Handsewn or stapled colorectal anastomosis? Or how evidence based is surgical practice?

Editorial

Delcio Matos

Suzana Angélica Silva Lustosa

Handsewn or stapled colorectal anastomosis?

Or how evidence based is surgical practice?

Responding to increasing demands for cost-effectiveness relation a recent randomized trial which compared the cost of stapled and hand-sutured anastomosis in the gastrointestinal tract, has concluded that stapled anastomosis are not efficcient and should be reserved for individual indications.¹ However, one can admit that in the general surgical practice, preference for stapler is so overwhelming that cost-effectiveness approach is being neglected since the first anastomotic machine has been fired. As a matter of fact most surgeons do not regard this as an issue of concern and as a result it has not been considered as a major study endpoint in the literature.²

Taken into account that health care cost is getting even more worrisome, any intervention in this area has to be soundly based. To save resources is important not only for developed countries but also and mainly for developing ones, where financial burden is too high.³ Therefore, one must pursue the best available scientific evidence in order to support decisions, otherwise it takes the risk of being restricted by financial pressure. Purchasers of anastomotic devices are well aware of this matter.

So far most of the research in colorectal surgery lack of the best epidemiological evidence which take us to infer on the limitation to use the conclusions of these studies in order to guide decisions. Surgeons tend to take theirs decisions based on series report or specialist opinion which are not considered first level quality of evidence. The so called unwillingness of the surgeon to perform randomized controlled trials has to be vanished once and for all. How could we do it? Just by doing wel designed randomized controlled trials, even with the restriction of this kind of research in the surgical area. A systematic review of these trials may be the final answer to research question, just in case of sample size being the problem.

Systematic review with homogeneity of randomized controlled trials on therapy has been regarded as top level evidence.The extent to which surgical practice is supported by satisfactory scientific evidence is currently under investigation. The first conclusion of these studies is that the majority of surgical treatment cannot be subjected to randomized controlled trials and that it will be necessary to develop better methods of categorizing the non randomized evidence supporting treatment choice.⁴

An unpublished systematic review and metanalysis on colorectal anastomosis has recently concluded that, so far, the evidence available is insufficient to show superiority of stapled to handsewn technique.² So until best evidence can be shown, the choice of which technique has to be used may be based on the surgeon experience and the best judgement.

REFERENCES

1. Izbicki JR, Gawad KA, Quirrenbach S, Hosch SB, Breid V, Knoefel WT. Can stapled anastomosis in viscera surgery still be justified? a prospective, randomized and controlled study of cost-effectiveness of handsewn and stapled anastomoses. Chirurg, 1998;69:725-34.

2. Lustosa, SAS. Stapled or handsewn colorectal anastomosis? systematic review and metanalysis. Master thesis (in Portuguese). UNIFESP - Escola Paulista de Medicina, 1999.

3. Attalah, AN. The Cochrane Collaboration in the Third World. Editorial. Rev Paul Med, 1998;116:1693.

4. Howes N, Chagla L, Thorpe M, McCullosh P. Surgical practice is evidence based. Br J Surg, 1997;84:1220-23.

Delcio Matos

Dean of Postgraduate Gastroenterological Studies and Head of Colorectal Surgery, UNIFESP - Escola Paulista de Medicina.

Suzana Angélica Silva Lustosa

Master of Gastroenterological Surgery, UNIFESP - Escola Paulista de Medicina.

Publication Dates

• Publication in this collection
  04 Oct 1999
• Date of issue
  May 1999