Download comparison of single with double layer intestinal anastomosis

ISRA MEDICAL JOURNAL Volume 1 Issue 1 Apr 2012
ORIGINAL ARTICLE
COMPARISON OF SINGLE WITH DOUBLE LAYER
INTESTINAL ANASTOMOSIS
Yasir Mehmood, Haroon ur Rashid, Naheed Hanif
ABSTRACT
OBJECTIVES: To compare management outcome of single layer interrupted extramucosal intestinal
anastomosis with double layer conventional method of intestinal anastomosis.
DESIGN: Comparative study.
MATERIAL AND METHODS:This prospective comparative study was conducted in Surgical Unit-II of
Benazir Bhutto Hospital, Rawalpindi over a period of two years from Jan 2007 to Dec 2008. Adult patients
undergoing elective or emergency small and large gut anastomosis were included. Esophageal, gastric and
biliary anastomosis were excluded. Sixty patients were divided in two groups of 30 patients each. In Group-A
single layer interrupted extra-mucosal anastomosis was done and in Group-B double layer anastomosis.
Main outcome measures were to compare duration of procedure, post-operative leakage and post operative
duration of hospital stay.
RESULTS: Anastomotic leakage occurred in two (6.6%) patients of group A and in one(3.3%) patient of
group B (p=0.55). Mean of time taken for anastomosis was 18.30 min in group A and 25.87 min in group B
(p=0.001). Mean of duration of post operative hospital stay was 6 days in group A and 5.87 days in group B
(p=0.8).
CONCLUSION: Single layer extramucosal intestinal anastomosis is equally safe and can be performed in
shorter time than the double layer intestinal anastomosis
KEY WORDS: Anastomosis. Extramucosal. Anastomotic leak.
INTRODUCTION
The basic principles of intestinal anastomosis were
established more than 100 year ago by Travers,
Lembert and Halsted, 1, 2 and have since undergone
little modification. An insecure intestinal anastomosis
is an unacceptable iatrogenic hazard. 3 The
breakdown of suture line or inappropriate
anastomosis may result into hemorrhage, leakage,
stenosis, diverticular formation and ultimately faecal
fistula with serious septic complication leading to
4
death. The prevalence of intraperitoneal anastomotic
leak varies in the literature between 0.5% and 30%,
5
but is generally between 2% and 5% . The sound
healing of process of anastomosis depends mainly
on anastomsis technique, which is most important
determinant.
Historically two- layer anastomosis using interrupted
silk sutures for an outer inverted seromuscular layer
and a running absorbable suture for a transmural
inner layer has been standard for most surgical
situations. The only appreciable shortcoming of the
two layer technique is that it is somewhat tedious and
Correspondence to:
Dr. Yasir Mehmood
Assistant Professor of Surgery
Al-Nafees Medical College
Isra University, Islamabad Campus, Pakistan
E-mail: [email protected]
time consuming to perform.6,7 Recently single layer
interrupted extramucosal anastomosis using
synthetic absorbable suture material has gained
popularity as it requires less time and cost without
8
incurring any added risk of leakage.
The rationale for extramucosal technique is that the
suture include the strongest part of the bowel wall
(submucosa) while not incorporating the mucosa with
the risk of inducing ischemia.9 Clinical studies have
fairly consistently demonstrated that single layer
anastomosis are associated with improved post
operative return to normal bowel function (as
measured by bowel sounds, passage of flatus and
return to oral intake). 10 Studies of anastomosis
leakage rate have not shown any difference between
single and double layer anastomosis in this regard.
Keeping these two views in mind this study was
conducted to evaluate the safety of single layer
technique.
MATERIAL AND METHODS
This prospective study was conducted in Surgical
Unit-II of Benazir Bhutto Hospital, Rawalpindi over a
period of two years from Jan 2007 to Dec 2008. Adult
patients undergoing elective or emergency small and
large gut anastomosis were included. Esophageal,
gastric and biliary Anastomosis and children below
the age of 13 were excluded.
26
Sixty patients were divided in two groups of 30
patients each. There was no preference for single or
double layer anastomosis and both techniques were
used alternatively. In Group-A single layer interrupted
extra-mucosal anastomosis was done and in GroupB double layer anastomosis. All patients were
operated by same group of surgeons and Suture
material was same for both type of anastomosis i.e.
(2/0 Vicryl on round body needle) (Fig I). All patients
received postoperative ceftriaxone and
metronidazole. Postoperative leakage was assessed
clinically. Ultrasound abdomen and pelvis and X-ray
abdomen erect view were done in doubtful cases
only. In case of leak, emergency exploration and
temporary ileostomy was done. Patients were
discharged after their first bowel activity, once they
started tolerating semisolid food.
Data was entered and analyzed using Statistical
Package for Social Sciences (SPSS software version
10).Descriptive statistics i.e. Means with standard
deviations were calculated for continuous variables
like patient's age, duration of hospital stay and time
taken for procedure. Frequencies along with
percentages were computed for presence or
absence of leakage. Risk ratios were calculated
along with their 95% Confidence Interval for risk of
leakage in both the study groups. t- test was applied
for comparison of means of duration of the procedure
and duration of hospital stay between group A and
group B. p value was calculated and a value of less
than 0.05 was considered as statistically significant.
RESULTS
There were total of 60 Patients who were included in
study. Out of these 60 patients, 37 (61.7%) were
males and 23(38.3%) were females.Patients were
between the ages of 16- 74 years with mean age of
34.30 and standard deviation of ±14.622. Elective
surgery was performed on 17 (28.3 %) patients and
emergency surgery on 43 (71.66 %). Maximum
number of cases were operated for traumatic injuries
and minimum number of cases for Meckel,s
diverticulitis.(Table I)
Anastomosis healed satisfactorily in 57 patients while
leakage was seen in 3 (5 %) patients out of total 60
patients. (Table II) Out of 30 patients in each group,
leakage was seen in 2 patients (6.6 %) in group A
(single layer interrupted extra-mucosal Anastomosis)
and in 1 patient (3.3 %) in group B (double layer
Anastomosis), difference being statistically
insignificant (p=0.55). (Fig. II)
Mean of time taken to complete anastomosis was
18.30 min (S.D ± 1.368) in group A (single layer
interrupted extra-mucosal Anastomosis) and 25.87
27
min (S.D ± 1.525) in group B (double layer
Anastomosis), which is statistically significant
difference (p=0.001). (Table III)
Mean of duration of post operative hospital stay was 6
days (S.D ± 2.017) in group A (single layer interrupted
extra-mucosal Anastomosis) and 5.87 days (S.D ±
2.224) in group B(double layer Anastomosis), which
is statistically insignificant difference (p=0.8). (Table
IV)
Figure I: Technique of double and single
layer anastomosis
Table I: Diagnosis of 60 pt's undergoing
intestinal anastomosis
Diagnosis
Frequency
Percent
19
31.7
12
11
6
10
2
60
20.0
18.3
10.0
16.7
3.3
100.0
Traumatic intestinal
perforation
Intesinal tuberculosis
Enteric perforation
Strangulated hernia
Intestinal obstruction
Meckel's diverticulitis
Total
Table II: Frequency of leakage of anastomosis
in 60 pt's undergoing intestinal anastomosis
Leakage of
anastomosis
yes
No
group of
Patients
Total
double
layer
anastomosis
single
layer
anastomosis
Total
28
2
30
29
1
30
57
3
60
ISRA MEDICAL JOURNAL Volume 1 Issue 1 Apr 2012
Figure II: Frequency of leakage in two groups
undergoing intestinal anastomosis
40
30
20
Leakage of
anastomosis
Count
10
no
yes
0
single layer anastom
double layer anastom
Group of patients
Table III: Mean of time taken for intestinal
anastomosis procedure in two groups of pt's
group of
patients
single layer
anastomosis
double layer
anastomosis
Mean
N
Std.
Deviation
18.30
30
1.37
25.87
30
1.53
Total
22.08
60
4.08
Table IV: Mean of duration of postoperative
hospital stay in two groups of pt's
group of
patients
single layer
anastomosis
double layer
anastomosis
Total
Mean
N
Std.
Deviation
6.00
30
2.02
5.87
30
2.22
5.93
60
2.11
DISCUSSION
Intestinal obstruction, peritonitis from a perforated
bowel, abdominal trauma and diseases of bowel are
common surgical indications that must be treated
operatively hence it is frequently necessary to
perform resection and anastomosis of the intestine.
Accurate approximation of the bowel ends without
tension and with a good blood supply to both of the
ends are obviously fundamental for anastomosis
healing. The process of intestinal anastomotic
healing mimics that of wound healing elsewhere in
the body in that it can be arbitrarily divided into an
acute inflammatory (lag) phase, a proliferative phase,
and, finally, a remodeling or maturation phase. The
strongest component of the bowel wall, the
submucosa, owes most of its strength to the
collagenous connective tissue it contains. Collagen is
thus the single most important molecule for
11
determining intestinal strength. A number of factors
both local and systemic significantly influence the
12
healing of anastomosis in the gastrointestinal tract.
These factors can be classified into preoperative,
operative and postoperative. The operative factors
which include technique of intestinal anastomsis,
play a significant role in the healing of the process of
intestinal anastomosis.13
Numerous techniques have been used to fashion
anastomosis. These techniques can be divided into 2
categories, hand sewn and stapled anastomosis.14
Hand sewn techniques include single layer
interrupted or various double layer techniques. One
aspect of intestinal suturing technique that has
remained controversial is the use of either one or two
layers of sutures for anastomosis. Historically twolayer anastomosis using interrupted silk sutures for
an outer inverted seromuscular layer and a running
absorbable suture for a transmural inner layer has
been standard for most surgical situations.
The concept of using the submucosal layer of the
bowel to hold stitches for a sound anastomosis was
first introduced by William Halsted in his publication
of 1887 15, but this described work in dogs, and there
is no evidence that Halsted ever applied his findings
to man. It fell to Matheson in Aberdeen, working from
the 1960s to the 1990s, to develop the technique for
clinical use 16, and the extramucosal, appositional,
interrupted serosubmucosal anastomosis has
become widely used, with reported leakage rates in
the region of 2%.17
Both techniques have potential weaknesses that
could threaten the anastomosis. Though the two
layers might provide adequate strength initially, they
increase the inflammatory response in the early
stages of healing owing to the extrasuture material
and the ischaemia of the inverted tissues as it
incorporates large amount of tissue in the suture line
leading to tension and increases the chance of
leakage and lumen narrowing. The inflammatory
reactions result in weaker anastomosis as more
collagen is broken during the inflammatory phase of
healing. Recently single layer interrupted
extramucosal anastomosis using synthetic
absorbable suture material has gained popularity.18
28
Single-layer Anastomosis take less time to create,
causes least damage to the sub-mucosal vascular
plexus, minimally disturbs the gut lumen, foster more
rapid vascularization and mucosal healing, increase
the strength of the anastomosis (as measured by the
bursting pressure) in the first few postoperative days
and are associated with improved postoperative
return to normal bowel function (as measured by
bowel sounds, passage of flatus, and return to oral
intake). 19, 20
The present study assessed the safety of single and
double layer intestinal anastomosis. In this study,
Anastomotic leakage occurred in 2 patients of group
A, and in 1 patient of group B (P=0.55). Mean of
duration of post operative hospital stay was 6 days in
group A and 5.87 days in group B ( p=0.8). Mean of
time taken for anastomosis was 18.30 min in group A
and 25.87 min in group B (p=0.001). There is no
statistically significant difference in terms of
anastomotic leakage and duration of post operative
hospital stay between these two treatment options
but there is significant difference in terms of time
taken for anastomosis.
One study was conducted by Muhammad Ayub et al,
at Department of Surgery, Unit 2 Dow University of
Health Sciences and Civil Hospital, Karachi from
2005 to 2008, to evaluate the safety of single layer
21
interrupted extramucosal intestinal anastomosis. 42
single-layer (Group A) and 48 double-layer(Group B)
anastomosis were performed. Two leaks (4.7%)
occurred in the single-layer group and four (8.3%) in
the two-layer group with overall mortality 0% in single
layer group and 4.1% in double layer group. Length of
hospital stay was 8.2 days for single layer group while
it was 10.5 days for double layer group.
Leslie A, Steele RJ, conducted a study at Department
of Surgery and Molecular Oncology, University of
Dundee, Dundee, UK. 22 The results of 553 singlelayer appositional serosubmucosal anastomosis
were compared with the results of 131 stapled
anastomosis carried out during the same period
using a circular anastomosing stapler. One
anastomotic leakage occurred in the group of
patients whose anastomosis was fashioned using the
interrupted serosubmucosal technique (0.2%) and 11
leaks occurred in those who had a stapled
anastomosis (8.4%). The mortality rate in each group
was similar (2% and 2.3%, respectively).
Rana Asrar et al, conducted a study in Surgical Unit 4
of District Headquarter Hospital, Faisalabad, to
evaluate the safety and cost effectiveness of single
layer interrupted intestinal anastomosis (Group 1) in
comparison with double layer conventional method of
23
intestinal anastomosis(Group 2). Average time for
construction of the single layer anastomosis was 20
29
minutes and in double layer was 35 minutes (p<.001)
while average duration of stay was 168hrs and
216hrs in group 1 and 2 respectively. Leakage rate
was 12% (double) in group 2 while 6% in group 1.
Suture material consumption was more in two layer
technique and longer stay added to that lead to more
hospital expenses on two layer technique. They
concluded that anastomosis using a single layer
interrupted extramucosal technique is faster to
perform, cost effective, less likely to leak and as
strong as two layer anastomosis.
Our study, like the studies of Muhammad Ayub, Leslie
A and Rana Asrar favors single layer interrupted
extra-mucosal intestinal anastomosis. This shows
single-layer anastomosis can be constructed in
significantly less time and with a similar rate of
complications compared with the two-layer technique
and can be incorporated into a surgical training
program without a signifi cant increase in
complications.
CONCLUSION
Statistically there is no significant difference in the
risk of leakage and post operative hospital stay but
there is significant difference in terms of time taken
for the intestinal anastomosis procedure between
two study groups. Single layer extramucosal
intestinal anastomosis is equally safe and can be
performed in shorter time than the double layer
intestinal anastomosis.
REFERENCES
1.
2.
3.
4.
5.
6.
Leaper DJ. Basic surgical skills and
anastomosis. In: Williams NS, Bulstrode CJK,
Connell PR, Editors. Bailey and Love's Short
th
practice of Surgery. 25 ed. London, England:
Arnold, 2008:234-46.
Boschung U. Milestones in the history of
intestinal anastomosis. Swiss Surg 2003;
9(3):99-104.
Pickleman J, Watson W, Cunningham J,
Fisher SG, Gamelli R. The failed gastrointestinal anastomosis; an inevitable
catastrophe. J Am Coll Surg 1999; 188:473.
Lodhi FB, Farooq T, Shafiq M, Hussain R.
Anastomotic leak after small gut surgery.
Professional Med J 2006; 13(1):47-50.
Samiullah, Israr M, Zada N. Comparison of
single layer interrupted intestinal anastomosis
with double layer intestinal anastomosis. J
Postgrad Med Inst 2003; 17:263-6.
Shikata S, Yamagishi H, Taji Y, Shimada T,
Noguchi Y. Single- versus two- layer intestinal
ISRA MEDICAL JOURNAL Volume 1 Issue 1 Apr 2012
7.
8.
9.
10.
11.
12.
13.
14.
15.
anastomosis: a meta-analysis of randomized
controlled trials. BMC Surg 2006; 6: 2.
Burch JM, Franciose RJ, Moore EE, Biffl WL,
Offner PJ. Single-layer continuous versus twolayer interrupted intestinal anastomosis: a
prospective randomized trial. Colorectal Dis
2003 Jul; 5(4):362-6.
Waheed M, Bhutta AR, Zahra F, Ahmed N, Ali
AM, Naazar A, et al. Experiance of single layer
anastomosis in small gut. Ann King Edward
Med Coll 2004; 10(3):269-70.
Brain AJL, Kiely EM. Use of single layer
extramucosal suture for intestinal
anastomosis in children. BJS 2005; 72(6):4834.
Khan N, Rahman A, Sadiq MD. Single layer
interrupted serosubmucosal (extramucosal)
intestinal anastomosis. J Med Sci.2006;
14(1):10-13.
Shomaf M. Histopathology of human intestinal
anastomosis. East Mediterr Health J 2003; 9:
413-21.
Wagner OJ, Egger B. Influential factors in
anastomosis healing. Swiss Surg 2003;
9(3):105-13.
Rudinskaite G, Tamelis A, Saladzinskas Z,
Pavalkis D. Risk factors for clinical
anastomotic leakage following the resection of
sigmoid and rectal cancer. Medicina (Kaunas)
2005; 41: 741-6.
Choy PY, Bissett IP, Docherty JG, Parry BR,
Merrie AE. Stapled versus handsewn methods
for ileocolic anastomosis. Cochrane Database
Sys Rev 2007 18; (3):CD004320.
Halsted WS. Circular suture of the intestine;
an experimental study. Am J Med Sci 1887;
16.
17.
18.
19.
20.
21.
22.
23.
94:436-61.
Matheson NA. Prospective audit of an
extramucosal technique for intestinal
anastomosis. Br J Surg 1992; 79: 843.
Rajput MJ, Memon AS, Rani S, Khan AI. Use
of single layer extramucosal interrupted suture
i n te sti n a l a n a sto m o si s : Th re e y e a r
experience. JLUMHS 2009; 8(1).
Aslam V, Bilal A, Khan A, Bilal M, Abideen Z,
Ahmed M. Gastroesophageal anastomosis:
Single layer versus double layer technique- An
experience on 50 cases. JAMC 2008; 20(3).
Askarpour S, Sarmast MH, Peyrasteh M,
Gholizadah B. Comparison of single and
double layer intestinal anastomosis in Ahwaz
educational hospitals (2005-2006). Internet J
Surg 2010; 23(2).
Matheson NA, McIntosh CA, Krukowski ZH.
Continuing experience with single layer
appositional anastomosis in the large bowel.
British Journal of Surgery Dec 2005;
72(51):104-6.
Ayub M, Sheikh R, Gangat S, Rehman A.
Single layer versus two layer intestinal
anastomosis- A prospective study. Pakistan J
Surg 2009; 25(3):141-3.
Leslie A, Steele RJ. The interrupted
serosubmucosal anastomosis – still the gold
standard. Colorectal Dis.2003; 5(4): 362-6.
Khan RAA, Hameed F, Ahmed B, Dilawaiz M,
Akram M. Intestinal anastomosis;
Comparative evaluation of safety; cost
effectiveness, morbidity and complications of
single versus double layer. Professional Med J
2010; 17(2):232-4.
30