Staple Line/Anastomotic Reinforcement and Other Adjuncts: Do They Make a Difference?

Abstract

). CME Objectives: At the completion of this article the reader should be able to summarize the complications of stapled anastomoses and the various staple line reinforcement agents.The first gastrointestinal anastomosis was performed over 200 years ago.1 Since then, there has been a push to improve anastomotic techniques with the goals of reducing complications, standardizing methods, and reducing operative time. These goals led to the development of the surgical stapler and the subsequent technological improvements by Ravitch and Steichen.2 Before the use of circular staplers, many patients were treated with sphincter extirpation. Staple technology has allowed for these patients to be treated with low colorectal anastomoses. However, anastomotic complications, especially leaks, remain the Achilles heel of these procedures. These complications have the potential to be devastating, and the rate of anastomotic leak in colorectal surgery has remained significant, hence the pursuit of adjuncts and reinforcements for stapled anastomoses. Complications Associated with Stapled AnastomosesComplications related to stapled anastomoses include bleeding, device failure, and anastomotic failure, which include stricture or leak (►Table 1). Some of these complications can be directly related to the device itself, with at least 112 deaths resulting from 20,000 malfunctions in a recent review. AbstractSince the development of the stapled intestinal anastomosis, efforts have been aimed at reducing complications and standardizing methods. The main complications associated with stapled anastomoses include bleeding, device failure, and anastomotic failure (leaks and strictures). These complications are associated with increased cost of care, increase in cancer recurrence, decreased overall survival, poor quality of life, and in some cases the need for further procedures including a diverting ostomy. Reducing these complications therefore has important implications. To this end, techniques to reduce the incidence of anastomotic complications have been the focus of many investigators. In this review, we summarize the current staple line reinforcement technology as well as other adjunctive measures, and specifically discuss the role of biologic materials in this realm.

Effect of reinforcement suture on anastomotic healing in rectal and sigmoid tumor resections, single-center experience: a retrospective case-controlled study

“…A number of factors influence anastomosis healing, including control of the systemic disease. Regarding systemic disease, both bursting pressure and collagen content of colonic anastomoses are negatively affected in the presence of abdominal sepsis [ 12 ]. To prevent impaired healing, reinforcement methods have been investigated.…”

Surgical considerations for the “perfect” colorectal anastomosis

“…Some other adjuncts for reinforcing the staple line for better apposition of tissue and added tensile strength have been described in the literature. Options include buttress with sutures, omentum, mesenteric flaps or synthetic materials ( 43 ). Fibrin and other associated sealants are purported to form a scaffold resistant to tension and compression while still remaining porous to cytokines and other immune cells essential for healing ( 44 - 47 ).…”

Survey on laparoscopic total gastrectomy at the 11th China‐Korea‐Japan Laparoscopic Gastrectomy Joint Seminar

“…However, this was a retrospective, uncontrolled study, so this single institution's experience provided low‐grade evidence. A systematic review concluded that biological materials are a promising prospect for anastomotic reinforcement in gastrointestinal anastomosis , but this needs to be further investigated in well‐designed prospective studies on LTG. The discussion on reinforcement of the duodenal stump to prevent duodenal stump fistula has been ongoing for decades in both conventional open surgery and laparoscopic gastrectomy.…”