Le Khang Duy Ricky, Martin Katherine, Read David
Department of Trauma, The Royal Melbourne Hospital, Melbourne, Victoria, Australia.
Geelong Clinical School, Deakin University, Geelong, Victoria, Australia.
ANZ J Surg. 2024 Apr;94(4):604-613. doi: 10.1111/ans.18925. Epub 2024 Mar 8.
Approach to enteric anastomotic technique has been a subject of debate, with no clear consensus as to whether handsewn or stapled techniques are superior in trauma settings, which are influenced by unique perturbances to important processes such as immune function, coagulation, wound healing and response to infection. This systematic review and meta-analysis compares the risk of anastomotic complications in trauma patients with gastrointestinal injury requiring restoration of continuity with handsewn versus staples approaches.
A comprehensive computer assisted search of electronic databases Medline, Embase and Cochrane Central was performed. Comparative studies evaluating stapled versus handsewn gastrointestinal anastomoses in trauma patients were included in this review. All anastomoses involving small intestine to small intestine, small to large intestine, and large intestine to large intestine were eligible. Anastomosis to the rectum was excluded. Outcomes evaluated were (1) anastomotic leak (AL) (2) a composite anastomotic complication (CAC) end point consisting of AL, enterocutaneous fistula (ECF) and deep abdominal abscess.
Eight studies involving 931 patients were included and of these patients, data from 790 patients were available for analysis. There was no significant difference identified for anastomotic leak between the two groups (OR = 0.77; 95% CI 0.24-2.45; P = 0.66). There was no significant improvement in composite anastomotic complication; defined as a composite of anastomotic leak, deep intra-abdominal abscess and intra-abdominal fistula, in the stapled anastomosis group (OR = 1.05; 95% CI 0.53-2.09; P = 0.90). Overall, there was limited evidence to suggest superiority with handsewn or stapled anastomosis for improving AL or CAC, however this was based on studies of moderate to high risk of bias with poor control for confounders.
This meta-analysis demonstrates no superiority improvement in anastomotic outcomes with handsewn or stapled repair. These findings may represent no effect in anastomotic outcome by technique for all situations. However, considering the paucity of information on potential confounders, perhaps there is a difference in outcome with overall technique or for specific subgroups that have not been described due to limited sample size and data on confounders. Currently, there is insufficient evidence to recommend an anastomotic technique in trauma.
肠吻合技术的应用一直是一个有争议的话题，对于在创伤情况下手工缝合或吻合器技术哪种更具优势，尚无明确共识，因为创伤会对免疫功能、凝血、伤口愈合和感染反应等重要过程产生独特干扰。本系统评价和荟萃分析比较了在需要恢复连续性的胃肠道损伤创伤患者中，手工缝合与吻合器吻合方法的吻合口并发症风险。
对电子数据库Medline、Embase和Cochrane Central进行了全面的计算机辅助检索。本评价纳入了评估创伤患者吻合器与手工缝合胃肠道吻合术的比较研究。所有涉及小肠与小肠、小肠与大肠以及大肠与大肠的吻合均符合条件。直肠吻合被排除在外。评估的结局包括：（1）吻合口漏（AL）；（2）由AL、肠皮肤瘘（ECF）和深部腹腔脓肿组成的复合吻合口并发症（CAC）终点。
纳入了八项研究，共931例患者，其中790例患者的数据可用于分析。两组之间在吻合口漏方面未发现显著差异（OR = 0.77；95% CI 0.24 - 2.45；P = 0.66）。吻合器吻合组在复合吻合口并发症（定义为吻合口漏、深部腹腔脓肿和腹腔内瘘的组合）方面没有显著改善（OR = 1.05；95% CI 0.53 - 2.09；P = 0.90）。总体而言，几乎没有证据表明手工缝合或吻合器吻合在改善AL或CAC方面具有优势，然而这是基于对混杂因素控制不佳的中到高偏倚风险研究。
本荟萃分析表明，手工缝合或吻合器修复在吻合口结局方面没有优势改善。这些发现可能代表在所有情况下技术对吻合口结局均无影响。然而，考虑到关于潜在混杂因素的信息匮乏，也许总体技术或因样本量有限和混杂因素数据未描述的特定亚组在结局上存在差异。目前，没有足够的证据推荐创伤情况下的吻合技术。
