The automatic staple versus the conventional gastrointestinal anastomosis in gynecological...

GYNECOLOGIC ONCOLOGY 12, 302-313 (1981)

The Automatic Staple versus the Conventional Gastrointestinal Anastomosis in Gynecological Malignancies

GREGORIO DELGAW, M.D. Division of Gynecologic Oncology, Georgetown University Hospital Medical Center,

Washington, D.C. 20007

Received February 11, 1981

Seventy-four patients with gynecologic malignancies and two with benign tumors underwent diierent types of gastrointestinal resections to relieve bowel obstruction or to correct fistulas. All but 2 of these patients had gynecologic cancer with one or more modalities of therapy prior to resection. The anastomoses of 47 patients were performed with open conventional techniques which included closure of the full thickness of the bowel. In 28 patients, the automatic stapler was used 63 times. In 3 of the 28 staple anastomosis patients, the EEA (end-to-end anastomosis) was used. In this study, the use of the staple anastomosis was shown to be as effective as the conventional method because it shortened the operating time, provided less contamination of the abdominal cavity, and provided a better blood supply.

INTRODUCTION

Several reports in the literature indicate use of automatic stapler gun anastomosis in pelvic exenterations and in gastrointestinal, thoracic, and urologic surgery [l-5,10,1 1,151. There are also reports indicating that staple anastomosis is as effective as conventional suturing techniques in patients with different types of gastrointestinal conditions. [6,9,13]. However, there is limited experience with this technique in patients with irradiated gastrointestinal tracts [7].

At the Gynecologic-Oncology Division of Georgetown University, gastrointestinal anastomosis using the automatic stapler (Fig. 1) was compared with the conventional open method as described by Hamilton [8] in patients with gynecologic malignancies who previously had different modalities of therapy, most frequently, pelvic irradiation (Fig. 2). Tumor recurrence, repeated surgery, and chemotherapy also characterized this group.

MATERIALS AND METHODS

Seventy-four patients with gynecologic malignancies and two with benign tumors (See Table 1) underwent different types of gastrointestinal resections to relieve obstructions or correct fistulas resulting from tumor or radiation therapy, as part of maximal surgical resections in ovarian cancer or in pelvic exenterations

302

0090-8258/81/060302-12$01.00/O Copyright (B 1981 by Academic Press, Inc. All rights of reproduction in any form reserved

AUTOMATIC STAPLE IN MALIGNANCIES 303

FIG. 1. Automatic stapling gun instruments (U.S. Surgical Corp.: TA instrument in three sizes (left); LDS instrument (upper center); GIA instrument (lower center); EEA instrument (far right).

and urinary diversions. All but two of these patients had gynecologic cancer with some previous therapy before their resections and anastomosis.

The anastomoses of 47 patients were performed with the open conventional technique which includes closure of the full thickness of the bowel with inter- rupted chromic 3-0, and a second row of sutures with 3-O silk through the seromuscular layers of the bowel (Fig. 2). In 28 patients, the automatic stapler was used 63 times (Fig. 1A). In 3 of the 29 staple anastomosis patients, the EEA (end-to-end anastomosis) as described by Fain et al. [14] was used for colonic resection and rectosigmoidal anastomosis (Fig. IB).

In some cases, bowel surgery was performed solely to relieve obstruction with no expectation of an improvement in prognosis.

Postoperatively, all patients had nasogastric suction and were given systemic antibiotics.

Instruments used for bowel resection and anastomosis were the gastrointestinal anastomoser (GIA), the thorocoabdominal instrument (TA), and the ligation and diversion instrument (LDS)’ (Fig. 3).

Table 2 shows the distribution of patients by cancer site and whether their anastomoses were performed by the staple or conventional technique. The distribution is similar between the two groups.

’ These instruments are available from the U.S. Surgical Corporation.

304 GREGORIO DELGADO

FIG. 2. Anastomosis techniques. (A) Open technique. With the open method, there is closure of the full thickness of the bowel, including the mucosa, with an absorbable material, usually 3-O GI catgut. (B) Closed technique. With the closed method, seromuscular sutures are used. (C) Narrowing of the lumen with the closed technique.

TABLE 1 NUMBER AND PERCENTAGE OF PATIENTS WITH

BOWEL SURGERY BY CANCER SITE

Cancer site No. Percentage

Cervix 38 50.0 ovary 25 32.9 Uterus 11 14.5 (Benign) 2 2.6

Total 76 100.0


FIG. 3. Bowel anastomosis with the automatic stapler. (A) The GIA instrument transecting small bowel segments: two rows of staples and a knife cutting between. The LDS instrument is shown cutting the mesentery of the small bowel. (B) Using GIA instrument for end-to-end anastomosis. (C) The TA instrument being used to close the remaining open ends of the bowel after the GIA instrument has been used.

As shown in Table 3, the majority of the patients had previous therapy such as surgery, chemotherapy, and radiation therapy. Some patients had had all three modalities of therapy before the gastrointestinal procedures were performed. Forty-eight of the seventy-six patients had pelvic irradiation prior to performing the gastrointestinal surgical procedure. Twenty of these irradiated patients had anastomosis performed with the staple technique and 28 with the conventional method.

TABLE 2 NUMBER OF PERCENTAGE OF PATIENTS WITH BOWEL SURGERY BY CANCER SITE

AND ANASTOMOSIS TECHNIQUE

Anastomosis technique

Cancer site No.

Staple

%

Conventional

No. %

Cervix 14 48.3 24 51.1 ovary 9 31.0 16 34.0 Uterus 6 20.7 5 10.6 (Benign) - 2 4.3

Total 29 100.0 47 100.0


TABLE 3 NUMBER OF PATIENTS WITH BOWEL SURGERY BY TYPE OF PRIOR THERAPY

AND ANASTOMOSIS TECHNIQUE


Prior therapy Staple Conventional

X-ray therapy 2 5 Surgery or chemotherapy 3 6 Surgery + chemotherapy 6 11 Surgery + X-ray therapy 15 17 Surgery + X-ray therapy + chemotherapy 3 6 No prior therapy - 2

Total 29 47

Bowel surgery was performed for maximal resection in 17 patients with advanced ovarian cancers requiring removal of the rectosigmoid. The rest of the patients had obstructions or fistulas resulting from tumor and/or radiation therapy. Five maximal surgical resection patients had the staple and 12 had the conventional surgical technique.

The types of surgical procedures performed are shown in Table 4; 29 urinary diversions and 41 small bowel resections were distributed between the two techniques. There were 24 bowel bypass procedures, 3 with mucous fistulas. Twelve patients had pelvic exenterations, 8 of whom had their gastrointestinal surgical procedure performed with staples. Two of these patients has sigmoid conduits. When the sigmoid was used as conduit at the time the bowel was opened into the abdominal cavity, the resection was done quickly and the LDS was used to detach the omentum from the greater curvature of the stomach and transverse colon. The omentum was used to carpet the pelvis, decreasing the operative time and the possible contamination in the abdominal cavity (Figs. 4 and 5).

Of the 29 patients with urinary diversions, three had uretero-neocystostomies. Seventeen patients had fistulas prior to surgery; the staple technique was used

TABLE 4 NUMBER OF SURGICAL PROCEDURES BY ANASTOMOSIS TECHNIQUE

Surgical procedure Staple Conventional Total

Colostomies 13 22 35 Intestinal urinary diversion” 16 13 29 Hemicolectomy 1 2 3 Anterior resection of sigmoid 4 4 8 Small bowel resection 21 20 41 Bowel bypassb 11 13 24 Pelvic exenteration 8 4 12


’ Uretero-ileo neocystotomy: 3. b With mucous fistula: 3.


FIG. 4. Automatic stapler in pelvic exenteration. (A) The proximal and distal sigmoid colon after transection, using the GIA instrument. This segment can now become the sigmoid conduit. (B,C) The proximal end of the colon which becomes the stoma of the colostomy, closed by the GIA instrument until it has been pulled through the skin. (D) Chromic sutures placed proximal to the metallic staples prevent stone formation.

in 4, and the conventional method in 13. Most of the patients with rectovaginal fistulas also required resection of some part of the intestines. The patients with vesicovaginal fistulas usually had had a urinary diversion. Four patients who had the conventional method had enterovaginal fistulas, and they were treated by resection of the segment of the fistula and reanastomosis.

RESULTS

Complications related to the surgical procedures are shown in Table 5. Five patients died within 30 days of surgery, 4 of them from pulmonary embolism.


FIG. 5. Complications of LDS instruments. (A) The ligation and division instrument (LDS) taching the omentum from the greater curvature of the stomach. (B) Too much tissue to sti adequately, which may result in bleeding. (C) An LDS instrument locking itself after firing. (D) LDS instrut ment being introduced into two openings which may result in bleeding.

NUMBER

TABLE 5 OF PATIENTS WITH COMPLICATIONS RELATED TO SURGICAL PMXEDURE BY ANASTOMOSIS

TECHNIQUE AND TYPE OF COMPLICATION

de- tple An


Complication Staple Conventional

Entero-cutaneous fistula - 1 Entero-vagina1 bypass bowel 1 1 Sepsis 1 - Short bowel syndrome 2 2 Small bowel obstruction - 1 Wound infection 6 7 Death 2 3b

a Pulmonary embolism. b Two by pulmonary embolism; one by sepsis.


Four patients developed short bowel syndrome. Two patients developed enterovaginal fistulas in the bypassed bowel, one in the staple group and one in the conventional group. However, these fistulas developed several months after the original gastrointestinal procedure. In the conventional method group, one patient developed enterocutaneous fistula from a breakdown of her anastomosis, and one patient developed a small bowel obstruction requiring surgery.

The present status of the patients is shown in Table 6. In the staple group, 12 patients are alive 6-52 months following surgery and 13 are alive in the conventional method group. Ten patients in the staple group and 18 patients in the conventional group died after 12 months following their operations.

DISCUSSION

The complications reported are directly related to the anastomoses (Figs. 6-8). When the cause of a complication was not clear and may have been related to the anastomosis, it was included. Complications resulting from other causes were not included. Sometimes it is difficult to attribute the cause, e.g., 2 patients developed enterovaginal fistulas in their bypass bowels (1 in the staple group and 1 in the conventional group) which occurred 6 months or more after the original bowel procedure. These patients were included in the study. There were also 4 patients who died from pulmonary embolism within the first 30 days following their surgical procedures. The complications rate using both techniques was low despite the debilitation of patients who had received previous radiation, chemotherapy, and surgical therapies. Twelve patients (41.4%) are still alive in the staple group and I3 (27.7%) in the conventional group. Several patients had their surgery for palliation although their life expectancies were relatively short.

None of the patients with sigmoid conduits or urinary diversions developed stones in the conduits or obstructions in the gastrointestinal anastomosis. Two patients later developed uretero-conduit obstructions requiring surgery which were not related to the anastomosis or to the use of staples.

TABLE 6 NUMBER AND PERCENTAGE OF PATIENTS BY PRESENT STATUS AND ANASTOMOSIS TECHNIQUE


Postsurgical status No.

Staple

%

Conventional

No. %

Alive 6-52 months Died

<l Month 6-12 Months >12 Months

Total Died

Total

12 41.4 13 27.1

2 6.9 3 6.4 5 17.2 13 27.7

10 34.5 18 38.3 17 58.6 34 72.4

29 100.0 47 100.1

GREGORIO DELGADO 310

FIG. 6. Correct and incorrect bowel anastomoses. (A) Including large amounts of tissue in the bowel can produce bowel obstruction. (B) Open technique which has avoided encroachment of the bowel lumen. (C) Clamps indicating incorrect straight incision resulting in poor blood supply to the anastomosis. (D) Diagonal clamps indicating correct incision of bowel to ensure good blood supply to anastomosis. (E) Overdissection of blood vessels resulting in necrosis and leakage. (F) Proper dissection of blood vessels.

Often, gastrointestinal surgical procedures are part of the overall management of advanced gynecologic cancer patients even for palliative reasons when life expectancy is short and the patients are debilitated from previous therapy. How- ever, there has been reluctance to use staples in the irradiated bowel. In this study, the use of the staple anastomosis was shown to be equally as good as the conventional method and perhaps better because it shortened the operating time, provided less contamination of the abdominal cavity, and produced a better blood supply because of the B shape of the staples [7]. Despite lack of random- ization, the two groups were shown to be similar by previous therapy, type of surgical procedure, and complication rate.


FIG. 7. Correct and incorrect bowel anastomoses. (A) Careful hemostasis avoiding hematoma. (B) Hematoma resulting from lack of hemostasis. (C) Not including mesentery of bowel in suture, resulting in leakage. (D) Including mesentery of bowel in suturing, avoiding leakage.

SUMMARY

Seventy-six patients underwent major gastrointestinal surgery. The automatic staple gun was used 63 times in 29 patients and the conventional open method was used in 47 patients. The surgical procedures were performed to relieve obstructions or correct fistulas resulting from tumor or radiation therapy; as part of maximal surgical resection in ovarian cancer; or in pelvic exenteration and urinary diversion. The results indicated that the use of the staple method is as safe as the conventional method of anastomosis.


FIG. 8. Complications with the automatic stapler. (A) Including the mesentery of the small bowel in the GIA instrument resulting in bleeding. (B) Inspection for bleeding following an anastomosis. (C) Ovoid hematoma in the mesentery of the bowel after being stapled and transected by the GIA instrument. (D) Edges of the bowel not included in the TA instrument leaving opening. (E) Closing bowel edges with suture material following incomplete TA instrument stapling. (F) Bowel edge not at the same level of each arm of the GIA instrument, resulting in large opening which must be closed. (G) Arm of GIA instrument improperly inserted in the bowel submucosa.


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