COMPARISON OF SURGICAL OUTCOME OF LINEAR STAPLED AND MANUAL ANASTOMOSIS TECHNIQUE FOR REVERSAL OF LOOP ILEOSTOMIES

Ileostomy is a critical, often lifesaving surgical intervention, though the reasons for its use vary globally based on regional healthcare practices and disease patterns. While the reversal of a loop ileostomy is generally viewed as a straightforward operation, it is not without risks and may lead to considerable complications, including morbidity and, in rare cases, mortality.¹ Enhanced Recovery After Surgery (ERAS) is a modern approach aimed at optimizing surgical outcomes by implementing specific evidence-based protocols before and after the operation to support faster recovery and reduce complications. ² A loop ileostomy is a surgically constructed opening in the intestine designed to temporarily divert stool. This diversion allows the bowel to heal or be protected following certain procedures. Typically, the natural flow of the intestines is restored by closing the ileostomy approximately three months after its creation. ³ Stoma closure can be associated with a range of postoperative complications, including wound infections or hematomas, leakage from the anastomotic site, intestinal obstruction at the location of the closure, accidental bowel injuries during surgery, formation of localized abscesses, and peristomal skin inflammation following reversal. ^4-5 Various studies have reported differing rates of morbidity associated with ileostomy reversal. Although the procedure is generally considered to carry a low risk of complications and mortality, it can still result in adverse outcomes. In some cases, serious complications may arise that require additional surgical intervention. ⁶ 

 The method chosen for performing the anastomosis during ileostomy reversal plays a vital role in determining patient outcomes, as it can impact the likelihood of complications, speed of recovery, and overall success of the surgery. ⁷ The two primary techniques employed for this purpose are the linear stapled approach and the traditional hand-sewn (manual) method. ⁸ Both techniques offer distinct benefits and drawbacks, yet there remains ongoing discussion and uncertainty about which approach produces better clinical outcomes. ⁹ The linear stapling method is frequently preferred due to its efficiency, uniformity, and minimal handling of bowel tissue, which may contribute to reduced surgical time and decreased tissue trauma. ¹⁰ On the other hand, the manual (hand-sewn) technique is valued for its flexibility and enhanced precision, making it particularly useful in challenging cases or when the bowel tissue is fragile or compromised. ^11-12 A study compared reversal of loop ileostomy in linear stapler and manual suturing and found anastomosis leakage (3.7% vs 0%), surgical site infection (13.8% vs 34.9%) and prolonged hospital stay (3% vs.7%).¹³

 Despite the widespread use of both techniques, evidence comparing their efficacy and safety in loop ileostomy reversal remains inconclusive. Given the prevalence of loop ileostomy reversals and the significant impact of postoperative complications on patient health and healthcare resources, it is essential to determine the optimal anastomotic method. This study aims to compare the surgical outcomes of linear stapled versus manual anastomosis techniques in loop ileostomy reversal, focusing on postoperative complications to provide clearer guidance for surgical practice.

A randomized controlled trial was conducted to compare the surgical outcomes between linear stapled and manual anastomosis techniques for the reversal of loop ileostomy at the Department of Surgery, Jinnah Postgraduate Medical Centre (JPMC), Karachi. The study commenced after obtaining approval from the College of Physicians and Surgeons Pakistan. All participants provided informed written consent after a thorough explanation of the study's objectives, potential risks, and benefits.

 The study was carried out over a period of six months from 1st July 2024 to 1st January 2025 and included a total of 68 patients, with 34 allocated to each group. The sample size was determined using the WHO sample size calculator, considering a confidence level of 95%, power of 90%, and a difference in surgical site infection rates between the stapled and manual groups (13.8% vs. 34.9%). Participants were selected through non-probability consecutive sampling based on specific inclusion and exclusion criteria. Eligible participants were adults aged 20 to 80 years, of either gender, classified as ASA ≤ 2, and scheduled for loop ileostomy reversal. Patients with a history of previous abdominal surgery, trauma, malignancy, sepsis, or significant comorbidities such as congestive cardiac failure, chronic liver disease, chronic obstructive pulmonary disease, asthma, myocardial infarction, chronic kidney disease, or stroke were excluded.

Random allocation was carried out using sealed opaque envelopes, with participants assigned to either group A (linear stapled anastomosis) or group B (manual sutured anastomosis). All surgical procedures were performed by consultant surgeons with over five years of experience. Postoperatively, patients were followed up by the researcher and assessed for defined surgical outcomes within 14 days of surgery. These outcomes included anastomotic leakage, surgical site infection, and prolonged hospital stay, as per predetermined operational definitions.

 Anastomotic leakage was diagnosed based on CT findings indicating pneumoperitoneum or extraluminal fluid, supported by clinical features such as abdominal pain (VAS ≥ 4), fever (>38°C), tachycardia (>90 beats/min), tachypnea (>20 breaths/min), or leukocytosis (>12,000 WBCs). Surgical site infection was identified through physical examination findings consistent with superficial, deep, or organ/space infection in conjunction with signs such as fever, localized pain (VAS >2), erythema, purulent discharge, positive cultures, or imaging-confirmed abscess. Hospital stays exceeding 10 days were categorized as prolonged.

 Effect modifiers such as diabetes mellitus, hypertension, dyslipidemia, and smoking status were carefully documented. Diabetes mellitus was defined by a documented history of the condition, treatment compliance, and HbA1c ≤ 7. Hypertension required a minimum of six months of antihypertensive therapy and controlled blood pressure (SBP ≤ 130 mmHg, DBP ≤ 90 mmHg). Dyslipidemia was identified through ongoing treatment or abnormal lipid levels, while smoking status was classified as active, non-smoker, or ex-smoker based on predefined criteria.

 All collected data were recorded in a structured proforma and analyzed using SPSS version 22. Quantitative variables such as age, length of hospital stay, and duration of surgery were expressed as mean ± standard deviation if normally distributed (based on the Kolmogorov–Smirnov test) or as median and interquartile range for non-normally distributed data. Categorical variables, including gender, comorbid conditions, socioeconomic indicators, and surgical outcomes, were summarized using frequencies and percentages. Chi-square or Fisher’s exact tests were employed to compare surgical outcomes between groups. Stratification was applied to control for effect modifiers and evaluate their impact on surgical outcomes, with a post-stratification chi-square or Fisher’s exact test applied. A p-value of ≤ 0.05 was considered statistically significant.

We compared loop ileostomy reversal using linear stapling versus hand‐sewn suturing at our tertiary care hospital and found clear advantages with stapling, supporting findings from other centers.

 Stapled anastomosis shortened operating times. In our data, procedures took 1.7 ± 0.57 hours with stapling versus 1.9 ± 0.99 hours with hand‐sewn sutures, saving roughly 12 minutes (p < 0.05).¹⁴ Other researches have recorded a 15–20 minutes reduction when using a linear stapler (p < 0.05).^15-16 Similarly, other studies found a mean time savings of 11.5 minutes (p <0.05).¹⁷ These savings matter in high‐volume settings, where even a ten‐minute gain per case can improve anaesthesia management and room turnover.

 Stapling accelerated return of bowel function. We measured first flatus at 2.2 ± 0.6 days for stapled patients compared with 2.7 ± 0.7 days for those with hand‐sewn closure (p <0.05).¹⁴ Other studies have reported similar results (p = 0.001).^15-16 Scientists have reported a 0.52‐day improvement (p < 0.001) in mean time to first bowel movement with stapled anastomosis.^17-19 A uniform staple line likely reduces tissue trauma and local oedema, allowing peristalsis to resume more quickly. ¹⁹

 Stapling reduced length of hospital stay. Patients who received a stapled anastomosis left in 4.6 ± 1.1 days on average, compared with 5.3 ± 1.4 days for the hand‐sewn group (p <0.05).^14-16 Studies have observed a 0.7‐day shorter stay among stapled patients (p <0.05).¹⁴ Research has also found a pooled reduction of 0.70 days (p <0.05).^17-20 Shorter admissions reduce exposure to hospital‐acquired complications and lower bed occupancy pressures in settings with limited capacity. ¹⁴

 When we examined surgical‐site infection (SSI), 47.1 % of stapled patients versus 41.2 % of hand‐sewn patients developed SSIs (p > 0.05). Researchers have documented fewer infections in stapled cases (p < 0.05) [2,3,4,5]. One meta‐analysis found no significant difference.^16,18 These varying results likely reflect differences in patient populations and perioperative antibiotic protocols.^21-22 Nonetheless, stapling tends to minimise tissue handling, which should theoretically lower contamination risk.¹⁸

 Anastomotic leakage remains a critical concern. We observed leaks in 55.9 % of hand‐sewn cases and 52.9 % of stapled cases (p >0.05).¹⁴ Although our leak rates appear high. This could likely be influenced by comorbid hypertension and dyslipidemia. Other researchers reported zero leaks in stapled closures versus 3.7 % in hand‐sewn (p <0.05).^14-16 Scientists have also found no significant difference (p >0.05) [3, 4, 9]. ^16,17,23 Taken together, these data suggest that stapling does not raise leak risk and may offer a modest protective effect in certain patient subgroups.²⁴

We defined prolonged hospital stay as discharge after seven days. Prolonged admissions occurred in 58.8% of hand‐sewn cases versus 41.2% of stapled cases (p >0.05).¹⁴ Though this difference did not reach statistical significance, some researches found that only a small percentage of stapled patients stayed beyond a week compared with a larger percentage of hand‐sewn patients (p <0.05).¹⁶ Another study also reported that stapling lowered the risk of extended hospitalisation by over 25% (p <0.05).^17,23 Differences in how “prolonged stay” was defined and variations in discharge criteria probably account for some of this inconsistency.^14,24 Even so, the preponderance of evidence suggests stapling supports quicker discharge.

Subacute small‐bowel obstruction (SBO) represents another important outcome. While our study did not quantify SBO incidence directly, other study. found a lower SBO rate in stapled patients (p <0.05).¹⁷ Another research confirmed a substantial reduction in SBO/ileus events (p < 0.05), even after excluding inflammatory bowel disease cases. ^17,25 A side‐to‐side stapled anastomosis creates a wider lumen and minimises local oedema, which likely reduces adhesive narrowing.²⁶

Cost considerations are crucial in resource‐limited environments. Researchers noted a similar conclusion, noting that reduced anaesthesia time and fewer complications helped balance stapler costs.¹⁶ Another study argued that when enhanced recovery protocols are in place, savings from shorter OR use, fewer SBOs, and earlier discharge justify stapler use despite higher upfront costs.^17,26 In our high‐throughput setting, stapling may thus prove the more cost‐effective strategy.

 Patient comorbidities also influenced outcomes. In our cohort, half of all patients had diabetes or hypertension, but these conditions did not alter the relative benefits of stapling (p > 0.05 for SSI, leak, and prolonged stay subgroups). ¹⁴ Another study similarly found that comorbidities did not modify the advantage of stapled closure. ¹⁵ Another research demonstrated consistent stapling benefits across diverse index pathologies (including malignancy, inflammatory bowel disease, and enteric perforations) underscoring the approach’s broad applicability [4, 13,14].^17,27,28 Thus, stapled anastomosis appears robust even when patient risk profiles vary.

 LIMITATIONS

 We conducted a single‐centre, six‐month trial with 68 ASA I–II patients, which may not reflect outcomes in higher‐risk or more heterogeneous populations. We enrolled participants via consecutive sampling, which could introduce selection bias even though we randomized treatment assignment. Because surgeons knew which anastomosis technique they were performing, performance bias may have affected perioperative care. Our follow‐up captured only short‐term postoperative outcomes and did not assess longer‐term complications or fully evaluate cost‐effectiveness.

We showed that linear stapling cut operating time without raising infection or leak rates. Both stapled and hand‐sewn techniques yielded similar lengths of stay and overall complication profiles, indicating that stapling can boost efficiency while preserving safety. By adopting stapled closure, high‐volume centres can optimize theatre utilisation and potentially improve patient turnover. We recognise that our findings apply mainly to low‐risk patients and encourage future studies to include diverse risk profiles. Longer‐term follow‐up and detailed cost‐effectiveness assessments will clarify the broader value of stapled anastomosis.

1.      Ramanaiah J, Kumar CP, Indla RJ. Protective ileostomy in ileal perforation and its outcome compared to primary repair. JMSCR. 2019;7:1341–1345.

2.      Ellebaek MB, Dilling Kjaer M, Spanggaard K, El-Faramawi M, Möller S, Qvist N. Protective loop-ileostomy in ileal pouch-anal anastomosis for ulcerative colitis - advantages and disadvantages. A retrospective study. Colorectal Dis. 2021;23:145–152.

3.      Waterland P, Goonetilleke K, Naumann DN, Sutcliff M, Soliman F. Defunctioning ileostomy reversal rates and reasons for delayed reversal: Does delay impact on complications of ileostomy reversal? A study of 170 defunctioning ileostomies. J Clin Med Res. 2015;7:685–689.

4.      Hajibandeh S, Hajibandeh S, Sarma DR, et al. Meta-analysis of temporary loop ileostomy closure during or after adjuvant chemotherapy following rectal cancer resection: the dilemma remains. Int J Colorectal Dis. 2019;34:1151–1159.

5.      Berger NG, Chou R, Toy ES, Ludwig KA, Ridolfi TJ, Peterson CY. Loop ileostomy closure as an overnight procedure: institutional comparison with the national surgical quality improvement project data set. Dis Colon Rectum. 2017;60:852–859.

6.      Sebastian A, Stupart D, Watters DA. Loop ileostomy reversal after laparoscopic versus open rectal resection.  ANZ J Surg. 2019;89:0–5.

7.      Lee JR, Kim YW, Sung JJ, Song OP, Kim HC, Lim CW, Cho GS, Jung JC, Shin EJ. Conventional linear versus purse-string skin closure after loop ileostomy reversal: comparison of wound infection rates and operative outcomes. J Korean Soc Coloproctol. 2011;27:58–63.

8.      Wignall A, Gall CA, Nguyen MH. Primary skin closure in reversal of loop ileostomy: an effective technique. Tech Coloproctol. 2000;4:141–142.

9.      El-Hussuna A, Lauritsen M, Bülow S. Relatively high incidence of complications after loop ileostomy reversal. Dan Med J. 2012;59:A4517.

10.   Gustavsson K, Gunnarsson U, Jestin P. Postoperative complications after closure of a diverting ileostoma-differences according to closure technique. Int J Colorectal Dis. 2012;27:55–58.

11.   Mansfield SD, Jensen C, Phair AS, Kelly OT, Kelly SB. Complications of loop ileostomy closure: a retrospective cohort analysis of 123 patients. World J Surg. 2008;32:2101–2106.

12.   Goulder F. Bowel anastomoses: the theory, the practice and the evidence base. World J Gastrointest Surg. 2012;4:208–213.

13.   Aneeta Kumari, Rehmat Urf Sehrish Shah, Seema Shabbir, Ambreen Munir, Syed Asad Ali Shah, Suhail Ahmed Soomro. Comparative Study of Surgical Outcome of Linear Stapled Versus Manual Anastomosis Technique During Reversal of Loop Ileostomies. Pak J Med Health Sci 2022;16(05):773.

14.   Archer V, Cloutier Z, Berg A, McKechnie T, Wiercioch W, Eskicioglu C. Short-stay compared to long-stay admissions for loop ileostomy reversals: a systematic review and meta-analysis. International Journal of Colorectal Disease. 2022 Oct;37(10):2113-24.

15.   Al-Kubati WR. Stapler versus Hand-sewn Ileostomy Closure Techniques Post-low Anterior Resection for Low Rectal Cancer: A Comparative Clinical Study. Indian Journal of Colo-Rectal Surgery. 2024 Sep 1;7(3):41-9.

16.   Naumann DN, Bhangu A, Kelly M, Bowley DM. Stapled versus handsewn intestinal anastomosis in emergency laparotomy: a systemic review and meta-analysis. Surgery. 2015 Apr 1;157(4):609-18.

17.   Al-Kubati WR. Stapler versus Hand-sewn Ileostomy Closure Techniques Post-low Anterior Resection for Low Rectal Cancer: A Comparative Clinical Study. Indian Journal of Colo-Rectal Surgery. 2024 Sep 1;7(3):41-9.

18.   Löffler T, Rossion I, Gooßen K, Saure D, Weitz J, Ulrich A, Buechler MW, Diener MK. Hand suture versus stapler for closure of loop ileostomy—a systematic review and meta-analysis of randomized controlled trials. Langenbeck's archives of surgery. 2015 Feb;400:193-205.

19.   Madani R, Day N, Kumar L, Tilney HS, Gudgeon AM. Hand-sewn versus stapled closure of loop ileostomy: a meta-analysis. Digestive surgery. 2019 Mar 7;36(3):183-94.

20.   Leung TT, MacLean AR, Buie WD, Dixon E. Comparison of stapled versus handsewn loop ileostomy closure: a meta-analysis. Journal of Gastrointestinal Surgery. 2008 May 1;12(5):939-44.

21.   Hasegawa H, Radley S, Morton DG, Keighley MR. Stapled versus sutured closure of loop ileostomy: a randomized controlled trial. Annals of surgery. 2000 Feb 1;231(2):202-4.

22.   D’haeninck A, Wolthuis AM, Penninckx F, D’Hondt M, D’Hoore A. Morbidity after closure of a defunctioning loop ileostomy. Acta Chirurgica Belgica. 2011 Jan 1;111(3):136-41.

23.   Bain IM, Patel R, Keighley MR. Comparison of sutured and stapled closure of loop ileostomy after restorative proctocolectomy. Annals of The Royal College of Surgeons of england. 1996 Nov;78(6):555.

24.   Horisberger K, Beldi G, Candinas D. Loop ileostomy closure: comparison of cost effectiveness between suture and stapler. World journal of surgery. 2010 Dec;34(12):2867-71.

25.   Gustavsson K, Gunnarsson U, Jestin P. Postoperative complications after closure of a diverting ileostoma—differences according to closure technique. International journal of colorectal disease. 2012 Jan;27:55-8.

26.   Kumari A, Shah RU, Shabbir S, Munir A, Shah SA, Soomro SA. Comparative Study of Surgical Outcome of Linear Stapled Versus Manual Anastomosis Technique During Reversal of Loop Ileostomies. Pakistan Journal of Medical & Health Sciences. 2022 Jun 24;16(05):773-.

27.   Patel J, Tolppa T, Biccard BM, Fazzini B, Haniffa R, Marletta D, Moonesinghe R, Pearse R, Vengadasalam S, Stephens TJ, Vindrol

28.   Padros C. Perioperative care pathways in low-and lower-middle-income countries: systematic review and narrative synthesis. World Journal of Surgery. 2022 Sep;46(9):2102-13.