A new analysis of a large, international audit undertaken by the European Society of Coloproctology (ESCP) in 2015 has examined the role of technical factors on the healing of the join in the bowel following operations on the right side of the colon.

The group found that neither the choice of type of stapler (cutting or non-cutting), nor over-sewing of the staple line affected the rate of leakage. However, having the surgery performed by a general rather than a specialist colorectal surgeon was associated with an increased risk of leak (12.1% versus 7.3%).

The paper, which has been published by the specialist journal Colorectal Disease, was co-authored by the 2015 European Society of Coloproctology collaborating group.

It was based on an international, multicentre prospective, observational study conducted around Europe. In total, the results were collated from 3,208 patients from 284 centres in 39 countries. Any hospital performing colorectal surgery was invited to contribute data on adult patients undergoing right hemicolectomy or ileocolic resection, for any indication.

In the group where a stapler was used to join the bowel, the overall anastomotic leak rate was 8.3%, higher than often reported. Within the adjusted analysis, factors such as having open or emergency surgery were found to have significant association with leak. Considering technical factors, there was found to be no difference in leak rates with the use of a cutting or non-cutting stapler for the top staple line, or after over-sewing of the staple line.

General surgeons had a significantly higher leak rate than colorectal surgeons even after risk adjustment (12.1% versus 7.3%, OR: 1.65, 95% CI:1.04-2.64, P=0.04). It is possible that the difference in the leak rates between general and colorectal surgeons may be explained by factors other than their surgical ability. For example, general surgeons more frequently performed emergency procedures and operations out of hours. Although the study took these factors into account when comparing the groups of surgeons, it is possible there were other factors not accounted for in the analysis, which may have biased the findings.

One of the authors of the paper Sanjay Chaudhri said:

“Colorectal resections carry a high burden of morbidity, with post-operative complications common. One significant complication is a leak from the join in the bowel. This impacts not only on short term survival, functional outcomes and quality of life, but in cancer patients also increases the risk of recurrence.”

“Surgical technique is an attractive target for reducing anastomotic leak rates, as it is operator-dependent, and is readily adaptable to new evidence. However, there is little high-quality evidence to support surgeons’ choices of technique including the type of stapler used for the join. This study provided real time data from a large, prospective, multicentre, international study.”

“The study highlights that anastomotic leak is a complex and multifactorial problem and that there exist multiple acceptable technical variations for stapled anastomosis in modern practice. The association between operator specialism and anastomotic failure may highlight a training need. The ESCP are working with stapler manufacturers to help provide enhanced training in the use of gastrointestinal staplers for the benefit of our patients across Europe.”

The Chair of the ESCP Research Committee, Dion Morton, said:

“The ESCP is grateful to the ESCP collaborating group and the ESCP Cohort sub-committee for demonstrating the ability of international collaborative research to improve the evidence base for the treatment of patients. Given the findings, the ESCP plans to implement an international quality improvement programme in stapling with the aim of reducing anastomotic failure.”

The Paper was published in the Colorectal Disease journal on 19 June 2018: https://onlinelibrary.wiley.com/doi/abs/10.1111/codi.14308

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