STAPLED VERSUS HAND-SEWN INTESTINAL ANASTOMOSIS IN PATIENTS UNDERGOING CYTOREDUCTIVE SURGERY WITH HYPERTHERMIC INTRAPERITONEAL CHEMOTHERAPY
Michael White*1, Dana Cox1, Kristen Robinson1, Bradford J. Kim1, Neal Bhutiani1, Paul Mansfield1, Richard Royal1,2, Keith Fournier1
1Surgical Oncology, MD Anderson Cancer Center, Houston, TX; 2Maine Medical Center, Portland, ME
Cytoreduction (CRS) and heated intraperitoneal chemotherapy (HIPEC) is a morbid operation often involving multi-visceral resections to complete a full cytoreduction. This frequently requires resection and reconstruction of the gastrointestinal tract in the setting of HIPEC, and the associated fluid shifts result in significant bowel edema. Anastomotic leak rates have been quoted to range from 2-20% in this setting
A retrospective review of a prospectively maintained database was conducted for all patients who underwent CRS and HIPEC for disseminated appendiceal adenocarcinoma between January 1, 2010 and October 1, 2014. Patients in whom a bowel resection was performed were included in the study. Those with a hybrid stapled/hand sewn anastomosis were excluded along with those in whom the type of anastomosis was unclear from the operative report. Rates of anastomotic leak were compared to demographic, pathologic, and clinical data Student's t-test and chi-squared where appropriate.
In 146 patients, 220 bowel anastomoses were performed and 11 anastomotic leaks occurred (7.5%). There was no association noted between demographic factors, preoperative therapy, histologic grade, or location of anastomosis. Diverting ostomy was performed in 36 (24.6%) of patients, but this did not result in any difference in leak rates (p=0.35). Readmission rates were equivalent by anastomosis type were 22 (34.9%) in the stapled group versus 20 (24.1%) in the handsewn group (p=0.15), although readmission for abscess neared significance 10 (15.9%) in the stapled group versus 5 (6.0%) in the handsewn group (p=0.05). When comparing the method of anastomosis in these patients, there were 3 (3.6%) leaks in the handsewn group of 83 patients and 8 (12.7%) leaks in the stapled group of 63 patients (p=0.039).
While rates of anastomotic leak are classically thought not to correlate with method of anastomosis whether it be hand-sewn versus stapled or various iterations thereof, gastrointestinal surgeons often elect to perform hand-sewn anastomoses for those patients with significant bowel edema, mismatch in size, or at a difficult location necessitating a sutured anastomosis. Here we demonstrate that in patients undergoing HIPEC, anastomotic leak rates are significantly reduced in those patients undergoing a hand-sewn anastomosis. Despite the limitations of this retrospective review, we now elect for hand-sewn anastomoses in all CRS/HIPEC patients and advocate for a more in-depth prospective study to minimize operative morbidity in this patient population.
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