.50 | 0.714 |
The Student’s t-test was used to assess the statistical significance of the differences in the tumor volume between the new manual and traditional groups. The traditional group involved double-layer manual and stapled suture. SD, standard deviation; WBC, white blood cell count; GRA, granulocyte; RBC, red blood cell count; HGB, hemoglobin; PLT, platelet count; T.BIL, total serum bilirubin; ALT, alanine transaminase; TP, serum protein; ALB, albumin; BUN, blood urea nitrogen; CR, creatinine; Na, sodium; K, potassium; Cl, chlorine.
Postoperative complications in the two groups.
Complications | New manual | Traditional | P-value |
---|---|---|---|
Hospital death | 0 | 0 | - |
Reoperation | 0 | 1 | - |
Cardiac complications | - | 1 | - |
Pulmonary complications | 1 | 7 | - |
Wound infection | 1 | 7 | - |
Severe bleeding | - | 3 | - |
Chylous leakage | - | 1 | - |
Anastomosis stricture | - | 1 | - |
Anastomosis leakage | - | 2 | - |
Any complication (%) | 2 (7.40) | 23 (31.08) | 0.018 |
Anastomotic complication (%) | 0 | 3 (4.05) | 0.288 |
The Chi-square test was used to assess the incidence of complications. The traditional group involved double-layer manual and stapled suture.
Logistic regression analysis of the association between postoperative complications and preoperative variables for the 101 patients.
Variables | Regression coefficient | Standard error | P-value |
---|---|---|---|
New manual suture | −1.69 | 0.96 | 0.078 |
Tumor stage | 0.92 | 0.52 | 0.080 |
Tumor grade | - | - | 0.402 |
Age | - | - | 0.550 |
Gender | - | - | 0.223 |
Pathological type | - | - | 0.744 |
Gastric/rectal cancer | - | - | 0.332 |
Underlying disease | - | - | 0.483 |
Surgical bleeding | - | - | 0.899 |
The new manual suture was coded as 1, yes, 2, no; tumor stage was coded from 1 to 4 with increasing stage; tumor grade was coded from 1 to 3 with increasing grade; gender was coded as 1, male and 2, female; pathological type was coded as 1, adenocarcinoma and 2, non-adenocarcinoma; underlying disease including hypertension, chronic bronchitis, diabetes mellitus and chronic hepatitis was coded as 0, absent and 1, present.
Evaluation of QOL scores in the two groups.
Symptoms | New manual (mean ± SD) | Traditional (mean ± SD) | P-value |
---|---|---|---|
Fatigue | 1.55±1.04 | 1.46±0.93 | 0.806 |
Sleep | 1.55±0.82 | 1.08±0.41 | 0.032 |
Pain | 1.73±1.27 | 1.71±1.27 | 0.968 |
Constipation | 1.18±0.40 | 1.00±0.00 | 0.032 |
Diarrhea | 1.27±0.65 | 1.38±0.88 | 0.732 |
Micturition problems | 1.09±0.30 | 1.00±0.00 | 0.142 |
Gastrointestinal problems | 2.18±1.25 | 1.83±1.24 | 0.447 |
Defecation problems | 1.45±0.69 | 1.04±0.20 | 0.010 |
Nausea/vomiting | 1.73±1.27 | 1.38±1.01 | 0.385 |
Loss of appetite | 2.18±1.33 | 1.75±1.19 | 0.343 |
Weight loss | 1.55±0.93 | 1.46±0.93 | 0.799 |
Dyspnea | 1.00±0.00 | 1.04±0.20 | 0.507 |
Sum | 18.45±6.59 | 16.13±6.03 | 0.310 |
Follow-up time (months) | 2.73±1.89 | 2.46±1.63 | 0.669 |
The Student’s t-test was used to analyze all the variables. The traditional group involved double-layer manual and stapled suture. SD, standard deviation; QOL, quality of life.