Int J Colorect Dis (1992) 7:231
Col6rec/al Disease 9 Springer-Verlag ~992
Correspondence Double versus single stapling technique in rectal anastomosis Dear Sir, I am unable to agree with the conclusion reached by Bozzetti et ai. in their paper "Double versus single stapling technique in rectal anastomosis" [Int J Colorect Dis 7:31-34 (1992)]. The choice between single or double stapling technique in rectal surgery should be based on scientific reasoning rather than personal preference alone. The single stapling technique is nearly impossible with anastomosis at 2 - 5 cm from the anal verge. At this low level, however, the double stapling technique comes into a place of its own and makes such low anastomosis relatively easy to perform. Above 8 - 1 0 cm the use of a single stapling instrument is usually straightforward and saves costs compared to using two instruments. The use of the double stapling technique is therefore unnecessary for high rectal anastomosis. Benefits of the double and single stapling techniques are therefore obvious below 5 cm from the anal verge and above 8 cm from the anal verge, respectively. Between 5 and 8 cm from the anal verge, the choice of technique relies on surgical expertise and experience and may perhaps be left to personal preference. Secondly, their reported incidence of anastomotic leak is high, and I suggest that this may be vascular in origin. This is perhaps hinted at by the fact that their dehiscence rate is higher when the anastomosis had been reinforced with manually inserted sutures than when this had not been performed. Additional suturing further compromises an already ischaemic segment of bowel. In the double stapling technique, a linear or transverse stapler is used to transect the rectum at a chosen point. This may be very difficult to achieve especially in a very low transection in a narrow pelvis. Where such difficulties are encountered, devascularised rectal wall is easily retained. Posterior
rectal wall is especially notorious and may occur even when the stapler is sitting squarely across the correct position anteriorly. The retained rectal wall need not be grossly excessive, but an additional 2 - 3 mm of devascularized rectal wall may be enough to result in an anastomotic leak. Devascularised rectum may appear only slightly pale or blue, and appreciation of a few millimetres of devascularised rectum is extremely difficult in a deep pelvis. Furthermore, the residual rectum flops down within the pelvis on removal of the linear stapler, and I have found that fine colour differentiation is impossible in this situation. Intra-operative air or fluid insuffiation does not demonstrate any defects as the leaks occur only when the segment involved necroses after several days. In a similar way, excessive clearance of the blood supply of the proximal colon or distal rectal stump in the single stapling technique is liable to result in potentially devascularised bowel. Excessive devascularisation must therefore be avoided. Both single and double stapling techniques have their rightful place in surgical practice, and the choice between the techniques must be based on scientific reasons rather than on personal preference alone. Meticulous technique with a respect for vascular integrity of retained intestine decreases anastomotic leaks and contributes to safe and sound surgery.
Yours sincerely, Mr. F. Seow-Choen Department of Colorectal Surgery Singapore Genera[ Hospital Outram Road Singapore 0316
Col6rec/al Disease 9 Springer-Verlag ~992
Correspondence Double versus single stapling technique in rectal anastomosis Dear Sir, I am unable to agree with the conclusion reached by Bozzetti et ai. in their paper "Double versus single stapling technique in rectal anastomosis" [Int J Colorect Dis 7:31-34 (1992)]. The choice between single or double stapling technique in rectal surgery should be based on scientific reasoning rather than personal preference alone. The single stapling technique is nearly impossible with anastomosis at 2 - 5 cm from the anal verge. At this low level, however, the double stapling technique comes into a place of its own and makes such low anastomosis relatively easy to perform. Above 8 - 1 0 cm the use of a single stapling instrument is usually straightforward and saves costs compared to using two instruments. The use of the double stapling technique is therefore unnecessary for high rectal anastomosis. Benefits of the double and single stapling techniques are therefore obvious below 5 cm from the anal verge and above 8 cm from the anal verge, respectively. Between 5 and 8 cm from the anal verge, the choice of technique relies on surgical expertise and experience and may perhaps be left to personal preference. Secondly, their reported incidence of anastomotic leak is high, and I suggest that this may be vascular in origin. This is perhaps hinted at by the fact that their dehiscence rate is higher when the anastomosis had been reinforced with manually inserted sutures than when this had not been performed. Additional suturing further compromises an already ischaemic segment of bowel. In the double stapling technique, a linear or transverse stapler is used to transect the rectum at a chosen point. This may be very difficult to achieve especially in a very low transection in a narrow pelvis. Where such difficulties are encountered, devascularised rectal wall is easily retained. Posterior
rectal wall is especially notorious and may occur even when the stapler is sitting squarely across the correct position anteriorly. The retained rectal wall need not be grossly excessive, but an additional 2 - 3 mm of devascularized rectal wall may be enough to result in an anastomotic leak. Devascularised rectum may appear only slightly pale or blue, and appreciation of a few millimetres of devascularised rectum is extremely difficult in a deep pelvis. Furthermore, the residual rectum flops down within the pelvis on removal of the linear stapler, and I have found that fine colour differentiation is impossible in this situation. Intra-operative air or fluid insuffiation does not demonstrate any defects as the leaks occur only when the segment involved necroses after several days. In a similar way, excessive clearance of the blood supply of the proximal colon or distal rectal stump in the single stapling technique is liable to result in potentially devascularised bowel. Excessive devascularisation must therefore be avoided. Both single and double stapling techniques have their rightful place in surgical practice, and the choice between the techniques must be based on scientific reasons rather than on personal preference alone. Meticulous technique with a respect for vascular integrity of retained intestine decreases anastomotic leaks and contributes to safe and sound surgery.
Yours sincerely, Mr. F. Seow-Choen Department of Colorectal Surgery Singapore Genera[ Hospital Outram Road Singapore 0316
