Surgical Challenges of

ANASTOMOTIC LEAKS

Despite a better understanding of the impact of
local and systematic factors on anastomotic
healing post-surgery, anastomotic leaks remain a
common concern.

The rate of anastomotic leaks per surgery varies
but is reported to be between 2.7-8.7%¹.

A successful anastomosis is a surgical connection between two structures and is commonly used on tubular structures, such as blood vessels or loops of the intestine.

One of the most severe bowel complications is an anastomotic leak, which occurs when fluid leaks from the surgical joint. In this article, we will look at the common risk factors for an anastomotic leak and the best practices to try to avoid them.

intestine

COMMON COLORECTAL PROCEDURES USING ANASTOMOSIS

There are several procedures that use anastomoses in the bowel:

Intestinal anastomosis

Involves removing part of the colon and joining the two remaining sections.

Ileocolic or ileocolonic anastomosis

Connects the end of the small intestine to the colon, usually after a bowel resection.

Colectomy

Connects the end of the small intestine to the colon, usually after a bowel resection.

Hepaticojejunostomy

Connecting a hepatic duct to a small bowel section and permitting food digestion following specific pathological processes that harm the bile ducts, pancreas, or the duodenum.

METHODS OF ANASTOMOSIS

There are three anastomosis techniques that can be performed in the bowel, which are:

Side-to-side

In this technique, the sides of each part of the bowel are either sutured or stapled rather than the two ends.

End-to-end

In this technique, the two open ends of the intestines are connected.

End-to-side

The end of the intestine, which is smaller, is connected to the side of the larger section².

ANASTOMOTIC LEAK

A leak of luminal fluid. It is one of the most serious complications of colorectal surgery².

Anastomotic leaks lead to the contamination of the abdominal cavity which can cause infection and if left untreated, patient mortality.

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Stapling Vs. Hand Sewn

There is some controversy around whether stapling or hand sewing results in better surgical outcomes, but there is no evidence that produces a definitive conclusion.

The widespread availability and use of stapling devices has changed colorectal surgery. In 1980, Knight and Griffen developed the “double-staple” technique, which is now widely accepted for anastomoses. Both linear and circular staplers can be used to conduct the double-staple technique, eliminating the need for a hand-sewn, distal purse string, which is sometimes difficult or even impossible to accurately place low in the pelvis⁴.

Despite there being no clinically significant difference in patient outcomes for stapling vs sewn procedures, studies have shown that stapled anastomoses took on average 22 minutes less operation time compared to sutured anastomoses (p=0.0001). This had a knock-on effect to both operational and overall hospital costs, providing a saving of 183 euros in operation costs and 496 in overall hospital costs⁵.

Single Vs Double-stapling Technique

In a prospective randomised trial examining single vs. double-stapling techniques, there was a trend in favour of double-stapling with a 2.8% rate of occurrence for leaks versus an 8.6% rate for the single-stapling method⁶. However, there is further data to suggest that the overlapping staples may be the cause of the anastomotic leaks in these occurrences

A study looking into numbers of staple intersections

found that the more staple intersections a person had, the higher the chance of anastomotic leak occurrence. The study divided 128 patients into 3 groups⁷:

128

Group A

58
Patients

0 intersection of staples

Group B

62
Patients

1 intersection of staples

Group C

8
Patients

2 intersection of staples

0%
had a leak

Results

0%
had a leak

12.5%
had a leak

Conclusion

the number of intersections of staple lines is associated with anastomotic leakage.

Furthermore, the FDA recently did an update (October 2021), reminding clinicians of the increased leak rates when staple lines are crossed⁸.

CIRCULAR STAPLERS

Traditional circular staplers with limited housing
Traditional circular staplers with limited housing

One challenge with circular staplers is the piston effect. The piston effect is an engineering challenge that is seen across industries with tubular structures, like train tunnels or the housing of a circular stapler.

Forced-air flow inside a tunnel or shaft caused by a moving object will lead to a build of pressure known as the piston effect. With staplers, this pressure build-up can cause the tissue to seep over the edge of the head of the stapler and cause the malformation of staples.

REVIEWING CIRCULAR STAPLERS

Touchstone saw the issues with circular
staplers and decided to go back to basics,
working with doctors to understand their
biggest challenges during surgery.

CST circular stapler which can has a wider anvil to prevent anastomotic leaks

Initially looked at the efficacy of the cutting blade which led them to design, a circular blade with a twisting action leading to a better across the stapler lines. This can be found in the CSC which has the rating blade feature.

Continuing from this they also looked to tackle the engineering concerns with circular stapler design and function. This combined approach led to the award-winning circular stapler design: the CST. The CST has taken circular stapling one step further, pushing innovation to ensure patient safety. Touchstone found that by significantly increasing the housing size by more than double, the CST eliminates the piston effect, creating clean and even doughnuts. Furthermore, an audible bell is rung when a staple is fired, to prevent from misfiring. The clear and concise steps required to fire these staplers, along with the clearly audible bell, signifying the firing and the automatic safety lock have contributed to patient safety and surgeon satisfaction.

We believe these changes can lead to a better anastomosis outcome and it warrants further investigation. Made with the aim to improve patient safety and help the surgeon make stronger and more secure anastomoses. However, as discussed, there are multiple causes for anastomotic leaks and while new innovations in circular stapling cannot completely remove these risks, they are a step in the right direction.

Learn more about the CST

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References

1. Park, Jong Seob MD, Jung Wook MD Huh, Yoon Ah MD Park, Yong Beom MD Cho, Seong Hyeon MD Yun, Hee Cheol MD Kim, and Woo Yong MD Lee. “Risk Factors of Anastomotic Leakage and Long-Term Survival After Colorectal Surgery.” Medicine 95, no. 8 (February 2016).
2.  Fang, Alex, Chao Wilson, and Melanie Ecker. “Review of Colonic Anastomotic Leakage and Prevention Methods.” Journal of Clinical Medicine 16, no. 9 (December 2020).
3.  Li, Yi-Wei, Peng Lian, Ben Huang, Ming-He Wang, and Wei-Lie Gu. “Very Early Colorectal Anastomotic Leakage within 5 Post-Operative Days: A More Severe Subtype Needs Relaparatomy.” Sci Rep 13, no. 7 (January 2017).
4. Baran, J, SD Goldstein, and AM Resnik. “The Double-Staple Technique in Colorectal Anastomoses: A Critical Review.” Am Surg 58, no. 4 (April 1992).
5.  Schineis, C, T Fenzl, L Aschenbrenner, L Lobbes, A Stroux, B Weixler, K Beyer, C Kamphues, M. E. Kreis, and J. C. Lauscher. “Stapled Intestinal Anastomoses Are More Cost Effective than Hand-Sewn Anastomoses in a Diagnosis Related Group System.” The Surgeon 19, no. 6 (May 2021).
6. Moritz E, Achleitner D, Hölbling N, Miller K, Speil T, Weber F. Single vs. double stapling technique in colorectal surgery. A prospective randomized trial. Dis Colon Rectum. 1991 Jun;34(6):495-7.
7. Lee, S, and B Ahn. “The Relationship Between the Number of Intersections of Staple Lines and Anastomotic Leakage After the Use of a Double Stapling Technique in Laparoscopic Colorectal Surgery.” Surg Laparosc Endosc Percutan Tech 27, no. 4 (August 2017).
8.https://www.fda.gov/medical-devices/letters-health-care-providers/safe-use-surgical-staplers-and-staples-letter-health-care-providers.
9. Roumen, Rudi M. H., PHD, Frank Rahusen, and Marc. M. D. Wijnen. ‘Dog Ear’ Formation after Double-Stapled Low Anterior Resection as a Risk Factor for Anastomotic Disruption.” Diseases of the Colon & Rectum 43, no. 4 (April 2000).
10. Villanueva-Sáenz E, Sierra-Montenegro E, Rojas-Illanes M, Peña-Ruiz Esparza JP, Martínez Hernández-Magro P, Bolaños-Badillo LE. Doble engrapado en cirugía colorrectal [Double stapler technique in colorectal surgery]. Cir Cir. 2008 Jan-Feb;76(1):49-53. Spanish.