Clinical and Experimental Studies on Gastrointestinal Anastomoses and Colorectal Cancer

Medicine, Surgery

Akyol, Ahmet Murat

University:University of Glasgow

关键词: Medicine, Surgery;   

Others  :  http://theses.gla.ac.uk/78223/1/11007615.pdf

来源: University of Glasgow

【 摘 要 】

The first section of this thesis discusses the role of stapling techniques in surgical practice. A prospective controlled clinical trial is described, where surgical stapling techniques were compared with conventional manual suturing techniques in the construction of gastrointestinal anastomoses. The following section deals with work on recurrence of colorectal cancer following surgical treatment. Two clinical studies are presented in this section, where "anastomotic techniques" and "anastomotic leaks" are examined respectively in relation to tumour recurrence. The final section of the thesis describes experimental studies in a rodent model, which were designed and conducted to investigate the association between anastomotic leaks and peri-anastomotic tumour growth. Suturing or stapling in gastrointestinal surgery Between April 1985 and April 1989 1,161 consecutive patients undergoing surgery under the care of 13 consultant surgeons throughout the West of Scotland and Highland regions were studied prospectively. All patients had operations that entailed the construction of a gastrointestinal anastomosis. If, at the time of surgery suturing and stapling techniques were considered equally appropriate, the method of anastomotic construction was determined by randomisation. Methods of data collection, bowel preparation, antibiotic prophylaxis, anastomotic materials and anastomotic techniques were standardised by the study protocol. Four hundred and ninety six patients received sutured and 508 received stapled anastomoses. In the remaining 157 patients randomisation was considered inappropriate. All patients were followed until death or discharge from the hospital. The incidence of clinically evident anastomotic dehiscence was 3. 3% in patients with sutured anatomoses, compared with 4.7% in the stapled group (p<0.22). Sub-clinical (radiologically detected) leaks were encountered with a significantly higher frequency in the sutured group (14.4% versus 5.2%; p < 0.05). Surgical stapling also afforded significantly quicker anastomoses and operations (Mean anastomosis time + SEM: 28.1 +/-0.7 versus 14.3 +/-0.5 minutes, p< 0.001; Mean operating time +/-SEM: 115.5 +/-2.4 versus 103.9 +/-2.2 minutes, p <0.001). With regard to other important outcome measures such as operative mortality, incidence of infective complications, recovery of gastrointestinal function and duration of hospital stay, suturing and stapling techniques produced comparable results. Further detailed analyses are presented, where the randomised and non-randomised patients were stratified according to anastomotic technique and various surgical categories. These data are hoped to provide guidance to surgeons in their selection of anastomotic technique. Anastomotic techniques and recurrence of colorectal cancer Recently some concern has been expressed in the literature regarding a potential adverse influence on the recurrence of rectal cancer associated with the use of stapling techniques. Prompted by these reports, the effect of anastomotic technique on the incidence of recurrence following potentially curative resections was studied in 294 patients. One hundred and forty two of these patients had their anastomoses randomised to suturing and 152 to stapling. By the end of the second postoperative year the incidence of tumour recurrence (+/-SEM) was 29.4% (4.4%) in the sutured group, compared with 19.1% (3.9%) in the stapled group (p< 0.05). Cancer specific mortality was also significantly higher in patients with sutured anatomoses (22.3% +/-4.1% versus 10.9% +/-3.0% at 24 months, p< 0.01). Further analysis revealed that the influence of anastomotic technique on recurrence and mortality rates was independent of tumour stage and other co-variates. These results suggest that in patients undergoing potentially curative resections for colorectal cancer, the use of stapling instruments for anastomotic construction may be associated with a significant reduction in recurrence and cancer specific mortality rates compared with conventional manual suturing techniques. Potential explanations for this previously unreported observation are discussed.(Abstract shortened by ProQuest.).