The Double Stapling Technique for Low Anterior Resection Results, Modifications, and Observations

F. DEAN GRIFFEN, M.D., CHARLES D. KNIGHT, SR., M.D., JOHN M. WHITAKER, M.D., and CHARLES D. KNIGHT, JR., M.D.

Since the introduction of the end-to-end anastomosis (EEA) stapler for rectal reconstruction, we have used a modification of the conventional technique in which the lower rectal segment is closed with the linear stapler (TA-55) and the anastomosis is performed using the EEA instrument across the linear staple line (double stapling technique). Our experience with this procedure includes stapled colorectal anastomoses in 75 patients and is the basis for the report. This review presents the details and advantages of the technique and the results. Complications include two patients with anastomotic leak (2.7%), and two with stenosis that required treatment (2.7%). Protective colostomy was not done in this series. There were no deaths. Our experience and that of others suggests that this modification of the EEA technique can allow a lower anastomosis in some patients, and that it can be done with greater safety and facility.

T n HE ORIGINAL TECHNIQUE for low rectal anastomosis with the end-to-end anastomosis (EEA) stapler was described by Ravitch and Steichen in 1979.' In 1980 our modification of this procedure was reported in which the lower rectal segment is closed with a linear stapler (TA-55) and the anastomosis is performed using the EEA stapler across the linear staple line (combined or double stapling technique).2 The rationale for the development of this technique came from Nance's 1979 report3 in which he described the successful use of the EEA stapler across linear staple lines in several gastrointestinal operations. Our experience with this procedure includes stapled colorectal anastomoses in 75 patients and is the basis of this report.

Materials and Methods From June 1979 to June 1989, seventy-five patients had colorectal anastomoses using the combined or double Presented at the 101st Annual Meeting of the Southern Surgical Association, Hot Springs, Virginia, December 3-6, 1989. Address reprint requests to F. Dean Griffen, M. D., Highland Clinic, 1455 E. Bert Kouns, Industrial Loop, P.O. Box 51455, Shreveport, LA 71135-1455.

745

From the Departments of Surgery, Highland Clinic and Louisiana State University, Shreveport, Louisiana

stapling technique. There were 33 men and 42 women, with a mean age of 65 years (range, 28 to 83 years); two thirds of these patients were in the seventh and eighth decades of life. Indications for surgery are shown in Table 1. Fifty patients had carcinoma of the rectosigmoid colon, 20 had diverticulitis, 3 had carcinoma of the ovary, 1 had volvulus, and 1 had rectal prolapse. Among the 50 patients with carcinoma of the rectosigmoid, preoperative locations of tumors measured from the anal verge at endoscopy, are shown in Table 2. Eighteen patients had tumors measuring 8 cm or less. Levels of anastamosis are shown in Table 3; 20 were less than 6 cm.

Technique Previously we have described the technique for low rectal reconstruction after extended low anterior resection using the combined stapler technique with the standard EEA instrument. Recently the United States Surgical Corporation (Norwalk, CT) modified its circular stapling device (Premium CEEA") and TA-55 stapler (Roticulator 55TM), making them even better suited for this technique. Although surgeons using the traditional EEA and TA-55 staplers can still gain technical advantage using the technique previously described, the following technique uses the new instruments. With the patient in the lithotomy-Trendelenburg position, providing for the simultaneous exposure of abdomen and perineum, the abdomen is entered through a low, midline incision and the abdominal cavity is explored. The rectosigmoid colon is mobilized, as in any other anterior resection, and if it is determined that a low anterior resection is feasible, the mesorectum is divided below the anticipated lower margin of resection. The 4.8-

746

GRIFFEN AND OTHERS TABLE 1. Indications for Operation

Ann. Surg. June 1990

TABLE 3. Distance ofAnastomosis from Anal Verge

Diagnosis

n

Distance (cm)

n

Carcinoma rectosignioid colon Diverticular disease Carcinoma ovary Volvulus sigmoid colonI

50 20 3

3-6 7-9 10-13

20 17 38

Prolapse rectumI

mm

Roticulator 55TM

at its

neck, is placed

TA-55

a

across

stapler modified

to rotate

the rectum at the distal

margin

of resection, angled to maximize exposure and resection

margin, closed,

and activated

applied perineum by region of dissection, aiding in to the

A

long, right-angle

line to prevent the

plied

at the

suture a

Pressure

be

can

assistant to elevate the

exposure when necessary.

clamp is placed proximal to the staple

soilage

and the rectum is divided

of the stapler. The

edge

(Fig. 1).

an

along pursestring instrument is ap-

proximal resection margin. The pursestring

is placed by

passing a 2-0 monofilament suture on through the pursestring instrument. An

Keith needle

Ochsner clamp is placed distal to the ment and the colon is transected. A

is applied

across

the

pursestring instru-

noncrushing clamp

proximal colon, and the pursestring

instrument is removed. Sizers

are

passed proximally into

the lumen. If

only the small sizer will enter, the 28-mm

cartridge

be used; if the middle sizer will enter the

can

facilitate irrigation with larger quantities of water. Any leaks detected are repaired with sutures. The Premium CEEATM stapler is introduced into the rectal segment with the anvil shaft assembly removed and the center rod retracted within the cartridge. The cartridge is advanced to the Roticulator 5 5TM staple line and the rod with the trocar attachment is extended a sufficient length to allow its transmural visualization anterior or posterior to the staple row. It is then advanced through the rectal wall adjacent to the staple line (Fig. 3). The trocar is removed and the anvil shaft is inserted into the rod (Fig. 4). The Premium CEEAT" is closed and activated to make a circular end-to-end inverting anastomosis (Fig. 5). No attempt is made to include the entire circumference of

lumen, the 3 1-mm cartridge is chosen. We caution against the

use

cause

it

of the 25-mm

may,,be

cartridge for this anastomosis

too small to accomodate the

be-

doughnut

from the thick-walled rectum and the risk of symptomatic stenosis may be increased. The anvil shaft bowel

assembly is then placed in the proximal through the pursestring (Fig. 2) and the pursestring

is tied into the groove can

then be removed.

proximal

extent of

mesentery

on

the shaft. The intestinal

Using

the

edge of the anvil

dissection, the fatty

clamp as

appendice's

the and

removed, allowing for the approximation

are

of bowel wall rather than fat at the anastomosis. Attention is then turned to the ment

anal

tray is moved

area.

The rectal segment is

sterile water under pressure ascertain leaks

or

perineum.

The instru-

to allow the surgeon access to the

irrigated transanally with

using

an

irrigating syringe

staple failures. If in high anterior

tions the distal pouch is too long to distend with 50 of fluid,

a

Foley catheter

can

be used

through the

TABLE 2. Distance of Tumor from Anal Verge

Distance (cm)

n

6-8 9-10 11-15

18 11 21

to

resecccs

anus

to

FIG 1Afterthe rectosigmoid colon~~~~~~~~~~~~~~~~~~~~~~~~~.. mobilied.th.Rotiu.ato hasbee 55 stapler is applied at the lower limit of the resection and a double row.. placed~ ~ ~ ~ . . .. ... .

Vol. 211 No. 6

DOUBLE STAPLING FOR LOW ANTERIOR RESECTION

*

747

the rectal segment; only that part that matches the prox~~~~~imalcolon is included. Two or three partial-thicknessmattress sutures of 3-0 silk are placed across the anastomosis when it is technically ; ;0 !feasible. The Premium CEEA" is then opened no more than three complete turns and the instrument is removed using the mattress sutures for counter traction. The tissue | in! the chamber is checked to ensure that two complete rings or doughnuts are present. A shoestring clamp is | il11|lEplaced across the colon above the staple row, and the integrity of the anastomosis is checked by irrigating the rec| tum with water under pressure. An alternative is insufflation with air instead of irrigation with water first filling | the | pelvic dead space with saline. If leaks are detected, they are repaired with silk sutures. A sump drain, covered with a Penrose drain, is placed deep within the pelvis and brought through a stab wound in the left lower quadrant. The pelvic peritoneum is not sutured and the abdomen is closed in the usual manner. Results

_.__

FIG. 2. After selection of the proper cartridge, the anvil shaft assembly is detached from the central rod, placed in the proximal bowel through the pursestring, and the suture is tied into the groove on the shaft.

FIG. 3. The Premium CEEA

staple is introduced into the rectal segment with the anvil shaft assembly removed and the center rod with the trocar attachment retracted within the cartridge. The instrument is advanced, placing the cartridge against the linear staple row. The center rod is extended, passing the trocar into the abdominal cavity adjacent to the staple line, following which the trocar is removed.

Intraoperative complications were infrequent and minor. All doughnuts were intact circumferentially, although several were not full thickness and others had mucosal tails. There were minor intraoperative water leaks in three anastomoses that were repaired with sutures. There was no intraoperative anastomotic disruption and protective colostomy was not performled in this series.

costo per formedain teres Postoperative complications were also rare .

Two patients developed a clinical anastomotic leak that healed

GRIFFEN AND OTHERS

748

Ann. Surg. June 1990

......

FIG. 4. The anvil shaft is inserted into the center rod and the closure is begun.

with conservative treatment. Neither surgical drainage nor colostomy was required. Two patients had stenosis and stricture of the anastomosis that required treatment. One

of these patients with carcinoma of the rectum developed benign anastomotic stricture at 10 cm. Digital dilatation under anesthesia was successful after the fibrous ring was

a

FIG. 5. The Premium CEEA stapler is closed and activated to make the circular end-toend inverting anastomosis. No attempt is made to include the entire circumference of the rectal segment; only that part that matches the proximal colon is included.

.. .... ....

VOl. 211.- NO. 6

DOUBLE STAPLING FOR LOW ANTERIOR RESECTION

fractured with biopsy forceps. A second patient developed high stricture after resection for diverticulitis and required reoperation and resection using the EEA stapler. Although 20 patients had anastomoses within 6 cm of the anal verge, no patient has been permanently incontinent. While there were no operative deaths in this series, the follow-up of patients with malignant disease has not been adequate for statistical evaluation of local recurrence. a

Discussion The chiefattraction of the EEA stapler is that it permits most surgeons to perform a low anterior anastomosis safely, at a lower level than was previously possible with

other intra-abdominal techniques. The double stapling technique described here offers several additional advantages: (1) it obviates the technical frustration involved in placing the lower pursestring suture and this permits a lower anastomosis in some patients; (2) the rectal segment is not opened, which minimizes intraoperative contamination; and (3) it avoids problems ofjoining segments of bowel of disparate size (wide rectal ampulla to normal or smaller proximal colon), which may cause anastomotic complications. There has been some concern that the intersecting staple lines that result from this procedure might increase the risk of anastomotic leak. In theory this concern seems justified. However Julian and Ravitch4 addressed this problem in experimental studies in dogs and showed that, although the linear staples are usually removed with the doughnuts and are deformed, cut, or squeezed out, no leaks occurred. Reports of increasing clinical experience also attest to the safety of stapling across staple lines.` Although we have found the original instrumentation introduced for end-to-end rectal reconstruction satisfactory for the double stapling procedure, recent innovations in the staplers have made the technique easier and safer. The Roticulator 55TM with its adjustable head allows the rectum to be stapled at a lower level in some patients. Two changes in the EEA instrument facilitate the anastomosis. The ability to recess the naked center rod within the cartridge allows safer passage of the instrument, especially if the pouch is long. The chief improvement, however, results from maintaining a part of the center rod on the anvil so that the anvil can be introduced into the proximal bowel before connecting it to the cartridge, and the proximal pursestring can be tied under direct vision. Then the anvil shaft with the pursestring already tied can be attached easily to the Premium CEEAT deep in the pelvis. This eliminates one of the difficult steps in the procedure-placing the proximal bowel over the anvil in the pelvis. Anastomotic leak is the most feared complication of gastrointestinal surgery and is the chief parameter by

749 which success of rectal reconstruction is measured. The incidence of clinical leaks in stapled colorectal anastomoses varies in reported series, but historical controls with hand-sewn techniques indicate that 10% is a traditional rate. In 1982, when the EEA instrument was relatively new and most reported series included 50 patients or less, we reviewed 23 reports, which included 919 patients with stapled anastomoses.8 Clinical leaks occurred in 8%. A recently collected series of 10 reports since 1982 yielded 1483 stapled colorectal anastomoses with 65 leaks, for a rate of 4.4% (Table 4). The complication rate with the double stapling technique is also encouraging. In our experience we noted two leaks in 75 patients with no sepsis and no protective colostomy. Feinburg and associates5 have reported the results of the double stapling method in 79 patients with carcinoma of the rectum and found six leaks, or 7.6%, with a mean level of anastomosis 5 cm above the dentate line. One of the criticisms of the EEA instrument is the possibility of stenosis or stricture after its use. The exact incidence of this complication is difficult to determine because the definition of stenosis is not standardized. In some series stenosis is reported as a complication when the anastomosis will not permit the passage of the proctoscope, even though the patient is asymptomatic. We believe that stenosis should be reported only when stricture formation requires treatment because most stenoses are self-limiting, as demonstrated by follow-up endoscopy. In the 1982 review of 919 patients with stapled colorectal anastomoses,8 31 had symptomatic stenoses, an incidence of 3%. A review of 10 reports since 1982 is summarized in Table 5. Gordon and Dalrymple'2 reported an incidence of 17% to 20%, but a review of their data shows symptomatic stricture requiring treatment in only 1.4%. The overall stenosis rate in this collected series is 1.6%. Symptomatic stenosis after the double stapling technique also occurs infrequently. Two of the seventy-five patients in our series required treatment for stenosis, and Feinburg TABLE 4. Incidence of Clinical Leaks with Stapled Colorectal Anastomoses

Number of Leaks

Series, Year

n

Cutait and Cutait,9 1986 Fazio,'0 1984 Fazio," 1985 Feinbergetal.,5 1986 Gordon and Dalrymple,'2 1986 Kennedy et al.,'3 1983 Polglase,'4 1986 Thiede et al.,'5 1986 Trollope et al.,6 1986 Knight and Griffen, 1990 Total

140 162 84 79

10 5 1 6

7.1 3.0 1.2 7.6

143 120 301 205 75

1 8 13 16 3 2

0.7 4.6 10.8 5.3 1.5 2.7

1483

65

4.4

174

% Leaks

750

GRIFFEN AND OTHERS

TABLE 5. Incidence ofClinical Stenosis with Stapled Colorectal Anastomoses

Series, Year

n

Number of Stenosis

% Stenosis

Cutait and Cutait,9 1986 Fazio," 1984 Fazio," 1985 Feinberg et al.,5 1986 Gordon and Dalrymple,'2 1986 Kennedy et al.,'3 1983 Polglase,'4 1986 Thiede et al.,'5 1986 Trollope et al.,6 1986 Knight and Griffen, 1990 Total

140 162 84 79

3 1 0 0

2.1 0.6 0 0

143 174 120 301 205 75

2 1 8 2 6 2

1483

25

1.4 0.5 6.6 0.6 2.9 2.7 1.7

et al.5 noted no significant stenosis in 79 patients who had

similar procedure. The etiology of anastomotic stenosis is not completely understood. It is generally agreed that anastomotic leak may result in failure to heal by first intention, causing granulation, fibrosis, and stricture (Fig. 6). Experimental studies'6"17 and clinical experience"8 indicate that stapled anastomoses also heal by second intention because the mucosa of the bowel segments is not in apposition but is separated by the muscular and serosal layers. Therefore the precise stapled anastomosis predictably forms a perfect a

Ann. Surg. * June 1990

circular scar, which results in narrowing of the intestinal lumen. Fortunately this stenosis is almost always subclinical and fecal dilatation ultimately provides for widely patent anastomoses as observed at follow-up endoscopy. We have noted that this process may take several months to 2 years. Postoperative stenosis is best prevented by avoiding anastomotic leaks and avoiding protective colostomy, which prevents normal fecal dilatation. We believe that the largest suitable cartridge should be used because the smaller the circumference of the circular scar, the more likely it is to be symptomatic. The double stapling technique has its greatest use in patients with rectal carcinoma when the need for a low anastomosis is essential. We have returned to hand-sewn anastomosis in some patients with diverticular disease when the proximal bowel for anastomosis is muscular and small or the distal segment is long and tortuous. These circumstances increase the risk for misadventure and complications in a subset of patients ideal for sutured anastomosis. There are three general categories of sphincter-saving procedures to consider when extended low resection with lymphadenectomy is required. These include abdominosacral resection and anastomosis, transabdominal transanal resection with coloanal anastomosis, and extended low anterior resection with stapled anastomosis. Data comparing the relative incidence of stenosis, anas-

FG.

6.

This

drawing of

hemisection of

a

a

double sta-

pled colorectal anastomosis shows the

precise separation

of mucosal edges by the other inverted

layers of bowel wall

characteristic of EEA tomoses.

intention

Healing by causes

and stenosis, ~~~~~~~scar

a

anas-

second

circular

which is

later corrected by fecal dilatations.

Vol. 211 - No.6

DOUBLE STAPLING FOR LOW ANTERIOR RESECTION

tomotic leak, incontinence, and local recurrence are not available. Reasons to expect difference in the incidence of local recurrence have been postulated, but we believe that all options share equally the paramount deterrent to success, which is the anatomically limited lateral margin of resection. Unique circumstances may sometimes dictate the procedure of choice, but most surgeons will find one approach preferable and almost always applicable. A few surgeons already skilled with the abdominosacral procedure will continue using it. Others comfortable with the ileoanal anastomosis for inflammatory bowel disease will favor the coloanal anastomosis. Many will likely prefer the extended low anterior resection using exposure and dissection, with which they are already familiar. With improved techniques for sphincter preservation after rectal resection, there is an inclination to compromise the lower margin of resection for low anterior resection in patients with carcinoma of the rectum. This should be avoided. If the same strict criteria are observed in selecting candidates for extended low anterior resection with stapled anastomosis that have been followed for low anterior resection with hand-sewn reconstruction, the recurrence and survival rates should remain the same at all levels. Of course lower lesions still have higher local recurrence rates because of the more limited lateral resection, just as has been observed with abdominoperineal resection for very low lesions. Cure of the patient's cancer should continue to be the overriding objective and preservation of the sphincter should be a secondary consideration.

751

189:791-797. 2. Knight CD, Griffen FD. An improved technique for low anterior resection of the rectum using the EEA stapler. Surgery 1980; 88: 710-714. 3. Nance FC. New techniques ofgastrointestinal anastomoses with the EEA stapler. Ann Surg 1979; 189:587-598.

4. Julian TB, Ravitch MM. Evaluation of the safety of end-to-end (EEA) stapling anastmoses across linear stapled closure. Surg Clin North Am 1984; 64:567-577. 5. Feinberg SM, Parker F, Cohen Z, et al. The double stapling technique for low anterior resection ofrectal carcinoma. Dis Colon Rectum 1986; 29:885-890. 6. Griffen FD, Knight CD. Stapling technique for primary and secondary rectal anastomoses. Surg Clin North Am 1984; 64:579590. 7. Trollope ML, Cohen RG, Lee RH, et al. A 7 year experience with low anterior sigmoid resections using the EEA stapler. Am J Surg 1986; 152:11-15. 8. Knight CD, Griffen FD. Techniques of low rectal reconstruction. Curr Prob Surg 1984; 20:391-456. 9. Cutait DE, Cutait R. Stapled anterior resection of the rectum. In Ravitch MM, Steichen FM, eds. Principles and Practice of Surgical Stapling. Chicago: Year Book Medical Publishers, 1987. pp. 388401. 10. Fazio VW. Advances in the surgery of rectal carcinoma utilizing the circular stapler. In Spratt JS, ed. Neoplasms of the Colon, Rectum, and Anus. Philadelphia: WB Saunders, 1984. pp. 268-288. 11. Fazio VW, Jagelman DG, Lavery IC, McGonagle BA. Evaluation of the proximate-ILS circular stapler. Ann Surg 1985; 201:108114. 12. Gordon PH, Dalrymple S. The use of staples for reconstruction after colonic and rectal surgery. In Ravitch MM, Steichen FM, eds. Principles and Practice of Surgical Stapling. Chicago: Year Book Medical Publishers, 1987. pp. 402-431. 13. Kennedy HL, Rothenberger DA, Goldberg SM, et al. Colocolostomy and coloproctostomy utilizing the circular intraluminal stapling devices. Dis Colon Rectum 1983; 26:145-148. 14. Polglase MS. Anterior resection for carcinoma of the rectum. In Ravitch MM, Steichen FM, eds. Principles and Practice ofSurgical Stapling. Chicago: Year Book Medical Publishers, 1987. pp. 373387. 15. Thiede A, Jastarndt L, Schroder D, et al. Prospective and controlled studies in colorectal surgery: a comparison of hand-sutured and stapled rectal anastomoses. In Ravitch MM, Steichen FM, eds. Principles and Practice of Surgical Stapling. Chicago: Year Book Medical Publishers, 1987. pp. 432-462. 16. Polglase AL, Hughes ESR, McDermott FT, et al. A comparison of end-to-end staple and suture colorectal anastomos in the dog. Surg Gynecol Obstet 1981; 152:792-796. 17. Penninckx FM, Kerremans RP, Geboes KJ. The healing of single and double-row stapled circular anastomoses. Dis Colon Rectum 1984; 27:714-719. 18. Wong J, Cheung H, Lui R, Fan YW, et al. Esophagogastric anastomosis performed with a stapler. The occurrence of leakage and stricture. Surgery 1987; 101:408-415.

DISCUSSION DR. FRANCIS C. NANCE (Livingston, New Jersey): For those of us who have had a long-term interest in mechanical devices in surgery, this technique that Charlie Knight, I think, first popularized is a definite innovation, and the authors were kind enough to give me credit for at least stimulating their interest. When I gave my paper here before the Southern 10 years ago, it was greeted with a deafening silence. There was not much enthusiasm for the use of mechanical devices in gastrointestinal surgery, and I guess those of us who were interested in the field have been in hog heaven since then because there has been a steady increase in the number of innovative techniques and innovative new instruments that allow us a wide range of possibilities. This technique, I think, is innovative because it obviates the most cumbersome remaining problem in dealing with these intraluminal staplers, and that is the placement of a purse string, and it does obviate the need for a distal purse string, which has always been difficult and had to be put in usually by hand and without the purse string instrument. Dean, in his manuscript, which is an excellent one, describes the use of the roticulator linear stapler which is an instrument by U.S. Surgical that has a head that can be angled ad lib. I have found that this is a

bulky and big instrument and that the new Ethicon linear stapler is a smaller instrument and that is a little easier to use in the low pelvis, and I wonder what his comments are about that. I was also a little disturbed as a stapler enthusiast to hear that he is backing off in some cases. I have always thought that the stapler had its greatest use in the more difficult cases. Those cases with a lot of edema and a lot of high risk anastomoses are the ones that are most ideally suited for the mechanical device. In his paper, and I would like to hear him make further comment about this, he warns against using the 25 or smaller stapler, and I concur with this. Our experience has been that the 25 instrument, which is the small end of the EA series, is really too small to use and the incidence of stenosis is too high. I maintain a great enthusiasm for the use of the EEA and the mechanical devices elsewhere in the abdomen, and I have been fascinated that while the EEA has almost displaced hand sewing in low rectal anastomoses, most surgeons around the country don't use it anywhere else, and I would like Dean to address the issue of whether he thinks staplers have a future in the rest of the GI tract, as I thought 10 years ago, but I would just like to see if he has learned something in those 10 years.

References 1. Ravitch MM, Steichen FM. A stapling instrument for end-to-end inverting anastomosis in the gastrointestinal tract. Ann Surg 1979;