Stapler Group Research Articles

Anorectal dysfunction following low anterior resection for rectal carcinoma: a comparison between handsewn and stapled anastomosis

Sphincter-saving resection for rectal carcinoma is frequently accompanied by anorectal dysfunction (increased stool frequency and varying degrees of faecal incontinence). Although numerous reports regarding this dysfunction have been published, the exact mechanism is still controversial. The purpose of the present study was to compare the functional results of low anterior resection (LAR) for rectal carcinoma following handsewn and stapled anastomosis. The patients with rectal carcinoma were divided into two groups: LAR with handsewn anastomosis (HS) (n = 15), and LAR with stapled EEA (U.S. Surgical Corporation) anastomosis (EEA) (n = 16; four with 28 mm stapler, 12 with 31 mm stapler). Sixteen patients with carcinoma of sigmoid colon who received high anterior resection (HAR) were taken as the control group. Anorectal functional study was performed preoperatively and post-operatively at 1 week and another after 6 months, whereas routine clinical assessment was carried out preoperatively and 6 months post-operatively. The post-operative maximal resting pressure was significantly reduced in both HS and EEA groups, while a tendency to recovery was observed in the HS and 28 mm stapler group 6 months later. A significant decrease in rectal capacity was noted in the EEA group. The return of rectoanal inhibitory reflex was observed in 67% of the HS group and 37.5% of the EEA group. Although clinically increased stool frequency was experienced in both HS and EEA groups, continence was significantly worse in the EEA group. LAR for rectal carcinoma results in impaired anorectal function, which might present clinically with increased stool frequency and minor faecal soiling. The former may be due partially to reduced neorectal capacity, while the latter may be due to internal anal sphincter dysfunction, possibly because of damage to innervation.

Radical Hysterectomy with the Endoscopic Stapler

Objective.Morbidity associated with radical hysterectomy is significant. Utilizing the endoscopic stapler for transection of the cardinal ligaments and uterosacral ligaments is a possible method to decrease operative time and blood loss.Methods.Two groups of patients, one group with the stapler used (n= 21) and the other with the traditional method utilized (n= 18), were compared in regard to operative and postoperative morbidity, operative time, and surgical margins. The groups were similar in regard to medical condition, age, and weight.Results.Median (243 min versus 284 min) and mean (246 min versus 287 min) operative times were significantly less in the stapler group than in the control group (P< 0.002). Median blood loss was reduced by 20% in the stapler group (400 ml versus 500 ml,P< 0.03). There was no significant difference in febrile morbidity, surgical complications, or length of hospital stay.Conclusion.Our data suggest significant reduction in blood loss and operative time with the use of the endoscopic stapler.

Laparoscopic‐assisted hysterectomy: disposable staples or diathermy?

A total of 114 patients underwent laparoscopic‐assisted vaginal hysterectomy in a 38‐month period from December 1991, to February 1994. In 65 patients, disposable staples were used to achieve pedicle haemostasis and in 49 cases bipolar diathermy was used. No learning curve cases were excluded. Three additional patients were converted to open hysterectomy. No difference in outcome for the two groups was noted. Average operating time was slightly longer when diathermy was used. Average postoperative bed days were 2.8 days for the staple group and 2.7 days for the diathermy group. The cost‐effectiveness of the procedure may be improved when non‐disposable equipment is used for pedicle haemostasis.

Comparison of absorbable uterine staples and traditional hysterotomy during cesarean delivery

To evaluate the use of the Auto Suture Poly CS-57 disposable surgical stapler to determine if the device offers any advantages over suture closure of the uterus. A matched case-control study design was used. Operative time, estimated blood loss, change in hematocrit, incidence of postoperative endometritis, length of stay, and total patient costs were compared. Patients were recruited from a university hospital setting and a private practice. There were 288 patients in the study, 144 in the staple group and 144 matched patients in the standard hysterotomy control group. Patients did not differ in age, parity, gestational age, number of primary or repeat operations, anesthesia, infant weights, or outcomes. Comparing the patients in the staple group and the control group, there was no significant difference in operative time (63.7 +/- 22.9 versus 62.0 +/- 22.3 minutes, staple group versus controls, respectively), estimated blood loss (822 +/- 338 versus 879 +/- 318 mL), change in hematocrit (-5.9 versus -6.5 volume percent), incidence of postoperative endometritis (15 versus 20%), length of stay (4.1 +/-1.3 versus 4.0 +/- 2.2 days), or total cost ($4490 +/- 1544 versus $3997 +/- 1117). Comparing patients operated upon by residents in the university to those operated upon by the private attending physicians, there were no significant differences noted in the above-mentioned variables between stapled and sutured patients. Compared with the usual suture technique for cesarean delivery, the uterine stapling device used in this study was not associated with a significant decrease in the incidence of postoperative anemia, infection, length of hospital stay, or cost. This device appears to offer no advantage over traditional hysterotomy and repair.

Cost analysis of stapling versus suturing for skin closure

A randomized, prospective study was performed to test the null hypothesis that there is no difference between the cost of stapling and suturing for skin closure of selected linear lacerations. Appropriate wounds were randomly assigned to be closed by staples or sutures. Wound lengths, skin closure times, and the number of staples or the number and types of sutures used were recorded. Costs for materials and labor were calculated. The average total cost per case was $17.69 (with suture kit) and $7.84 (without suture kit) for the staple Group compared with $21.58 for the suture Group ( P = .0001 for each). It is concluded that stapling is less costly than suturing and that the advantage appears to increase as laceration length increases.

Surgical Stapling Technique for Radical Hysterectomy

We developed a new technique for performing radical hysterectomy using surgical staplers. An endoscopic stapler was used to transect the uterosacral and cardinal ligaments and a roticulating stapler with absorbable staples was used to transect the vaginal cuff. Fifteen consecutive patients with primary stage IA2 or IB cervical carcinoma underwent class III radical hysterectomy using the new stapling technique and were compared to the previous 15 consecutive similarly staged patients who underwent class III radical hysterectomy by the traditional clamp, cut, and suture ligation technique. Median operative time for the stapler group was 3 hr (1.3-4 hr) versus 4.3 hr (2.5-5.8 hr) for the traditional technique (P = 0.0002). Estimated blood loss for the stapler technique was 650 ml (200-1200 ml) versus 1100 ml (450-2600 ml) for the traditional technique (P = 0.009). Three patients (20%) received transfusions in the stapler group versus 10 (67%) in the traditional group (P = 0.05). There was no difference in the rate of infections, venous thrombosis, lymphocysts, fistuli, bladder atony, or obstipation between the two groups. At a median follow up of 22 months, only one patient has recurred (from the traditional group). In conclusion, the surgical stapling technique of radical hysterectomy does not appear to adversely affect survival or increase complications while operative blood loss and operative time are significantly reduced.

Abdominal hysterectomy without internal peritonealization: primary vaginal closure with stapler or open and drained vagina

The purpose of this study was to compare the postoperative course in 127 patients undergoing abdominal hysterectomy without closure of the visceral peritoneum, who were assigned to either staple closure of the vaginal cuff or drain use. In 31 patients, the vaginal cuff was closed with absorbable staples, and in the 96 patients of the control group, vaginal drain was used. Both, the rate of postoperative complications requiring antibiotic treatment and febrile morbidity were significantly lower in the staple group. This may be attributable to the fact that primary closure of the vaginal cuff prevents bacterial contamination of the peritoneal cavity. In the drain group, two patients had to undergo laparotomy immediately postoperatively due to ileus. Because of pelvic discomfort as a late complication, one patient had to undergo pelvic reexploration, and the other patient laparoscopy-assisted adhesiolysis. It is interesting to note, that, at the time of second-look intervention, adhesion in the region of the peritoneal defect was seen in only one of these 4 patients. In the staple group, both, the surgical procedure and anaesthesia time were shorter than in the drain group; the postoperative course was comparatively uneventful, and the period of hospitalisation was reduced. Thus, we conclude, that there is a clear advantage of the use of staples over drainage for vaginal cuff treatment in abdominal hysterectomy without closure of the visceral peritoneum.

Vaginal Cuff Closure at Abdominal Hysterectomy

To compare two methods of vaginal cuff closure during abdominal hysterectomy, 60 patients were randomized to one of two cuff-closure methods. The vaginal cuff was closed with three interrupted 0-Dexon sutures in 30 and with absorbable staples in 30. Both groups were similar with respect to age, gravidity, parity, preoperative indication, hemoglobin, and hematocrit. The operative technique and quantity of irrigation used was standardized. Operative blood loss was calculated by the weight method and an unactivated, medium flat Jackson-Pratt drain was left in place for collecting postoperative cuff cultures at 24 and 48 hours. The mean operative times in the suture group (97.4 minutes) and staple group (93.4 minutes) were not significantly different (P greater than .05). Cuff-closure time was more rapid (P = .0001) in the staple group (5.8 minutes) than in the suture group (9.3 minutes). Intraoperative cultures were positive in eight of 30 suture patients (26.7%) and eight of 30 staple patients (26.7%). Postoperative cultures at either 24 or 48 hours were positive in four women (13.3%) in the suture group and six (20%) in the staple group. Febrile morbidity occurred in six (20%) in each group. Three staple and two suture subjects developed a vaginal cuff abscess or hematoma, one of whom was readmitted to the hospital for intravenous antibiotics and draining of the vaginal cuff abscess. The presence of a positive vaginal cuff culture did not predict clinical outcome. Based on these observations and the increased cost of the stapling device, we conclude that there is no significant clinical advantage of surgical staples over traditional sutures for vaginal cuff closure at abdominal hysterectomy.

Abstracts of the Combined Program of the Association for the Study of Obesity and Section of Obesity Surgery of the British Surgical Stapling Group&lt;BR&gt;&lt;/BR&gt; 20 November 1991, Royal Society of Medicine, London, UK

Abstracts of the Combined Program of the Association for the Study of Obesity and Section of Obesity Surgery of the British Surgical Stapling Group&lt;BR&gt;&lt;/BR&gt; 20 November 1991, Royal Society of Medicine, London, UK

Stapled or manual suturing in esophagojejunostomy after total gastrectomy: A comparison of outcome in 379 patients

From January 1983 to December 1989, we performed esophagojejunostomy on 379 patients who underwent total gastrectomy for gastric cancer. A mechanical EEA stapler or conventional manual suturing was used. The clinical outcomes of 199 patients in whom stapling was used (stapler group) and 180 patients in whom manual suturing was done (manual group) were compared. Two of the 199 patients in the stapler group and 3 of the 180 patients in the manual group died of causes directly related to the anastomosis. In the stapler group, 16 stapled anastomoses were formed supradiaphragmatically, and manual suturing was done for 6 patients. The highly placed anastomosis was formed without left thoracotomy or with median sternotomy in 8 of the 16 patients in whom the stapling device was used and in 1 of the 6 patients in whom manual suturing was used. The incidence of anastomotic leakage and stenosis did not differ between the groups. Thus, the mechanical stapler facilitated the construction of a rapid, reliable esophagojejunostomic anastomosis.

Reduced blood loss during Caesarean section due to a controlled stapling technique

Blood loss during Caesarean section is mainly due to the hysterotomy. A new technique to reduce this blood loss has been evaluated in a prospective controlled clinical trial in 89 patients. The operation technique was standardized according to Joel-Cohen. In the control group (n = 45) the low transversal incision was enlarged by scissors in an upward swing, in the staple group (n = 44) the incision was enlarged by introducing the poly CS 57 instrument with absorbable staples. A double row of staples sealed blood vessels and secured the three uterine layers just before the instrument's blade cut the uterine wall. The two groups were comparable as to the indications for the CS, first or repeat CS, primary or secondary CS, maternal age and parity. The duration of the operation, postoperative complications and hospital stay was equal. However, the blood loss in the ‘staple’ group was significantly less than in the control group. The conclusions are that this new technique reduced blood loss during Caesarean section, and moreover, it appeared to be extremely useful in patients with varicose veins in the lower uterine segment or placenta praevia.

Biomechanics of fascia lata ligament replacements: Early postoperative changes in the goat

Mechanical properties of fascia lata autografts used to replace the anterior cruciate ligament (ACL) in the goat were measured at 0, 2, 4, and 8 weeks after surgery. The ACL was replaced in the right knee of 50 animals divided equally into two groups according to graft fixation technique: (a) two smooth staples at each end, with the tissue pulled back toward the joint over the first staple and (b) reinforced fixation with a spiked bushing placed through the tissue and a 3-cm-long flat polypropylene braid sutured to each end of the graft. Eleven unoperated contralateral knees were tested as controls. All statistically significant effects of the reinforced versus staple fixation were observed at 0 weeks, with the reinforced group showing less anteroposterior (AP) translation of the joint and greater maximum force and stiffness of the femur-graft-tibia units. The reinforced group had increased AP translation and decreased strength and stiffness by 2 weeks after surgery. Increased AP translation resulted primarily from increases in the low-stiffness region of the force-displacement curve (primary AP translation) and to a lesser extent from increased translation in the high-stiffness region (secondary anterior translation). Failures at 0 weeks with the reinforced fixation occurred at the bushing or end of the reinforcing braid, while all but one of the later failures occurred in the tissue mid-substance. In the staple group, maximum force was greater at 8 weeks than at 0 weeks, as the failure locations changed from the fixation to the tissue mid-substance.(ABSTRACT TRUNCATED AT 250 WORDS)

The World Food Situation in Perspective

MY TASK TODAY is to set the stage for a discussion of U. S. policies and policy alternatives for food, agriculture, and trade. I shall attempt to describe the past and present and to establish a perspective from which to view the likely future world food situation. My analysis will attempt to separate the short-lived events that so often draw the greatest public attention from the persistent underlying trends that will shape world agriculture of the future. This is no easy job. What is an aberration to one man is the beginning of a new trend to another. I shall conclude by listing some of what I believe to be the most important questions and issues suggested by the analysis. In reacting to production shortfalls throughout the world in 1972, we tended to lose sight of the fact that there has been much stability in the trends for food production over the past two decades. World food production per capita trended upward during the 1954-72 period, with an annual increase of about 3/4 of 1 percent (Table 1). The drop in 1972 was the largest during this entire period. Total food production increased at about the same rate in both the developed and developing world, but the very rapid pace of population growth in the less developed regions cut the per capita increase in production to less than Y2 of 1 percent annually while the developed regions enjoyed an annual per capita increase of about 12 percent. We cannot, of course, conclude from these indices that there has been an equivalent lifting in nutrition levels everywhere or a reduction in the number of hungry people or improvement in other measures of human welfare. Still, our data indicate the world's growing potential for improving diets around the globe. Cereals comprise the most important food staple group among the high carbohydrate foods upon which most of the world's population relies for a major share of its diet. Cereals are also the major protein source, although a somewhat less important source in areas where animal products are relatively plentiful. In less developed areas, dependence on cereals for protein is especially important. But they are more than foodstuffs. According to FAO food balances for 1964-66, 48 percent of cereals produced outside Communist Asia were used for food, 38 percent for animal feed, and 14 percent for seed, starch, liquor, and other uses. We can expect the total direct food use of cereals to rise in the future as poulation grows, but use of cereal food will decline in importance to other foods as incomes rise. When we look at the total production of grain over the last two decades, we see a great difference in the performance of the developed and less developed regions. In the developed countries grain production increased more than 60 percent while planted area was nearly unchanged at something under 300 million hectares-all the increase was from higher yields. Grain production of less developed countries increased even more, almost 75 percent, but it required a '3 increase in area since yields were increasing only about Y2 as fast as in the developed regions. While the area planted to grains in both the developed and developing countries is now about equal, average grain yields in the developing countries are now only about 60 percent of those in the developed countries. Another way to look at it is that average yields in the less developed countries now equal those recorded for the developed countries in the early 1950's. Have recent events signaled a fundamental deterioration in the world food situation? Unusually poor weather in 1972 contributed to severe DON PAARLBERG is Director of Agricultural Economics, U. S. Department of Agriculture.