CHAPTER
Suturing, Stapling, and Tissue Adhesion
David Giles
| Ethan Talbot
S
urgical procedures typically involve excision, resection,
or transection to address a pathologic situation.
Subsequent reconstruction, which includes maneuvers
to secure a restoration of function, often allows the choice
of a variety of methods. Surgical and general medical
principles, safeguards, and prophylactic measures require
planning, vigilance, and support across the health care
spectrum to facilitate a completely successful result. Pre-
operative planning should be anticipatory, perioperative
monitoring appropriate, surgical technique thoughtful
and carefully executed, and postoperative care robust.1
Frequently during the course of a gastrointestinal (GI) or
abdominal operation, whether for benign or malignant
disease, a resection of a hollow viscus with subsequent
reconstruction is required. The anastomosis often anchors
the procedure. Successful healing influences the outcome
positively. Conversely, anastomotic failures not only increase
morbidity and permanent stoma rates but delay adjunctive
therapy, increase the intensity and duration of hospital care,
and are associated with increased rates of distal recurrence
(of malignancy) and mortality (short-term and long-term
all cause).2 Because a majority of the factors influencing
an anastomosis’s subsequent behavior are determined by
the time a patient leaves the operating room, attention
must first include the timing and choice of procedure,
as well as the technique itself.
Wound healing proceeds in a stepwise, time-dependent
fashion. Healing a GI anastomosis has parallels but impor-
tant differences.3–5 No chronic wound exists in a healing
anastomosis, a situation in which repair must allow for
rapid recovery of tensile strength and function. The goal
of eliminating anastomotic leaks is challenged by our poor
understanding of this pathophysiology. The multilayered
architecture, the heavy colonization of the lumen, the
influence of the different bowel layers, the vasoactive
vascular supply, and variations in the rate and process of
healing set the GI tract apart from subcutaneous tissues.
When the bowel is surgically transected, there is an
immediate inflammatory response elicited by activation
of the clotting cascade and by recruitment of platelets.
The inflammatory cascade is propagated via the release
of inflammatory mediators stored in platelet granules.
Neutrophils are subsequently mobilized into the wound. At
this time, the collagen matrix is degraded by collagenases
and metalloproteinases. Collagenolysis is necessary to create
a local pool of amino acids, especially those unique to
collagen—proline and lysine. The newly formed collagen
“recycles” these amino acids. The extent of collagenolysis
varies among tissue, proceeding along the sides of the
wound for variable distances. These tissues undergoing
collagenolysis around the wound become weaker than
normal tissue and are the site most susceptible to failure
in the early phases of wound healing. It is during this
85
initial phase that the integrity of the anastomosis depends
almost entirely on the mechanical sealing of the lumen
by sutures or staples.4
Between the third and fifth postoperative day there is
a transition from the inflammatory phase to the prolifera-
tive phase of wound healing. With the proliferation of
fibroblasts and smooth muscle cells, there is a shift from
collagen degradation to collagen deposition. Once collagen
deposition predominates over collagenolysis, the approxi-
mation of the two ends of bowel is no longer dependent on
sutures or staples but on the cellular matrix surrounding
the collagen fibers. Although bursting strength is 50%
of normal in small bowel anastomoses (35% to 75% of
normal in large bowel anastomoses) at 2 to 3 days post
procedure, it approaches 100% by 7 days.
It is important to recognize that the time frames of
tissue healing stages are shifted by factors impairing
wound healing, potentially with catastrophic consequences.
Corticosteroids, chemotherapeutics, and antirejection
medications attenuate and prolong the inflammatory
phase. Antiangiogenic drugs and nutrient deficiencies
extend collagenolysis and blunt collagen synthesis, as
does hypoxia. Similarly, the presence of local infection
intensifies collagenolysis. Consequently, the selection of
materials, sutures, and/or staples should be made with
consideration to these factors.5–7
Successful gastrointestinal anastomosis (GIA) healing
relies on a good blood supply to the bowel that is not
under tension as it is accurately (“watertight”) anastomosed.
Adequate vascular supply includes local anatomy as well as
systemic perfusion. Ischemia inhibits collagen deposition
and maturation in particular. Tension leads to ischemia
in addition to loss of closure (of the defect), especially
with stapled anastomoses. Although the submucosa is the
strongest layer of the bowel wall and must be included
in all anastomoses, all layers of the bowel wall contribute
to wound healing. Closure in the process of creating
anastomoses must be watertight/airtight, involving healthy
and “clean” bowel edges. Distal obstruction, whether
mechanical or not, leads to increasing bowel diameter,
with increasing wall tension resulting in local ischemia.
Hypoalbuminemia represents a marker of a much broader
physiologic derangement than just malnutrition. Animal
experiments have demonstrated that the body prioritizes
visceral wound healing over most other sources of protein
consumption, including parietal wound healing.
As a GIA is created, the tolerance for anastomotic leak
is essentially zero. Multiple approaches have been shown
to be effective, including surgical stapling as equally
secure to suturing under many conditions. The indica-
tions to staple are generally the same as those to suture.
Given that surgical stapling or suturing is not equally
applicable in every situation, the surgeons’ facility with
1005
 Suturing, Stapling, and Tissue Adhesion CHAPTER 85 1005.e1

ABSTRACT
Fundamental principles regarding suturing and stapling
are reviewed. A variety of intraoperative surgical adjuncts
are examined briefly.

KEYWORDS
Suture, suturing, stapler, stapling, omentum, tissue
adhesives, adhesion barrier, abdominal drain
1006 SECTION II Stomach and Small Intestine
both techniques may vastly improve the outcome of an
operation requiring an intestinal anastomosis. A number
of older studies looked at differences between handsewn
and stapled bowel anastomoses. In general, no differences
were noted in the leak rate, morbidity, mortality, and
cancer recurrence.8,9 A meta-analysis of the emergency
laparotomy setting suggested, in the context of sparse
evidence and high bias, neither technique was favored.10
Preference for handsewn repair of small bowel injuries
in trauma settings remains strong.11,12
SURGICAL SUTURING AND TECHNIQUE
As with any other skill, handsewing an intestinal anasto-
mosis requires practice. Having observed or done a few
handsewn intestinal anastomoses under direct supervision
does not necessarily allow for the development of the skills
necessary to perform an anastomosis, particularly in critical
situations (i.e., any situation where a stapler cannot be
used). Therefore it may be to everyone’s benefit (patient,
surgeon, and operating team) to perform handsewn
anastomoses, particularly in straightforward cases.
The ideal suture material for intestinal anastomosis
is one that produces the smallest amount of tissue reac-
tion while providing maximal strength during the lag or
inflammatory phase of wound healing. All sutures result
in some degree of tissue inflammation because the act of
pulling the suture thread through the bowel wall causes
some tissue injury. This inflammatory reaction affects levels
of activated collagenases and matrix metalloproteinases
leading to decreased tensile strength of the healing wound.
It is critical to avoid this strength imbalance during the
critical lag period (days 1 to 5) as the wound transitions
from the inflammatory phase to the proliferative phase.
Similarly, other factors that foster inflammation (e.g.,
necrotic tissue, debris, and infection) will delay healing
of the anastomosis, and should be minimized.13
In current clinical practice, most handsewn colorectal
anastomoses are constructed with polydioxanone sutures.14
These possess most of the qualities of the ideal suture for
this purpose. As a monofilament suture, coupled with an
appropriate needle, it allows for the least amount of tissue
injury from the act of suturing. It is slowly absorbed with
good retention of strength for up to 6 weeks, well past
the critical lag period.15
With the pathophysiology of wound healing in mind,
other types of suture and coatings have been experimented
with. Application of basic fibroblast growth factor (bFGF)
on the rat anastomosis was shown to significantly increase
neovascularization, fibroblast infiltration, and collagen
production around the anastomotic site, along with
significant increases in the bursting pressure.16 Coating
suture with a matrix metalloproteinase inhibitor (in this
case, doxycycline) resulted in higher breaking strength
in rat intestinal anastomosis.17 Using a knotless barbed
suture for intestinal anastomosis has also been shown to
be safe and reproducible.18,19 These adjuncts have variably
reached clinical use, but warrant further research.
The adherence of bacteria to the suture material has
been postulated as a possible explanation for bacterial
infection and weakening of the intestinal anastomosis.
Polydioxanone has been shown to have the lowest affinity to
adherence of bacteria among the absorbable sutures.13 This
same group of researchers showed that bacterial adherence
is 5 to 8 times higher for braided versus monofilament
sutures. Others showed the degree of infection in mice
in the presence of suture correlated with the adherence
properties of that suture for bacteria.20 A different group
of researchers showed that polyglycolic acid suture had
the highest rate of bacterial adherence, concluding that
absorbable braided suture should not be used in closure
of contaminated wounds or wounds at risk for developing
infection.21
With this evidence of suture potentiating wound
infection, it is not surprising that research has focused
on the effects of coating suture with antibiotic. Coating
suture with an antibacterial agent (triclosan) significantly
reduces adherent bacteria to polyglactin, is associated with
decreased microbial viability and significantly increased
bursting pressure in colonic anastomoses. 22,23 PVDF
(polyvinylidene fluoride; a permanent suture) coated
with gentamicin was shown to increase the stability and
bursting strength of colonic anastomosis in the rat. 24
In summary, polydioxanone suture has low affinity for
bacterial adherence, furthering its position as the suture
of choice for intestinal anastomosis. Although there are
animal data supporting the use of antibacterial-coated
suture for this purpose, it will require human study before
this becomes routine clinical practice.
SUTURE METHODS
Suture lines can be created either in an interrupted fashion
or in a continuous, running manner. The continuous
suture has the advantage of being more watertight with
the disadvantage that the integrity of the entire suture
line is based on one stitch. Although hemostasis is also
improved with a continuous suture, the converse effect,
that continuous suture may constrict anastomotic blood
flow leading to ischemia and anastomotic dehiscence, is
also true. Most human studies indicate that a continuous
anastomosis can be performed safely and quickly, with no
significant difference between continuous and interrupted
suture pattern.25,26
Intestinal anastomosis can be constructed in a single-
layer or double-layer method. Single-layer anastomosis
consists of one layer of interrupted or continuous absorb-
able sutures, whereas a double-layer typically consists of
an inner full-thickness layer of absorbable suture and an
outer layer of interrupted absorbable or nonabsorbable
sutures.27 Single-layer does not differ from double-layer
anastomosis in terms of rates of anastomotic leak, periop-
erative complications, length of hospital stay, and mortality,
while also shortening operative time and total cost.27–29
These findings were confirmed in a Cochrane review
encompassing seven randomized controlled trials and 842
patients.30 Anastomosis in the trauma setting gravitates
toward the double-layer anastomosis.
Anastomoses with the inverted technique heal faster31
with superior bursting pressure and more prompt return
to normal bowel architecture.32 The majority of both
animal and human studies indicate the superiority of the
inverting anastomotic technique. Everted anastomoses are
associated with increased rates of adhesion formation,
anastomotic leak, wound infection, peritonitis, and fecal

Continuous Lembert Cushing
Interrupted Lembert
Purse string
Halsted
Connell
FIGURE 85.1 Intestinal suture methods. (From Orr TG. Operations
of General Surgery. 2nd ed. Philadelphia: Saunders; 1949.)
fistulation.33–35 Regardless of the suture particulars, a bowel
anastomosis must adhere to the following principles (in
addition to those articulated earlier): the anastomosis
must be watertight and have mucosal apposition; the
submucosa, which supplies much of the strength to a
bowel anastomosis, must be incorporated into the closure;
and care must be taken not to strangulate or instrument
the edges of the bowel during closure to avoid stricture
or necrosis and subsequent anastomotic leakage.
The Lembert suture is the most commonly used suture
in GI surgery (Fig. 85.1). It is used as the outer layer of
a two-layer bowel anastomosis and is also used to repair
seromuscular tears in the bowel wall. The stitch is started
approximately 3 to 4 mm lateral to the incision and placed
at a right angle to the long axis of the incision (“follow
the curve of the needle”). It incorporates only the sero-
muscular layer; care must be taken to not incorporate the
full thickness of the bowel wall. The tip of the needle is
brought out close to the edge of the incision and is then
reinserted in the apposing wound edge and brought out
3 to 4 mm lateral to the wound edge. The suture is then
tied down to a tension that approximates the tissue but
not tight enough to tear the tissue. The most commonly
used material for a Lembert suture is either (3-0) silk or
PDS. This stitch can be performed in an interrupted or
continuous manner.
A horizontal mattress suture, or Halsted suture, is pre-
dominantly used for seromuscular apposition in multilayer
Suturing, Stapling, and Tissue Adhesion CHAPTER 85 1007
bowel anastomoses (see Fig. 85.1). The suture is passed
through the seromuscular layer 2 to 3 mm lateral to the
wound edge and brought out at the wound edge; the
needle is then passed through the opposing edge of the
wound and brought out 2 to 3 mm lateral. On that same
side of the wound, approximately 2 mm distal, the suture
is passed through both edges of the wound to create two
free ends of the suture on one side of the wound edge
with the loop of the suture on the other side. This stitch
is particularly useful in damaged, inflamed, or abnormal
tissue where a Lembert suture pulls through the tissue.
Because the horizontal mattress stitch distributes tension
in a plane perpendicular to that of a Lembert suture, it
allows for apposition of tissues with less crushing effect.
A purse-string suture is used to invert appendiceal
stumps or to secure feeding tubes or drainage tubes in
place. It is basically a circular continuous Lembert suture
about a fixed point or opening in the GI tract. It is most
commonly performed with nonabsorbable suture (see
Fig. 85.1).
The Connell suture is a full-thickness, usually con-
tinuous, suture that allows for the mucosa to be inverted
into the lumen of a bowel anastomosis (see Fig. 85.1).
The suture is started at the edge of the anastomosis and
brought, full thickness, from inside to out on one side
and then outside to in on the opposite side. The suture
is tied so that the knot is inside the lumen. The suture
is then passed through the tissues from inside to out
on one side to begin the Connell stitch. On the other
limb of the anastomosis the suture is driven through the
tissues, full thickness, from outside to in. On the inside
of the bowel lumen the stitch is advanced 2 to 3 mm
along the wall and then driven through the (transmural)
bowel wall from inside to out on the same side. With the
suture now on the outside of the bowel, the next pass is
performed on the opposite side in an identical manner.
This creates a U-shaped, full-thickness, running inverted
suture line. It usually serves as an inner layer of a two-layer
anastomosis. Absorbable sutures are generally used for
these applications. The Cushing suture is the same as
the Connell, except the suture does not enter the lumen,
rather it exits through the submucosa.
The Gambee suture is an interrupted single-layer suture
that inverts the mucosa into the lumen (Fig. 85.2). The
suture is brought full thickness from outside to in and
then passed back through the mucosa to exit through
the submucosal layer on the same side. It is then passed
from the submucosa through the mucosa on the opposite
limb. The final pass is a full-thickness one from inside to
out on this side. The suture is tied extraluminally. This
creates a full-thickness, inverting suture line. Absorbable
sutures are typically used for this type of anastomosis.
Some surgeons prefer the Gambee stitch for closure of
a pyloroplasty; it is rarely used elsewhere.36
A double-layer closure, also known as the Czerny-
Lembert suture, is still considered by some as the “gold
standard” of bowel anastomoses. This technique features
an inner, full-thickness, continuous, absorbable suture
layer surrounded by an outer layer of interrupted, often
permanent, seromuscular (Lembert) sutures. Typically
the deep or posterior outer layer is placed first, after
(seromuscular) stay sutures of the lateral aspects of this
1008 SECTION II Stomach and Small Intestine
lleum Colon
FIGURE 85.2 The Gambee method of intestinal suturing. (From
Gambee LP, Gamjobst W, Hardwick CE. 10 years experience
with a single layer anastomosis in colon surgery. Am J Surg.
1956;92:222.)
layer had been placed to allow the bowel to be aligned.
With the deep, outer layer completed between the stay
sutures, a simple running suture of all layers commences
in both directions of the posterior wall, converting to
running Connell, or Cushing, on the anterior surface
to meet in closure on the antimesenteric aspect. The
anterior aspect of the second layer is completed last. The
outer layer might be constructed with 3-0 silk, the inner
transmural layer with 3-0 polyglycolic acid, polyglactic
acid, or chromic gut suture.
A single-layer anastomosis begins at the mesenteric
border and sequentially moves in both directions to the
antimesenteric aspect. This can be done as interrupted or
continuous suture. The interrupted approach described by
Gambee used permanent suture (cotton or silk originally).
The continuous suture described by others starts on the
outside of the lumen at the mesentery. Using a double-
armed suture to sew in both directions, it includes all layers
except mucosa and will end on the antimesenteric border.
Being on the outside, the two ends are tied to produce
watertight/airtight anastomosis without compromising
the luminal diameter. Polypropylene or polydiaxonone
(3-0) are typically used.37
STAPLERS AND STAPLING TECHNIQUE
Staplers permit or facilitate surgical techniques, specifically
resection, transection, and/or anastomosis, in a rapid,
accurate, and reproducible fashion. Part of the attraction
(historically) was the need to generate high-quality surgical
work by individuals who did not possess the skills (training
and/or experience) to successfully complete surgical
maneuvers. The continued refinement of the stapler has
allowed their widespread deployment and adaptation (to
open, laparoscopic, or robotic uses) by all members of
the surgical community. Although not a replacement for
sound surgical judgment or competence, staplers enlarge
TABLE 85.1 Defined/Predetermined Staple Heights
Open Staple Closed Staple
Color Length (mm) Height (mm) Usage Application
White 2.5–2.6 1.0 Thin/Mesentery
Blue 3.5–3.8 1.5 Regular use
Gold 3.8 1.8 Regular/thick
Green 4.1–4.8 2.0 Thick (stomach)
Black 4.2 2.3 Very thick
the spectrum of approaches available to address problems,
situations, pathologies, and/or locations.1
Almost 200 years ago the Belgian surgeon Dr. Henroz
DeMarche devised a ring for small bowel anastomoses that
he tested successfully in dogs. In 1892 John B. Murphy
of Chicago developed a sutureless metallic compression
device for GIA. Both inventions were in recognition of
high anastomotic leak rates with handsewn anastomoses.
The “Murphy button” enjoyed human use for several
decades. Concerned with spillage at a time of frequent
gastric surgeries (resections, partial or complete), Húmer
Hültt, MD, of Budapest developed a bulky stapler and
elaborated several fundamental stapling principles. After
World War II, the USSR’s Scientific Institute for Surgical
Devices made a major step forward studying and developing
a number of staplers, thereby promoting safe, standard-
ized surgical treatment nationwide. A visiting American
surgeon from Johns Hopkins, Mark Ravitch, MD, brought
a stapler to the United States in 1958, eventually leading
to the founding of the United States Surgical Corporation
and much research into and development of surgical
stapling.38
The principles underlying surgical stapling began with
Húmer Hültt. He stressed compression of the tissue,
placing (metal) staples in a closed “B” shape, with two
rows of staples in a staggered formation. Similar to a
standard office stapler, a B-shaped staple is formed from the
interaction with an anvil. This action allows maintenance
of the compression, with its hemostasis and watertight/
airtight sealing, while encouraging viability, minimizing
tissue damage, and stabilizing the new configuration.
Formed in the tissue at the time of deployment, each
staple, individually and collectively, contributes to these
goals. The promotion of compression, accurate staple
formation, and desired tissue configuration must underlie
the methods needed in deployment of the stapler.7,38
TYPES OF STAPLERS
Intestinal tissue is biphasic, with both solid and liquid
components in varying ratios (dependent on the type of
tissue, and the milieu). Staples are therefore of varying
sizes, as good compression enhances the results of stapling
(lower leak notes, improved hemostasis, minimized wound
contraction, and decreased stricture rates).7 Historically,
staplers have either used predetermined (uniform) staple
heights or variable staple height (Table 85.1). With time,
manufacturers are modifying the technology of stapling
with changes that include varying the predetermined
heights of the staples, using rectangular wires (instead of

Linear staplers
Vascular linear stapler (30mm)
Linear stapler (30, 55, 60, 90 mm)
FIGURE 85.3 (Modified from Feil W, Lippert H, Lozac’h P, Palazzini
G, Amaral J. Atlas of Surgical Stapling. Heidelberg, Germany:
Johann Ambrosius Barth; 2000.)
Linear cutter staple line
(55-mm, 75-mm, 100-mm)
Double staggered rows of staples
with cut line between them
FIGURE 85.4 (Modified from Feil W, Lippert H, Lozac’h P, Palazzini
G, Amaral J. Atlas of Surgical Stapling. Heidelberg, Germany:
Johann Ambrosius Barth; 2000.)
round), using gripping surface technologies, and adjusting
the closure and anvil mechanisms.
In brief, skin staplers are popular for their ease of use,
enhanced comfort (especially during removal), and rapid
application. Clip applicators have a wide range of clip
sizes, clip numbers, and working lengths. LDS (ligating,
dividing, and stapling device) was historically used to
divide omental and mesenteric tissue in open operations.
This stapler is infrequently used today.
Linear (noncutting) staplers (e.g., thoracoabdominal
[TA] staplers) deliver a double-staggered row of staples
(Fig. 85.3). They are used in a wide variety of situations,
including closure of a hollow viscus and incisions (enter-
otomies and others), and ligation of large vessels. Staple
length/height is fixed, but various lengths and heights
are available. The stapler mechanism/head comes in
four lengths and can be articulating or nonarticulating.
A third row of staples is found on the vascular subtype.
Linear cutting staplers (e.g., GIA) both close and
transect hollow viscera by first delivering two (historically)
double-staggered rows of staple lines and then deploying
a knife to divide the tissue between the staple lines (newer
versions may use triple-staggered rows) (Fig. 85.4). GIA
staplers were used to transect tubular structures, create
side-to-side anastomosis (both functional end-to-end
and otherwise), and resect solid organs. These versatile
instruments, in open, laparoscopic, and robotic varieties,
feature varying fixed lengths and widths, articulating and
nonarticulating heads, straight and newer curved (only
nonarticulating) types.
Suturing, Stapling, and Tissue Adhesion CHAPTER 85 1009
Circular stapler
Circular
blade
Two circumferential,
staggered rows of staples
FIGURE 85.5 Circular stapler.
Circular staplers (e.g., creating an end-to-end anasto-
mosis [EEA] with intraluminal [staple] deployment) are
used for inverted end-to-end, end-to-side, and occasional
side-to-side anastomoses (Fig. 85.5). These staplers have
a detachable head/anvil and place a circular, double-
staggered row of staples of varying diameters (21, 25, 29,
and 33 mm). The staples can be variably tightened to a
closed staple height of 1 to 2.5 mm, depending on the
desire of the surgeon.
The creativity displayed in the deployment of staplers
is remarkable. Several atlases have been dedicated to
surgical stapling techniques.38,39 Two of the more prominent
maneuvers follow.
FUNCTIONAL END-TO-END ANASTOMOSIS
A functional EEA (Fig. 85.6), first described in the 1960s,
is the most frequent side-to-side anastomosis created with
the GIA stapler. Antimesenteric surfaces of two segments
of bowel are apposed. Enterotomies in each segment
allow one arm of the GIA stapler to be placed in each
lumen. The stapler is fired to create a common lumen.40
The lumen is examined and the staple lines checked
for hemostasis. Bleeding points along the staple line
in the lumen may be controlled with fine suture, but
the application of cautery on the staple lines should be
discouraged (because the current can be transmitted along
the length of the staple line due to the metal of the staples
and thereby harm otherwise healthy tissue). The common
enterotomy (involving both limbs of the bowel) is grasped,
full thickness, at its edges, usually transversely, with Allis
clamps to ensure that all layers are closed. A single firing
of the TA stapler is used to close this common enterotomy.
Before firing the TA across the common enterotomy, an
important technical point is to ensure that the anterior
termination and posterior termination of the GIA staple
lines are staggered to avoid the crossing of three staple
lines.41 When multiple staple lines cross at the same point,
the staples may not close properly, which could lead to
anastomotic leakage (see Fig. 85.6). This staple line is an
everting one. Placing seromuscular sutures to cover the
staple line may attenuate the propensity to form adhesions.
Alternatively, the common enterotomy may be closed in
an inverting (one- vs. two-layer) handsewn fashion.
Hocking et al. demonstrated in a canine model that
creation of a functional EEA alters small bowel motility
1010 SECTION II Stomach and Small Intestine
FIGURE 85.6 Example of a side-to-side, functional end-to-end stapled intestinal anastomosis. (From Chassin JL, Rifkind KM, Turner JW.
Errors and pitfalls in stapling gastrointestinal tract anastomoses. Surg Clin North Am. 1984;64:447.)
to a greater degree than an EEA does and that this may
predispose to bacterial overgrowth.42 Even 2 years after
surgery, only 50% of the myoelectrical impulses crossed
the functional EEA. Case reports have also shown that this
dysmotility and bacterial overgrowth can lead to massive
luminal dilation and subsequent volvulus.
STAPLED END-TO-END ANASTOMOSIS
This type of anastomosis is performed with a circular
stapler (e.g., EEA) and is commonly used for the creation
of esophagogastrostomy, esophagoenterostomy, gastro-
enterostomy, and coloproctostomy. After resection of the
pathology, the anvil is typically placed in the mid or distal
esophagus, the small bowel that is to be anastomosed to
the stomach, or the proximal bowel to be anastomosed to
the rectum. With the use of the anvil, an integral part of
using the EEA stapling device, a monofilament purse-string
suture is placed in the open lumened bowel, cinched
around the rod of the anvil and tied tightly. If there are
any gaps in the purse-string suture, the suture line might
be incomplete and a leak may ensue. A mattress suture
may be tied around the rod to reinforce the purse-string
suture. Care must be taken to dissect free any fat that may
be incorporated into the staple lines because this may
predispose the anastomosis to leakage. The blood supply
should not be too close to the ends of the involved bowel
for fear of intraluminal bleeding after the stapler is fired.
Once the pin is advanced, the anvil and stapler are engaged,
the device is closed tightly, and the stapler deployed.
The cervical esophageal anastomosis is typically hand-
sewn with or without the use of a GIA; the EEA is often
used in the mid to distal esophagus. To ensure the purse
string involves all the layers of the esophagus and the
anvil is placed appropriately, the mucosa is grasped and
exteriorized (prior to the placement of the purse-string
suture and the anvil). Supporting sutures to affix the
anastomosing stomach or small bowel to the mediastinal
pleura, diaphragm, and/or hiatus are used to diminish
the tension on the completed esophageal anastomosis.
X Y
When performing a colorectal anastomosis, the proximal
bowel (typically colon) may be dilated with sizers. An
anastomosis of either 29 or 31 mm is desired to promote
a good result and less stricturing. Care should be taken to
avoid creating serosal or muscular tears during dilatation,
relaxing the smooth muscle with intravenous glucagon
(1 mg) to help prevent these tears if needed. Placing the
stapling device into the rectum transanally, care is taken
to follow the contour of the rectum and the sacrum as it
is advanced to the end of the rectal cuff. The pin should
be advanced to come out in the middle of the staple line
rather than advancing the pin at any other point through
the mesorectum, or incorporating bladder or the vaginal
wall in females.
STAPLING PRINCIPLES
Important steps in the use of staplers include the following:
1. For each device you plan to use, familiarize yourself with
the “IFU” (instructions for use) document generated
by the (device) manufacturer.43
2. Following standard surgical principles, ensure the
viability and reasonable condition of the tissue to be
manipulated. Exclude a distal obstruction and care-
fully evaluate areas that have experienced radiation,
peritonitis, and local changes (including swelling,
fistula, inflammatory-based disease and cancer).41
3. Avoid tension on staple lines.
4. Precisely dissect tissues included in the anticipated
stapling to avoid incorporating extraneous, vascular,
or necrotic-prone tissue.1
5. Use adequate compression to cause hemostasis and
prevent leakage, but avoid excessive compression
leading to tissue damage. Stapler configuration/choice
may need to be adjusted even within the same organ
when multiple firings are indicated (especially the
stomach).43–46
6. Ensure that the stapler is properly loaded and config-
ured. Leave the safety mechanism engaged until ready
to deploy the stapler.

7. Allow 15 (plus) seconds of compression before deploying
the stapler. This allows for more accurate formation of
staples and more stable and hemostatic configuration.45,46
8. If stapler appears to function abnormally, do not force
the stapler to deploy. If creating a long staple line,
check for a crotch staple.43
9. Be prepared to oversew or repair/reanastomose stapled
material. Consider prophylactically addressing staple
line crossings. When completed, check the anastomosis
for integrity.47
SURGICAL ADJUNCTS
With the severity of complications that can result from
anastomotic dehiscence, much research has gone into
development and testing of adjuncts for intestinal
anastomosis, including novel techniques that have yet to
reach wide clinical practice. Wrapping omentum around
an intestinal anastomosis to reinforce the anastomosis
and foster the natural process of healing theoretically
allows the omentum to mechanically seal the anastomosis
in adhesions and play a role in angiogenesis.48,49 These
theories were confirmed by several early animal studies,50–52
which led many surgeons to use an omental wrap when
worried about the integrity of an anastomosis. Called into
question in 1998 by the French Association for Surgical
Research, their study showed no significant difference in
the rates of anastomotic leakage or death between patients
who did or did not have an omental wrap of a colorectal
anastomosis.53 It remains commonplace for surgeons to
use an omental wrap for anastomoses they are worried
about, despite conflicting clinical evidence regarding the
benefit from this practice.
Tissue adhesives are fibrin glues that are commonly used
for hemostasis, bone sealing, and other straightforward
tissue repairs. They rely on the conversion of fibrinogen to
cross-linked fibrin to aid in hemostasis and the reinforce-
ment of tissue strength. A systematic review of tissue
adhesives applied to GIA (published since 2000), the
majority being animal studies, demonstrated mixed results
with colonic anastomoses and largely positive results more
proximally.54 In experimental studies in the rat, the use
of fibrin sealant for intestinal anastomosis is associated
with increased adhesion formation, lower anastomotic
bursting pressure, and lower hydroxyproline concentra-
tions.55 Sealing a “high-risk” colonic anastomosis with fibrin
glue (human or bovine derived) is also associated with
higher rates of anastomotic leak, excessive perianastomotic
adhesion formation, and poor clinical outcome.56–58 This
may result from the fibrin glue impairing the ingrowth
of vascular granulation tissue during the early stages of
healing. In conclusion, the routine clinical use of tissue
adhesives for the reinforcement of bowel anastomoses
has to be made with consideration. Further research is
needed to clarify the influence on anastomotic healing.
Adhesion barriers are hyaluronic acid–based absorbable
films whose goal is to reduce adhesion formation during
the normal healing process. They mechanically separate
adhesiogenic tissue by becoming a hydrated gel and
then absorbing over the course of approximately a week.
Although there is some evidence that it may be beneficial
in healing ischemic colonic anastomosis in the rat,59 there
Suturing, Stapling, and Tissue Adhesion CHAPTER 85 1011
is a preponderance of evidence against its use with an
intestinal anastomosis. Use of a hyaluronic acid–based film
has been shown to increase the rate of fistula formation and
peritonitis in patients undergoing intestinal anastomosis.
Furthermore, in a subgroup of patients who had the film
wrapped around a fresh anastomosis, anastomotic leak,
fistula, peritonitis, abscess, and sepsis occurred significantly
more frequently.60 Therefore use of adhesion barriers
cannot be recommended when performing intestinal
anastomosis; wrapping a fresh anastomosis in an adhesion
barrier should be avoided.
In 1985 a biofragmentable anastomotic ring was devel-
oped with the intention to facilitate sutureless intestinal
anastomosis. The device consists of two identical circular
rings composed of Dexon and 12% barium sulfate. Prolene
sutures are used to create purse-string stitches at the two cut
ends of the bowel, and the sutures are tightened around
the rings after the rings are placed inside the bowel lumens.
The device is closed by applying pressure to both sides of
the anastomosis. The device is broken down and passed
in stool at some later time. The feasibility and safety of
this device was confirmed in a dog model.61 The safety
and efficacy of the device for human use was examined
in a prospective, randomized, multicenter clinical study,
with confirmation by a different research group.62,63 There
was no significant difference in the morbidity, mortality,
and clinical course of the patients, including anastomotic
leak, fistula, hemorrhage, wound infection, ileus, small
bowel obstruction, length of stay, diet, or return to bowel
function. Further study has shown this device to be safe
for use also in emergency anastomosis.64,65
A newer novel intestinal anastomotic device, the com-
pression anastomosis clip, has been shown to be safe and
efficacious in humans.66 It can be used during open or
laparoscopic surgery but requires counterincisions on both
sides of their anastomosis. Both of these devices likely
need long-term follow-up before they will be considered in
clinical practice for replacement of traditional anastomotic
techniques.
Animal studies using a bovine pericardium patch to
reinforce intestinal anastomosis have shown promising
results. Use of a porcine model indicates the patch is
safe and effective and demonstrated improvement in
mitochondrial function and normalization of mucosal
transport after wrapping the anastomosis with the patch.67
Other results indicate its safety of use, some promotion
of microscopic wound healing, but without a change in
anastomotic strength at 30 days in the pig.68 This anasto-
motic adjunct also requires further research. Although
these results are promising, future research will have to
focus on human results before either patch can enter
routine clinical practice.
Prophylactic placement of an abdominal drain after GI
surgery has the theoretical advantage of early detection
of postoperative complications. Early results indicate no
significant difference in terms of outcome, leak rate,
or infection for patients with intestinal anastomosis.69,70
Retrospective studies demonstrate a drain increases the
risk of anastomotic leak in rectal anastomoses71 even as an
independent predictor of anastomotic leak (in intestinal
anastomoses) (odds ratio, 8.9).72 Thus there is no strong
clinical evidence showing a benefit of prophylactic drainage
1012 SECTION II Stomach and Small Intestine
after intestinal anastomosis,73 and with the evidence of
increased leak rate, the routine use of prophylactic drain-
age after intestinal anastomosis is not recommended.
The ideal time to resume oral feeding after intestinal
anastomosis has been the subject of much debate. Tra-
ditional teaching centered around keeping the patient
nil per os (NPO) until resolution of intestinal ileus. The
preponderance of evidence points to the lack of harm,
and often the benefit, of early oral feeding. A number
of studies indicate there is no clear advantage to keeping
patients NPO post operation, especially after colorectal
surgeries, and that early feeding is safe, tolerated by the
majority of patients, and may provide some benefits.74–78
Data from the pediatric population also affirm the safety of
early oral feeding after intestinal anastomosis, along with
increased patient satisfaction and reduction in hospital
stay and cost.79,80 In conclusion, early oral feeding after
intestinal anastomosis is generally safe and may benefit
the patient and the health system.
CONCLUSION
A number of principles regarding GI anastomoses have
been discovered. Despite their articulation and the
appreciated importance of a number of preoperative
and postoperative maneuvers, the ideal technique appears
to vary by location, patient factors, general context, and
surgeon perspective, skill, and experience. Because of
the biology involved in this activity, the creation of an
anastomosis remains something of an art form.
REFERENCES
1. Steichen FM, Wolsch RA. Mechanical Sutures in Operations on the Small
& Large Intestine & Rectum. Woodbury, CT: Ciné-Med; 2008.
2. Kraup PM, Nordholm-Cartsensen A, Jorgensen LN, Harling H.
Anastomotic leak increases distant recurrence and long-term mortality
after curative resection for colonic cancer. Ann Surg. 2014;259(5):
930-938.
3. Thonton FJ, Barbul A. Healing in the gastrointestinal tract. Surg
Clin North Am. 1997;77(3):549-573.
4. Thompson SK, Chang EY, Jobe BA. Clinical review: healing in
gastrointestinal anastomoses, Part I. Microsurgery. 2006;26(3):131-136.
5. Phillips B. Reducing gastrointestinal anastomotic leak rates: review
of challenges and solutions. Open Access Surg. 2016;9:5-14.
6. Witte MB, Barbul A. Repair of full-thickness bowel injury. Crit Care
Med. 2003;31(8 suppl):S538-S546.
7. Chekan E, Whelan R. Surgical stapling device–tissue interactions:
what surgeons need to know to improve patient outcomes. Med
Devices (Auckl). 2014;7:305-318.
8. Macrae HM, Mcleod RS. Handsewn vs. stapled anastomoses in colon
and rectal surgery. Dis Colon Rectum. 1998;41(2):180-189.
9. Docherty JG, Mcgregor JR, Akyol AM, Murray GD, Galloway DJ.
Comparison of manually constructed and stapled anastomoses in
colorectal surgery. Ann Surg. 1995;221(2):176-184.
10. Naumann DN, Bhangu A, Kelly M, Bowley DM. Stapled versus
handsewn intestinal anastomosis in emergency laparotomy: a systemic
review and meta-analysis. Surgery. 2015;157(4):609-618.
11. Goulder F. Bowel anastomoses: the theory, the practice and the
evidence base. World J Gastrointest Surg. 2012;4(9):208.
12. Mattox KL, Moore EE, Feliciano DB, eds. Trauma. 7th ed. New York:
McGraw-Hill; 2013.
13. Chu C, Williams DF. Effects of physical configuration and chemical
structure of suture materials on bacterial adhesion. Am J Surg.
1984;147(2):197-204.
14. Slieker JC, Daams F, Mulder IM, Jeekel J, Lange JF. Systematic
review of the technique of colorectal anastomosis. JAMA Surg.
2013;148(2):190-201.
15. Ethicon. Wound Closure Manual. Somerville, NJ: Ethicon, Inc.;
2007:11-16.
16. Hirai K, Tabata Y, Hasegawa S, Sakai Y. Enhanced intestinal anasto-
motic healing with gelatin hydrogel incorporating basic fibroblast
growth factor. J Tissue Eng Regen Med. 2013;10(10):E433-E442.
17. Pasternak B, Rehn M, Andersen L, et al. Doxycycline-coated sutures
improve mechanical strength of intestinal anastomoses. Int J Colorectal
Dis. 2007;23(3):271-276.
18. Facy O, Blasi VD, Goergen M, Arru L, Magistris LD, Azagra J.
Laparoscopic gastrointestinal anastomoses using knotless barbed
sutures are safe and reproducible: a single-center experience with
201 patients. Surg Endosc. 2013;27(10):3841-3845.
19. Blanc P, Lointier P, Breton C, Debs T, Kassir R. The hand-sewn anas-
tomosis with an absorbable bidirectional monofilament barbed suture
Stratafix® during laparoscopic one anastomosis loop gastric bypass.
Retrospective study in 50 patients. Obes Surg. 2015;25(12):2457-2460.
20. Katz S, Izhar M, Mirelman D. Bacterial adherence to surgical sutures.
Ann Surg. 1981;194(1):35-41.
21. Masini BD, Stinner DJ, Waterman SM, Wenke JC. Bacterial adherence
to suture materials. J Surg Educ. 2011;68(2):101-104.
22. Edmiston CE, Seabrook GR, Goheen MP, et al. Bacterial adherence
to surgical sutures: can antibacterial-coated sutures reduce the risk
of microbial contamination? J Am Coll Surg. 2006;203(4):481-489.
23. Arikanoglu Z, Cetinkaya Z, Akbulut S, et al. The effect of different
suture materials on the safety of colon anastomosis in an experimental
peritonitis model. Eur Rev Med Pharmacol Sci. 2013;17(19):2587-2593.
24. Schoeb DS, Klink CD, Lambertz A, et al. Influence of gentamicin-
coded PVDF suture material on the healing of intestinal anastomosis
in a rat model. Int J Colorectal Dis. 2015;30(11):1571-1580.
25. Law WL, Bailey RH, Max E, et al. Single-layer continuous colon and
rectal anastomosis using monofilament absorbable suture (Maxon®).
Dis Colon Rectum. 1999;42(6):736-740.
26. Koruda MJ, Rolandelli RH. Experimental studies on the healing of
colonic anastomoses. J Surg Res. 1990;48(5):504-515.
27. Chen C. The art of bowel anastomosis. Scand J Surg. 2012;101(4):238-
240.
28. Garude K, Tandel C, Rao S, Shah NJ. Single layered intestinal
anastomosis: a safe and economic technique. Indian J Surg. 2012;
75(4):290-293.
29. Shikata S, Yamagishi H, Taji Y, Shimada T, Noguchi Y. Single- versus
two-layer intestinal anastomosis: a meta-analysis of randomized
controlled trials. BMC Surg. 2006;6(1):2.
30. Sajid M, Siddiqui M, Baig MK. Single layer versus double layer suture
anastomosis of the gastrointestinal tract. Cochrane Database Syst Rev.
2012;(1):CD005477.
31. Ortiz H, Azpeitia D, Casalots J, Sitges A. [Comparative experimental
study of inverting and everting sutures in the colon]. J Chir (Paris).
1975;109(5-6):691-696. [French].
32. Trueblood HW, Nelsen TS, Kohatsu S, Oberhelman HA Jr. Wound
healing in the colon: comparison of inverted and everted closures.
Surgery. 1969;65(6):919-930.
33. Gill W, Fraser SJ, Carter DC, Hill R. Everted intestinal anastomosis.
Surg Gynecol Obstet. 1969;128(6):1297-1303.
34. Abramowitz HB. Everting and inverting anastomoses. An experimental
study of comparative safety. Rev Surg. 1971;28(2):142.
35. Goligher JC, Morris C, Mcadam WA, Dombal FT, Johnston D. A
controlled trial of inverting versus everting intestinal suture in
clinical large-bowel surgery. Br J Surg. 1970;57(11):817-822.
36. Gambee LP, Garnjobst W, Hardwick CC. Ten years’ experience with
a single layer anastomosis in colon surgery. Am J Surg. 1956;92(2):
222-227.
37. Burch JM, Franciose RJ, Moore EE, Biffl WL, Offner PJ. Single-layer
continuous versus two-layer interrupted intestinal anastomosis. Ann
Surg. 2000;231(6):832-837.
38. Barth JA. Atlas of Surgical Stapling. Heidelberg: Barth; 2000.
39. Rubio PA. Contraindications and precautions. In: Rubio PA, Phelps
TH, eds. Atlas of Stapling Techniques. Rockville, MD: Aspen Publishers;
1986:13-15.
40. Steichen FM. The use of staplers in anatomical side-to-side and
functional end-to-end enteroanastomoses. Surgery. 1968;64(5):948-953.
41. Chassin JL, Rifkind KM, Turner JW. Errors and pitfalls in sta-
pling gastrointestinal tract anastomoses. Surg Clin North Am.
1984;64(3):441-459.
42. Hocking M, Carlson R, Courington K, Bland KI. Altered motility
and bacterial flora after functional end-to-end anastomosis. Surgery.
1990;108(2):384-391.

43. Baker RS, Foote J, Kemmeter P, et al. The science of stapling and
leaks. In: Obesity Surgery. New York, NY: Springer Science + Business
Media; 2013:1290-1298.
44. Mery C, Shafi B, Binyamin G, Morton JM, Gertner M. Profiling
surgical staplers: effect of staple height, buttress, and overlap on
staple line failure. Surg Obes Relat Dis. 2008;4(3):416-422.
45. Nakayama S, Hasegawa S, Nagayama SA, et al. The Importance of
Precompression Time for Secure Stapling With a Linear Stapler. New York:
Springer Science + Business Media; 2011:2382-2386.
46. Myers SR, Rothermel WS, Shaffer L. The effect of tissue compression
on circular stapler line failure. Surg Endosc. 2011;25(9):3043-3049.
47. Offodile AC, Feingold DL, Nasar A, Whelan RL, Arnell TD. High
incidence of technical errors involving the EEA circular stapler: a
single institution experience. J Am Coll Surg. 2010;210(3):331-335.
48. Genzini T, D’Alburquerque LA, de Miranda MP, Scafuri AG, de Oliveira
e Silva A. Intestinal anastomoses. Rev Paul Med. 1992;110:183-192.
49. Enestvedt CK, Thompson SK, Chang EY, Jobe BA. Clinical review:
healing in gastrointestinal anastomoses, Part II. Microsurgery.
2006;26(3):137-143.
50. Mclachlin A, Denton D. Omental protection of intestinal anastomoses.
Am J Surg. 1973;125(1):134-140.
51. Katsikas D, Sechas M, Antypas G, Floudas P, Moshovos K, Gogas J,
et al. Beneficial effect of omental wrapping of unsafe intestinal anas-
tomoses. An experimental study in dogs. Int Surg. 1977;62(8):435-437.
52. Adams W, Ctercteko G, Bilous M. Effect of an omental wrap on the
healing and vascularity of compromised intestinal anastomoses. Dis
Colon Rectum. 1992;35(8):731-738.
53. Merad F, Hay J, Fingerhut A, Flamant Y, Molkhou J, Laborde Y.
Omentoplasty in the prevention of anastomotic leakage after colonic
or rectal resection. Ann Surg. 1998;227(2):179-186.
54. Vakalopoulos KA, Daams F, Wu Z, et al. Tissue adhesives in gastro-
intestinal anastomosis: a systematic review. J Surg Res. 2013;180(2):
290-300.
55. Haukipuro KA, Hulkko OA, Alavaikko MJ, Laitinen ST. Sutureless
colon anastomosis with fibrin glue in the rat. Dis Colon Rectum.
1988;31(8):601-604.
56. Ham AC, Kort WJ, Weijma IM, Van Den Ingh HFGM, Jeekel H.
Healing of ischemic colonic anastomosis. Dis Colon Rectum. 1992;
35(9):884-891.
57. van der Ham AC, Kort WJ, Weijma IM, van den Ingh HF, Jeekel J.
Effect of fibrin sealant on the healing colonic anastomosis in the
rat. Br J Surg. 1991;78(1):49-53.
58. Byrne DJ, Wood H, McIntosh R, Hopwood D, Cuschieri A. Adverse
influence of fibrin sealant on the healing of high-risk sutured colonic
anastomoses. J R Coll Surg Edinb. 1992;37(6):394-398.
59. Erturk S, Yuceyar S, Temiz M, et al. Effects of hyaluronic acid-
carboxymethylcellulose antiadhesion barrier on ischemic colonic
anastomosis. Dis Colon Rectum. 2003;46(4):529-534.
60. Beck DE, Cohen Z, Fleshman JW, Kaufman HS, van Goor H, Wolff
BG. Adhesion Study Group Steering Committee. A prospective,
randomized, multicenter, controlled study of the safety of Seprafilm
adhesion barrier in abdominopelvic surgery of the intestine. Dis
Colon Rectum. 2003;46(10):1310-1319.
61. Hardy TG Jr, Pace WG, Maney JW, Katz AR, Kaganov AL. A biofrag-
mentable ring for sutureless bowel anastomosis. An experimental
study. Dis Colon Rectum. 1985;28(7):484-490.
Suturing, Stapling, and Tissue Adhesion CHAPTER 85 1013
62. Corman ML, Prager ED, Hardy TG, Bubrick MP. Comparison of
the Valtrac biofragmentable anastomosis ring with conventional
suture and stapled anastomosis in colon surgery. Dis Colon Rectum.
1989;32(3):183-187.
63. Dyess L, Curreri PW, Ferrara J. A new technique for sutureless
intestinal anastomosis. A prospective, randomized, clinical trial. Am
Surg. 1990;56(2):71-75.
64. Ghitulescu GA, Morin N, Jetty P, Belliveau P. Revisiting the biofrag-
mentable anastomotic ring: is it safe in colonic surgery? Can J Surg.
2003;46(2):92-98.
65. Choi HJ, Kim HH, Jung GJ, Kim SS. Intestinal anastomosis by
use of the biofragmentable anastomotic ring. Dis Colon Rectum.
1998;41(10):1281-1286.
66. Lee H, Woo J, Park S, Kang N, Park K, Choi H. Intestinal anastomosis
by use of a memory-shaped compression anastomosis clip (Hand CAC
30): early clinical experience. J Korean Soc Coloproctol. 2012;28(2):83.
doi:10.3393/jksc.2012.28.2.83.
67. Testini M, Gurrado A, Portincasa P, et al. Bovine pericardium
patch wrapping intestinal anastomosis improves healing process
and prevents leakage in a pig model. PLoS One. 2014;9(1):e86627.
doi:10.1371/journal.pone.0086627.
68. Hoeppner J, Crnogorac V, Marjanovic G, et al. Small intestinal
submucosa for reinforcement of colonic anastomosis. Int J Colorectal
Dis. 2009;24(5):543-550.
69. Johnson CD, Lamont PM, Orr N, Lennox M. Is a drain necessary
after colonic anastomosis? J R Soc Med. 1989;82(11):661-664.
70. Rolph R, Duffy JM, Alagaratnam S, Ng P, Novell R. Intra-abdominal
drains for the prophylaxis of anastomotic leak in elective colorectal
surgery. Cochrane Database Syst Rev. 2004;(4):CD002100.
71. Vignali A. Factors associated with the occurrence of leaks in stapled
rectal anastomoses: a review of 1,014 patients. J Am Coll Surg. 1997;
185(2):105-113.
72. Morse BC, Simpson JP, Jones YR, Johnson BL, Knott BM, Kotrady JA.
Determination of independent predictive factors for anastomotic leak:
analysis of 682 intestinal anastomoses. Am J Surg. 2013;206(6):950-956.
73. Samaiya A. To drain or not to drain after colorectal cancer surgery.
Indian J Surg. 2015;77(S3):1363-1368.
74. Lewis SJ, Egger M, Sylvester PA, Thomas S. Early enteral feeding
versus “nil by mouth” after gastrointestinal surgery: systematic review
and meta-analysis of controlled trials. BMJ. 2001;323(7316):773-776.
75. Reissman P, Teoh T, Cohen SM, Weiss EG, Nogueras JJ, Wexner
SD. Is early oral feeding safe after elective colorectal surgery?
A prospective randomized trial. Ann Surg. 1995;222(1):73-77.
76. Hartsell PA, Frazee R, Harrison J, Smith R. Early postoperative
feeding after elective colorectal surgery. Arch Surg. 1997;132(5):518.
77. Ortiz H, Armendariz P, Yarnoz C. Is early postoperative feeding
feasible in elective colon and rectal surgery? Int J Colorectal Dis. 1996;
11(3):119-121.
78. Dag A, Colak T, Turkmenoglu O, Gundogdu R, Aydin S. A randomized
controlled trial evaluating early versus traditional oral feeding after
colorectal surgery. Clinics (Sao Paulo). 2011;66(12):2001-2005.
79. Mamatha B, Alladi A. Early oral feeding in pediatric intestinal
anastomosis. Indian J Surg. 2013;77(S2):670-672.
80. Amanollahi O, Azizi B. The comparative study of the outcomes of
early and late oral feeding in intestinal anastomosis surgeries in
children. Afr J Paediatr Surg. 2013;10(2):74.