The impact of stapled compared to handsewn repair on anastomotic outcomes in trauma patients: a systematic review and meta-analysis.

Abstract

Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta-analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches. A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess. Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24-2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra-abdominal abscess and intra-abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53-2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders. This meta-analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma.