Critical Review of the Value of Stapling Techniques in Gastrointestinal Surgery

Abstract

The aim of this study is to objectively review the experimental and clinical literature comparing stapled and hand-sutured anastomoses in gastrointestinal surgery. Experimental studies support the hypothesis that stapled sutured lines heal by primary intention, i.e. the inflammatory lag period is avoided, what leads to a superior wound strength during the first postoperative week. On the contrary, sewn sutures always produce an early inflammatory reaction with a transitory rise in collagenase activity in the submucosa, what explains the particular fragility of the anastomosis during this phase. Nevertheless, it is difficult to observe a concordance between this histological quality of the stapled suture line and the clinical results. Because of the difficulties to interprete global comparative retrospective studies, each organ is separately analyzed. In esophageal surgery, an elevated rate of stenosis and a decreased rate of anastomotic leakage is observed. In gastric and colorectal surgery, the superiority of the stapled suture is not proved. Nevertheless, in randomized studies on colorectal surgery, the presence of a withdrawn group where the stapler was the only technically possible alternative undeniably proves that this technique is an indispensable adjunct in modern digestive surgery. Its value seems negligible, however, in small bowel or intraperitoneal descending colon surgery, where hand suturing remains the technique of choice.