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Stapled versus Sutured Gastrointestinal Anastomoses in the Trauma Patient: A Multicenter Trial

Brundage, Susan I. MD, MPH; Jurkovich, Gregory J. MD; Hoyt, David B. MD; Patel, Nirav Y. MD; Ross, Steven E. MD; Marburger, Robert RN; Stoner, Michael MD; Ivatury, Rao R. MD; Ku, James MD; Rutherford, Edmund J. MD; Maier, Ronald V. MD; for the WTA Multi-institutional Study Group

Journal of Trauma-Injury Infection & Critical Care: December 2001 - Volume 51 - Issue 6 - pp 1054-1061
Annual Meeting Articles

Background : Construction of gastrointestinal anastomoses utilizing stapling devices has become a familiar procedure. In elective surgery, studies have shown no significant differences in complications between stapled and sutured anastomoses. Controversy has recently arisen regarding the accurate incidence of complications associated with anastomoses in the trauma patient. The objective of this multi-institutional study was to determine whether the incidence of postoperative complications differs between stapled and sutured anastomoses following the emergent repair of traumatic bowel injuries.

Methods : Using a retrospective cohort design, all trauma registry records from five Level I trauma centers over a period of 4 years were reviewed.

Results : A total of 199 patients with 289 anastomoses were identified. A surgical stapling device was used to create 175 separate anastomoses, while a hand-sutured method was employed in 114 anastomoses. A complication was defined as an anastomotic leak verified at reoperation, an intra-abdominal abscess, or an enterocutaneous fistula. The mean abdominal Abbreviated Injury Scale score and Injury Severity Score were similar in the two cohort groups. Stapling and suturing techniques were evenly distributed in both small and large bowel repairs. Seven of the total 175 stapled anastomoses and none of the 114 hand-sewn anastomoses resulted in a clinically significant leak requiring reoperation (RR = undefined, 95% CI 1.08–infinity, p = 0.04). Each anastomotic leak occurred in a separate individual. Nineteen stapled anastomoses and four sutured anastomoses were associated with an intra-abdominal abscess (RR = 2.7, 95% CI 0.96–7.57, p = 0.04). Enterocutaneous fistula formation was not statistically associated with either type of anastomoses (stapled cohort = 3 of 175 and sutured cohort = 2 of 114). Overall, 22 (13%) stapled anastomoses and 6 (5%) sutured anastomoses were associated with an intra-abdominal complication (RR = 2.08, 95% CI 0.89–4.86, p = 0.076).

Conclusion : Anastomotic leaks and intra-abdominal abscesses appear to be more likely with stapled bowel repairs compared with sutured anastomoses in the injured patient. Caution should be exercised in deciding to staple a bowel anastomosis in the trauma patient.

From the Department of Surgery, Baylor College Of Medicine (S.I.B), Houston, Texas, University Of Washington, Harborview Medical Center (G.J.J., R.V.M.), Seattle, Washington, University Of California, San Diego (D.H, N.P.), San Diego, California, University Of Medicine and Dentistry of New Jersey (S.R., R.M.), Camden, New Jersey, Medical College Of Virginia (M.S., R.I.), Richmond, Virginia, and University Of North Carolina, Chapel Hill (J.K., E.J.R.), Chapel Hill, North Carolina.

Submitted for publication April 18, 1999.

Accepted for publication July 26, 2001.

Presented at the 29th Annual Meeting of the Western Trauma Association, February 28–March 6, 1999, Crested Butte, Colorado.

Address for reprints: Susan I. Brundage, MD, MPH, Department of Surgery, One Baylor Plaza 404D, Baylor College of Medicine, Houston, TX 77030; email: brundage@bcm.tmc.edu.

© 2001 Lippincott Williams & Wilkins, Inc.