“A Study of Surgical Management of Intestinal Obstruction”



RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

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SYNOPSIS

OF

DISSERTATION

“A COMPARATIVE STUDY ON THE OUTCOME OF STAPLER ANASTOMOSIS AND HAND SEWN ANASTOMOSIS IN ELECTIVE GASTRO INTESTINAL SURGERIES’’

Submitted by

Dr. NAGANANDA. L

MBBS

POST GRADUATE STUDENT IN

GENERAL SURGERY (M.S.)

Under the guidance of

Dr. ABINASH HAZARIKA

M.B.B.S, M.S,

ASSOCIATE PROFESSOR

DEPARTMENT OF GENERAL SURGERY

S.A.H. & R.C., B.G.NAGARA

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DEPARTMENT OF GENERAL SURGERY

ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES,

B.G.NAGARA-571448

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES, BANGALORE, KARNATAKA

ANNEXURE II

PROFORMA FOR REGISTRATION OF SUBJECTS FOR DISSERTATION

| | | |

|1. |NAME OF THE CANDIDATE AND ADDRESS |Dr. NAGANANDA. L |

| | |NO. 97, KALPATARU BHAVAN, |

| | |A.I.M.S., B.G.NAGARA, |

| | |NAGAMANGALA TALUK, |

| | |MANDYA DISTRICT, |

| | |KARNATAKA - 571448. |

|2. |NAME OF THE INSTITUTION |SRI ADICHUNCHANAGIRI INSTITUTE OF MEDICAL SCIENCES, B.G.NAGARA |

|3. |COURSE OF THE STUDY & SUBJECT |M.S. IN GENERAL SURGERY |

|4. |DATE OF ADMISSION TO COURSE |31st JULY 2013 |

| |TITLE OF THE TOPIC |“A COMPARATIVE STUDY ON THE OUTCOME OF STAPLER ANASTOMOSIS AND HAND |

|5. | |SEWN ANASTOMOSIS IN ELECTIVE GASTRO INTESTINAL SURGERIES’’ |

| |BRIEF RESUME OF INTENDED WORK |APPENDIX – I |

|6. |6.1 NEED FOR THE STUDY |APPENDIX – IA |

| |6.2 REVIEW OF THE LITERATURE |APPENDIX – IB |

| |6.3 OBJECTIVES OF THE STUDY |APPENDIX – IC |

| |MATERIALS AND METHODS |APPENDIX – II |

|7. | | |

| |7.1 SOURCE OF DATA |APPENDIX – IIA |

| | | |

| |7.2 METHOD OF COLLECTION OF DATA-INCLUDING SAMPLING PROCEDURE IF ANY | |

| | |APPENDIX – IIB |

| |7.3 DOES THE STUDY REQUIRE ANY INVESTIGATIONS OR INTERVENTIONS TO BE | |

| |CONDUCTED ON PATIENTS OR OTHER ANIMALS; IF SO PLEASE DESCRIBE BRIEFLY| |

| | | |

| |7.4 HAS ETHICAL CLEARANCE BEEN OBTAINED FROM YOUR INSTITUTION FOR|APPENDIX – IIC |

| |THE ABOVE | |

| | | |

| | | |

| | | |

| | | |

| | |APPENDIX – IID |

|8. |LIST OF REFERENCES |APPENDIX – III |

|9. |SIGNATURE OF THE CANDIDATE | |

| | |Gastro-intestinal anastomosis is an integral part of GI surgeries. |

|10. |REMARKS OF THE GUIDE |Comparing the traditional hand-sewn method and the most advanced |

| | |stapling system, helps us understand the pros and cons of each method |

| | |and the better method of the two. |

| | | |

|11. |NAME AND DESIGNATION OF {IN BLOCK LETTERS} | |

| | | |

| |11.1 NAME & DESIGNATION OF GUIDE |Dr. ABINASH HAZARIKA MBBS, MS |

| | |ASSOCIATE PROFESSOR |

| | |DEPARTMENT OF GENERAL SURGERY, |

| | |A.I.M.S, B.G.NAGARA |

| |11.2 SIGNATURE OF GUIDE | |

| | | |

| | | |

| | | |

| |11.3 CO-GUIDE (IF ANY) |NO |

| |11.4 SIGNATURE OF CO-GUIDE |NO |

| | | |

| |11.5 HEAD OF DEPARTMENT |Dr. R. SRINATH M.B.B.S., M.S., |

| | |PROFESSOR AND HEAD |

| | |DEPARTMENT OF GENERAL SURGERY, |

| | |A.I.M.S, B.G.NAGARA. |

| |11.6 SIGNATURE | |

| | | |

| | | |

| | | |

| | | |

|12 |12.1 REMARKS OF THE CHAIRMAN & PRINCIPAL |The facilities required for the investigation will be made available |

| | |by the college |

| | | |

| | |Dr. SHIVARAMU. M.G., M.B.B.S., M.D. |

| | |PRINCIPAL, |

| | |AIMS, B.G. NAGARA. |

| | | |

| |12.2 SIGNATURE | |

| | | |

| | | |

APPENDIX - I

6. BRIEF RESUME OF INTENDED WORK

APPENDIX - IA

6.1 NEED FOR THE STUDY:

• Conventional (hand-sewn) technique of intestinal anastomosis has been in vogue for several decades. Staplers which were developed to simplify surgery began to have significant impact.

• To compare staplers versus conventional anastomosis with respect to certain intra-operative and post-operative parameters.

• Although stapling is an alternative to hand-suturing in gastro-intestinal surgery, recent trials specifically designed to evaluate differences between the two in surgery time, anastomosis time, and return to bowel activity are lacking.

• This trial compares the outcomes of the two in subjects undergoing elective surgery requiring a single gastric, small, or large bowel anastomosis.

• Restoring intestinal continuity after partial enterectomy and/or colectomy is central to gastrointestinal surgery. In recent years, mechanical stapling devices have improved and become more versatile so that many surgeons now consider stapling technique as best alternate method of anastomosis to suture technique, for speed, safety, efficiency and easy access.

• The purpose of the study is to compare the feasibility, safety and efficacy of the outcome of stapler and hand-sewn anastomosis in gastro intestinal surgeries.

APPENDIX - IIB

6.2 REVIEW OF LITERATURE

• Prior to nineteenth century, intestinal surgeries were limited to exteriorization by means of a stoma or closure of simple lacerations.1

• Lembert then described his seromuscular suture technique in 1826, while Senn advocated a two layer technique for closure.1

• Kocher’s method utilised a two-layer anastomosis, first a continuous all-layer suture using catgut, then an inverting continuous seromuscular layer suture using silk. 1

• Anastomosis may be created between two segments of a bowel in a multitude of ways. It may be end-to-end, side-to-side, or side-to-end.2

• The submucosal layer of the intestine provides the strength of the bowel wall and must be incorporated in the anastomosis to assume healing.2

• Numerous surgical conditions require the resection of bowel segments and the creation of reliable anastomoses. As such, anastomotic techniques have been central to the development of modern surgical practice.

• Traditionally, a wide variety of suture materials have been used to create hand-sewn anastomoses.

• Although surgical stapling devices have existed since the early 20th century, their use in routine gastrointestinal surgery has not been widespread until approximately 30 years ago when their design became much more efficient and convenient. Today, stapled anastomoses are an integral part of most major abdominal operations.

• Undoubtedly, two of the most significant complications related to intestinal anastomosis remain dehiscence and leakage.

• Indeed, breakdown of an anastomosis is associated with considerable perioperative morbidity and mortality.

• That being said, the odds of creating a safe and reliable anastomosis can be greatly increased if certain surgical tenets are respected. These include meticulous technique, avoidance of tension at the anastomosis, maintenance of good tissue vascularity, perioperative nutritional optimization, avoidance of concomitant systemic illnesses, perioperative optimization of medical comorbidities, and avoidance of certain drugs such as steroids and vasopressors.

• Intestinal anastomoses can nevertheless leak despite optimal conditions, hence the need for dependable and consistent methods.

• In this context, the current review focuses on operative techniques for stapled small bowel anastomoses. This is undoubtedly one of the most frequently encountered areas of elective general abdominal surgery.

• Excellent technique in stapled anastomoses of the small bowel is of paramount importance to both practicing surgeons and trainees.

• Restoring intestinal continuity after partial enterectomy and/or colectomy is central to gastrointestinal surgery.

• Lembert described his interrupted seromoscular suture technique in 1826 which became the mainstay in gastrointestinal surgery in the second half of the century.

• Next a Connell stitch is made in both ends. The Connell stitch is made by passing the suture from the outside in, then inside out, on one end. The same step is repeated on the other end in the form of a continuous U-shape.

• Currently, the single-layer extramucosal anastomosis is popular, as advocated by Matheson of Aberdeen, as it probably causes the least tissue necrosing or luminal narrowing.

• However, in all cases catgut and silk are being replaced by synthetic polymers.

• The introduction and widespread application of stapling devices helped revolutionize the technical aspects of surgery that have allowed minimally invasive procedures to be developed.

• Thus, in recent years, mechanical stapling devices have improved and become more versatile so that many surgeons now consider the stapling technique as best alternate method of anastomosis to the suture technique, for speed, safety, efficiency and easy access.

• A number of benefits conferred by the use of stapling instruments such as minimizing tissue manipulation and trauma, less bleeding and edema at the anastomosis, a quicker return of gastrointestinal function and a more rapid patient recovery, have been claimed by the manufactures.

• Conversely, stapling techniques have been criticized on the grounds of expense, that no improvement in anastomotic security has been observed and that there is the possibility of stricture formation.

• During the first 3 to 5 days, termed the inflammatory phase of wound healing, the collagen matrix undergoes degradation by metalloproteinases.2

• It is in this initial phase that the integrity of the anastomosis depends almost entirely on technical factors, suture materials, or the integrity of stapled margins of bowel.2

• Around the fifth postoperative day there is a crucial switch from collagen degradation to collagen deposition, which corresponds to the transition from the inflammatory phase to the fibroplasia phase.

• The fibroplasia phase reaches its maximal level at day 7.

• Any delay or impairment of the fibroplasia phase can result in the potentially catastrophic consequence of anastomotic dehiscence.

• Indeed, it is at the end of the first postoperative week that anastomotic dehiscence usually occurs and becomes clinically evident.

• Although it may seem that surgical stapling devices have completely supplanted hand suturing of bowel anastomoses, hand suturing remains a crucial skill in every surgeon's armamentarium.

• Hand suturing uniformly invokes an inflammatory response from dragging the suture material through the bowel.

• The choice of suture material used by surgeons is not based on a strong preponderance of scientific evidence.

• Everting and inverting anastomoses have come in and out of favor over the last 2 centuries, as have many anastomotic techniques.

• Recommendations for best practices in creating a GI anastomosis :

1. Ensure an adequate blood supply, eliminate tension, maintain hemostasis, and handle tissues gently. Expert opinion without explicit critical appraisal, or based on physiology, bench research or “first principles.”3

2. Use an inverting (serosa-to-serosa), or an everting, with minimal exposed mucosa, technique.

3. Close mesenteric defects to avoid internal hernia.

4. Consider a stapled technique for ileocolic anastomoses; elsewhere in the GI tract either a hand-sutured or stapled anastomosis may be employed. 3

5. A single-layer anastomosis is an acceptable technique.

• Many published studies have compared inverting and everting anastomoses through out the GI tract.

• It is clear that with everting anastomoses, the role of the omentum and other peritoneal defense mechanisms is increased because of the need to seal the anastomosis and assist in healing.

• Although everting patterns do not initially impinge on intestinal lumen, stenosis of the anastomosis may result from extraluminal adhesions and increased fibroplasia.

• Currently, inverted anastomosis is the most widely used technique worldwide.

• In this study, we compare hand suturing with surgical stapling in patients undergoing elective gastric surgery.

• Surgical stapling were first introduced by Hultl, Humer in 1908.4

• The modern era of mechanical staplers was launched when American surgeon Mark Ravitch observed a Russian surgeon in Keiv operating with a stapler on the lung.4

• The basic instruments are the LDSTM (Ligates and divides to save), TA 30TM (thoracoabdominal), TA 55TM, TA 90TM, GIATM (gastrointestinal anastomosis), and the EEATM (end-to-end) surgical staplers.5

• The LDS is employed in dividing mesentry, mesocolon, and the omentum. Although ingenious has been the least successful of the stapling instruments.5

• The GIA, TA 30, TA 55, and the TA 90 are used for opening, closure, resection and anastomosis.5

• Despite comparable results in terms of mortality, anastomotic leak, and duration of procedure, the rate of stricture at the anastomotic site is considerably higher with staples anastomosis than with strictures.

• The source of foreign materials eliciting this reaction was the stapler cartridges.

• Randal Baker’s group has popularized the “science of stapling” to promote awareness on how gastro-intestinal leaks from staple lines can occur.2

• The cause of leaks fall into two key categories: mechanical/tissue causes that occur postoperative day 0 to 2 and make up the vast majority of leaks. Ischemic causes that occur postoperative days 5 to 7, but are very rare.2

• Principles of avoiding mechanical/tissue causes of leaks include the following :

- Optimimal stapling allows adequate time for tissue compression and creep(elongation when crushing force applied)

- Stress relaxation is reduction in the amount of force required to maintain applied displacement and is important to avoid tearing of tissues from excess tissue shear or tensile stress.2

APPENDIX - IC

6.3 AIMS AND OBJECTIVES

To compare hand suturing with surgical stapling in a prospective cohort study in patients undergoing elective gastrointestinal surgeries.

APPENDIX - II

7. MATERIALS AND METHODS

APPENDIX - IIA

7.1 SOURCE OF DATA:

This study is conducted in the Department of General Surgery at Sri Adichunchanagiri Hospital and Research Centre, B.G.Nagara, Mandya district.

A total of 30 cases which meet the inclusion and exclusion criteria to be included in this hospital based prospective comparative study conducted for a duration of 18 months. The study population includes all patients who undergo elective gastrointestinal surgeries.

Study design: Open-label, prospective, randomized, interventional, parallel, controlled trial to compare surgical and subject outcomes between stapled and hand-sutured groups.

APPENDIX - IIB

2. METHOD OF DATA COLLECTION:

• Data will be collected from patients who are admitted in surgical wards of SAH & RC, requiring gastro intestinal surgeries.

• Clinical study will be through questionnaires and clinical examination.

• All patients will undergo routine and special investigations.

• All 30 patients to be classified accordingly into 2 groups with 15 in each of them. The first group will be the hand-sewn anastomosis group which include cases with at least one bowel anastomosis without the use of staplers. The second group is the stapler anastomosis group which includes cases with at least one bowel anastomosis done with a stapler. It also includes cases with multiple bowel anastomoses done with both hand sewing and stapler.

Following parameters to be compared :

1. Duration of surgery.

2. Return of bowel movments.

3. Oral feeding starting day.

4. Hospital stay.

5. Duration of anastomosis.

6. Early postoperative complications, and late postoperative complications.

7. Return to work and mortality.

The following statistical test to be used to compare the results of control group and study group:

• Patients to be randomly allotted to control or study group.

• Independent samples T-Test to compare mean values between methods.

• Chi-Square test to compare proportion of the two value.

The observation will be analysed statistically and concluded.

INCLUSION CRITERIA :

1. All patients admitted to the surgery wards requiring elective gastro-intestinal surgeries who undergo bowel anastomosis.

2. Male or female subjects (between the ages of 18 and 80 years) undergoing elective surgery requiring a gastric, small, or large bowel anastomosis.

3. Subjects who give written informed consent after reviewing the informed consent document, will be eligible for enrollment into the trial.

EXCLUSION CRITERIA

1. Paediatric age group (< 18 years)

2. Gastro-intestinal anastomosis done in emergency setting, Biliary-enteric anastomosis.

3. Patients refusing to join the study or left the hospital before final evaluation.

4. Patients with prior chemo-radiation.

5. Patients unfit for anaesthesia excluded from the study.

6. All pregnant women are excluded from the study.

7. Patient above 80 years of age who are not operated on.

8. Patients of coagulopathy and on anti-coagulant therapy.

APPENDIX - IIC

7.3 Does the study require any investigations or interventions to be conducted on patients or other animals; if so describe briefly:

YES, but the study does not include any animal experiments. The following routine pre-operative investigations will be carried out in both the group of patients after taking written and informed consent.

INVESTIGATIONS:

1. Routine investigations

a. Haemoglobin percentage

b. Total count

c. Differential count

d. Erythrocyte sedimentation rate

e. Bleeding time

f. Clotting time

g. Urine for protein, sugar and microscopy

h. Random blood sugar

i. Blood urea

j. Serum creatinine

k. Serum electrolytes

l. HIV/ HbsAG

m. Blood grouping

n. Chest radiograph

o. Electrocardiogram

2. Specific investigations

a. Ultrasound abdomen and pelvis

b. Liver function test

c. PT, aPTT, INR

d. CT Scan

e. Esophagogastrodoudenoscopy

f. Colonoscopy

g. Erect abdomen radiograph

INTERVENTION

1. The subjects will be allocated into two groups according to the type of anastomosis, hand sewn and stapler. The allocation to the groups will be at random decided by affordability of stapler by the patient and need for use of stapler. Both hand sewn and stapled anastomosis will be further divided into three sub-groups according to the site of anastomosis.

2. All the hand sewn anastomosis will be with either single layer or double layer / interrupted or continuous technique of anastomosis using 3-0 / 2-0 polyglactin (vicryl).

3. In the double layered technique, 3-0 silk to be used for outer seromuscular layer. A full standard exploration to be done as per the pathology under necessary anaesthesia decided by anaesthesiologist.

4. Staplers to be used in Anastomosis are Linear cutting staplers (TLC 55, 75), Linear anastomosing staplers (TCR 55, 75), Circular anastomosing staplers (CDH 25, 29)

APPENDIX – II D

7.4 PROFORMA APPLICATION FOR ETHICS COMMITTEE APPROVAL

| |SECTION A | |

|a |Title of the study |“A COMPARATIVE STUDY ON THE OUTCOME OF STAPLER ANASTOMOSIS AND HAND |

| | |SEWN ANASTOMOSIS IN ELECTIVE GASTRO INTESTINAL SURGERIES’’ |

|b |Principle investigator | |

| |(Name and Designation) |Dr. NAGANANDA. L |

| | |NO. 97, KALPATARU BHAVAN, |

| | |A.I.M.S., B.G.NAGARA, |

| | |NAGAMANGALA TALUK, |

| | |MANDYA DISTRICT, |

| | |KARNATAKA - 571448. |

|c |Co-investigator | |

| |(Name and Designation) |Dr. ABINASH HAZARIKA MBBS, MS |

| | |ASSOCIATE PROFESSOR |

| | |DEPARTMENT OF GENERAL SURGERY, |

| | |A.I.M.S, B.G.NAGARA |

|d |Name of the Collaborating |DEPARTMENT OF GENERAL SURGERY, A.I.M.S., B.G.NAGARA |

| |Department/Institutions | |

|e |Whether permission has been obtained from the heads of the |YES |

| |collaborating departments & Institution | |

| |Section – B |APPENDIX I |

| |Summary of the Project | |

| |Section – C |APPENDIX IC |

| |Objectives of the study | |

| |Section – D |APPENDIX IIB |

| |Methodology | |

|A |Where the proposed study will be undertaken |SAH & RC, B.G.NAGARA |

|B |Duration of the Project |18 MONTHS |

|C |Nature of the subjects: | |

| |Does the study involve adult patients? |YES |

| |Does the study involve Children? |NO |

| |Does the study involve normal volunteers? |NO |

| |Does the study involve Psychiatric patients? |NO |

| |Does the study involve pregnant women? |NO |

|D |If the study involves health volunteers | |

| |Will they be institute students? |NO |

| |Will they be institute employees? |NA |

| |Will they be Paid? |NA |

| |If they are to be paid, how much per session? |NA |

|E |Is the study a part of multi central trial? |NO |

|F |If yes, who is the coordinator? | |

| |(Name and Designation) |NA |

| | | |

| |Has the trial been approved by the ethics Committee of the other |NA |

| |centers? | |

| | | |

| |If the study involves the use of drugs please indicate whether. |NA |

| | | |

| |I. The drug is marketed in India for the indication in which it will | |

| |be used in the study. |NA |

| | | |

| |II. The drug is marketed in India but not for the indication in | |

| |which it will be used in the study | |

| | |NA |

| |III. The drug is only used for experimental use in humans. | |

| | | |

| |IV. Clearance of the drugs controller of India has been obtained for:| |

| | |NA |

| | | |

| |Use of the drug in healthy volunteers | |

| |Use of the drug in-patients for a new indication. |NA |

| |Phase one and two clinical trials | |

| |Experimental use in-patients and healthy volunteers. | |

| | | |

| | |NA |

|G |How do you propose to obtain the drug to be used in the study? |NA |

| |Gift from a drug company | |

| |Hospital supplies | |

| |Patients will be asked to purchase | |

| |Other sources (Explain) | |

|H |Funding (If any) for the project please state |NA |

| |None | |

| |Amount | |

| |Source | |

| |To whom payable | |

|I |Does any agency have a vested interest in the out come of the Project? |NO |

|J |Will data relating to subjects /controls be stored in a computer? |NO |

|K | Will the data analysis be done by | |

| |The researcher? | |

| |The funding agent |YES |

| | |NO |

|L |Will technical / nursing help be required from the staff of hospital. | |

| | | |

| |If yes, will it interfere with their duties? |NO |

| | | |

| |Will you recruit other staff for the duration of the study? |NA |

| | | |

| |If Yes give details of |NA |

| |Designation | |

| |Qualification | |

| |Number |NA |

| |Duration of Employment | |

|M |Will informed consent be taken? If yes |YES |

| |Will it be written informed consent: |YES |

| |Will it be oral consent? Will it be|NO |

| |taken from the subject themselves? |YES |

| |Will it be from the legal guardian? If no, give reason: |YES |

|N |Describe design, Methodology and techniques |APPENDIX II |

Ethical clearance has been accorded.

Chairman,

P.G Training Cum-Research Institute,

A.I.M.S., B.G.Nagara.

Date :

PS : NA – Not Applicable

APPENDIX – III

LIST OF REFERENCES

1. Williams SN, Bulstrode KJC, O’ Connell RP, Bailey And Love’s Short Practice of Surgery, 26 edn; Chapter 4, 2013; 42-44.

2. Brunucardi. C, Andersen K, Billiar. R, Dunn. L, Hunter. G, Pollock. E, Schwartz Principles of Surgery, Ninth edn; chapter 29, Colon, Rectum, and Anus. 2010; 1028-1029

3. Jones RS, Richard K: Office of Evidence-Based Surgery charts course for improved system of care. Bull Am Coll Surg; 2003; 88: 11-21.

4. Josef E. Fischer, Fischer’s Mastery of Surgery, Sixth edition Volume One 2012, part II Basic Surgical skills: New and Emerging Technology. 2011; 174-177.

5. Hugh Dudlay, David Cartar and RCG Russel, Rob and Smith’s Operative Surgery Alimentary Tract and Abdominal Wall (Colon, Rectum and Anus) Fourth edition; Stapling techniques in intestinal surgery: 92-95.

6. Migaly J, Lieberman J, Long W, Fisher C, Rolandelli RH: Effect of adenoviral-mediated transfer of transforming growth factor-beta 1 on colonic anastomotic healing. Dis Colon Rectum; 2004; 47: 1699-1705.

7. Buckmire M, Parquet G, Greenway S, Rolandelli RH: Temporal expression of TGF-beta 1, EGF, and PDGF-BB in a model of colonic wound healing. J Surg Res; 1998; 80: 52-57.

8. Fukuchi SG, Seeburger JL, Parquet G, Rolandelli RH: Influence of 5-fluorouracil on colonic healing and expression of transforming growth factor-beta 1. J Surg Res; 1999; 84: 121-126.

9. Mellish RWP: Inverting or everting sutures for bowel anastomoses. J Pediatr Surg 1966; 1: 260-265.

10. Getzen LC, Roe RD, Holloway CK: Comparative study of intestinal anastomotic healing in inverted and everted closures. Surg Gynecol Obstet; 1966; 123: 1219-1227.

11. Scher KS, Scott Conner C, Ong WT: A comparison of stapled and sutured anastomoses in gastric operations. Surg Gynecol Obstet; 1982; 154: 548-552.

12. Damesha N, Lubana P, Jain DK, Mathur R: A comparative study of sutured and stapled anastomosis in gastrointestinal operations. The Internet Journal of Surgery; 2008: 15.

13. Hori S, Takenori O, Yoshio G, Hideki H, Takao S, et al.: A prospective randomised trial of hand-sutured versus mechanically stapled anastomoses for gastroduodenostomy after distal gastrecomy. Gastric Cancer; 2004; 7: 24-30.

14. Irvin TT, Goligher JC. Aetiology of disruption of intestinal anastomosis. Brit J Surg. 1973;60:461-464.

15. Ravitch MM, SteichenFM. Techniques of staple suturing in the gastrointestinal tract.Ann Surg. 1972;175:815-837.

16. Smith SRG, Connolly JC, Crane PW: The effect of surgical drainage materials on colonic healing. Br J Surg 69:153, 1982.

17. Matheson NA, McIntosh CA, Krukowski ZH: Continuing experience with single layer appositional anastomosisin the large bowel. Br J Surg 72(suppl): S104, 1985.

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