Manual Colorectal Surgery
Tommye Hope
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Background: The diffusion in the years '80 of the stapler has modified the habits of the surgeons, determining the reduction of the operative time in colorectal surgery and the possibility to operate cancer of lower rectum, but leaving unchanged the rates of postoperative complications and bringing to the footlights some new complications. Aim of paper is to report our experience about of mechanical sutures in the colorectal anastomoses, with particular attention to the risk factors and complications procedure-related.
Patients and method: From January 2000 to January 2006 in the Section of General and Thoracic Surgery of the University in Palermo, 26 stapled colorectal anastomosis and 11 mechanical terminal colostomies after Miles' amputation have been performed; 12 patients have been submitted to low colorectal termino-terminal anastomosis, 6 to termino-terminal ultralow anastomosis, 1 to coloanal anastomosis and 7 to Knight-Griffen technique.
Discussion: From the literature review emerges the absence of statistically differences between manual and mechanical suture in the colorectal anastomosis in terms of mortality, morbidity (clinical and radiological incidence of the anastomotic gaps, anastomotic stenosis, redo, bleeding, infection of the wound) of employed time to make the anastomosis and of staying in hospital. These data are from American Schools, while greater incidence of radiological leakage is recorded in the European schools is for the manual suture.
Conclusions: At present does not exist clinical trial that shows the superiority of mechanical stapling versus manual suture in the colorectal anastomosis. Stapler makes possible the lower colo-rectal anastomosis often avoiding abdomino-perineal amputation of the rectum, with better quality of life and oncological radicality, but increasing however the incidence of complications as anastomotic dehiscence and stenosis, even if not statistically significant.
This book provides essential didactic content for the SAGES University Masters Program Colorectal Surgery Curriculum. Surgeons seeking to complete the competency, proficiency, or mastery curriculum of the MASTERS Colorectal Pathway for a particular anchoring colorectal procedure will find relevant educational content in this SAGES Manual. Written by experts in the field, each chapter provides detailed guidance on preoperative and peri-procedural considerations for right and left elective and emergency colorectal resections, for both benign and malignant pathologies. Technical pearls and strategies to manage pitfalls and complications are also extensively reviewed along with detailed guidance for both laparoscopic and robotic procedures.
The SAGES Manual of Colorectal Surgery provides a wealth of practical guidance to surgeons along their journey to progress from competency to mastery in various minimally invasive approaches to colorectal surgery.
Written by experts in the field from around the world, this book exposes the many critical gaps in our knowledge base and inspires the next generation to answer them through thoughtful and high level scientific inquiry.
This edition was edited by Drs. Scott R. Steele, Tracy L. Hull, Neil Hyman, Justin A. Maykel, Thomas E. Read and Charles B. Whitlow.
The ASCRS Manual of Colon and Rectal Surgery, 3rd Edition (2019), was designed to provide a rapid access pocket reference for residents, fellows, private clinicians, and allied health professionals caring for patients with colorectal surgical diseases.
An ASCRS manual was produced in in 2009 and 2014, each accompanying their original textbooks. This has been formed by abstracting the textbook into a bullet format; all figures and most tables were retained. The 3rd edition of the Textbook (published by Springer) included completely new chapters and authors. This 3rd edition of the Manual is indicated to conform to the new edition of the Textbook and incorporate newer information in the field of colon and rectal surgery. This Manual will serve as a very useful resource for physicians and researchers dealing with diseases of the colon and rectum. It will provide a concise yet comprehensive summary of the current status of the field that will help guide education, patient management and stimulate investigative efforts. All chapters were written and abstracted by experts in their fields and will include the most up to date scientific and clinical information.
The information presented on The American Society of Colon and Rectal Surgeons (ASCRS) website is solely intended to provide you with information that will help educate you on various conditions. No information provided on this website or otherwise offered by ASCRS is intended to replace or in any way modify the advice of your health care professional.
The study, published in Surgical Endoscopy, shows the groundbreaking device is just as effective in reducing life-threatening and costly surgical complications in real-world surgical practice as demonstrated in recent clinical studies, where the leak rate was 1.7% for the ECHELON CIRCULAR and as high as 11.8% for manual staplers.[3]
For the real-world study, investigators drew from data in the ECHELON CIRCULAR clinical trial (165 patients) and the Premier Healthcare database (1,348 manual circular patients) for a matching adjusted indirect comparison of patients who underwent left-sided colorectal resection.
Each year, more than 600,000 colorectal surgical procedures are performed in the United States[4] and despite advances in surgical technique, the incidence of anastomotic leaks remains high, occurring in nearly 12% of colorectal procedures.[5]
An anastomosis is a critical part of colorectal surgery in which two ends of the colon are connected with staples after part of the organ has been resected or removed due to damage or disease. If this connection is faulty or weak, an anastomotic leak may occur, which can lead to lengthier hospitalization, increased healthcare costs, and/or death.[6],[7] Studies show the mortality rate associated with anastomotic leaks can range from 10% to 15%.[8] The risk of death can be 3- to 15-times greater if an anastomotic leak is present.[9],[10],[11],[12]
The ECHELON CIRCULAR combines two innovative and proprietary technologies -- 3D Stapling Technology that evenly distributes compression[13] and Gripping Surface Technology (GST) for gentler handling that reduces compressive forces on tissues.[14] ECHELON CIRCULAR significantly reduced leaks at the staple line without compromising perfusion.[15]
ECHELON CIRCULAR is the latest addition to a clinical and real-world evidence program that includes the publication of nine peer-reviewed studies in seven countries spanning more than 60 authors and more than 46,000 patients. ECHELON Powered Staplers are the only brand of staplers back by large-scale real-world evidence in bariatric, colorectal and thoracic surgery. Click here to learn more about ECHELON CIRCULAR.
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Assuming 100 procedures per year, the anastomotic leak rate was 1.79 and 29.76 per 100 procedures in the ECP and MCS cohorts, respectively. LOS was 1,426.91 days in the ECP cohort, compared to 1,702.38 days in the MCS cohort. The 90-day readmission rate was also lower in the ECP cohort than the MCS cohort (19.10 vs. 26.19 per 100 procedures). For the 100 procedures, the annual total hospitalization costs for left-sided colorectal anastomosis were reduced from 7,152,251 using manual circular staplers to 6,919,306 using ECP. Despite a higher acquisition cost of ECP compared to the manual staplers (711,200 vs. 441,700), an annual saving of 232,945in the total cost resulted from lower rates of complications and shorter LOS. Sensitivity analyses presented consistent savings using ECP, and the ECP cost and cost of the index hospitalization with anastomotic leak were found the most influencing factors.
There were clinical and economic benefits of ECP, compared to manual circular staplers for left-sided colorectal anastomoses. Further direct comparative studies on the use of ECP in practice in Chinese hospital settings are warranted.
Because ECP was launched in China in 2020, there is a lack of evidence on the use of ECP in China to inform decisions with both clinical and economic considerations. Therefore, this study aimed to evaluate clinical and economic outcomes of ECP relative to manual staplers in Chinese patients undergoing left-sided colorectal anastomoses using a combination of decision tree modeling and real-world evidence.
A decision analysis model was constructed to provide clinical and economic estimates of adult patients who underwent left-sided colorectal anastomoses, using either the powered stapling systems or the conventional manual circular staplers. The occurrence of anastomotic leak and 90-day readmission from an indirect comparison was assessed as the clinical outcomes and the decision model parameters for budget impact analysis. Deidentified information on the use of ECP was derived from the single-arm ECP trial (NCT03326895) [5]. Briefly, the ECP trial enrolled 168 adult patients from the USA and Europe, who underwent left-sided colorectal resections with anastomoses using the 29 mm or 31 mm ECP staplers. The MCS cohort consisted of adult Chinese patients from 20 Chinese tertiary hospitals in 13 cities, who received left-sided colorectal resections with anastomoses using manual circular staplers in January-June 2018. Deidentified information on demographic and clinical characteristics of the patients and billing information of relevant treatments/health care usage was available in the China Health Information System (HIS) database.
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