Improved Outcomes in Colon and Rectal Surgery part 6. Written by many of the worlds leading colorectal surgeons, this evidence-based text investigates the risks and benefits of colorectal surgeries. By using clinical pathways, algorithms, and case discussions, the authors identify the best practices for patient safety and positive outcomes to ensure that physicians correctly recognize potential problems and carefully manage complications | IMPROVED OUTCOMES IN COLON AND RECTAL SURGERY included anastomotic leak tear during extraction anvil not extractable complete anastomotic failure that required conversion to another technique instrument failure and bleeding . This report represents surgeons early experience with the use of staplers and therefore the results must be evaluated in the proper context. Improvements in the instruments anastomotic technique and surgeon experience have resulted in fewer complications. An early experience with 73 consecutive stapled end-to-end colorectal anastomoses by Gordon and Vasilevsky identified intraoperative complications in 19 patients 26 . 31 These included instrument failure 4 incomplete or inadequate doughnuts 5 bleeding 3 bowel injury associated with use of sizers 1 anvil extraction 1 anvil insertion 3 difficulty with stapler extraction 1 and anvil not extractable 1 . The relative high incidence of these problems reflects the early learning curve with stapling instruments and the early developmental nature of the instruments used. Increased experience and advances in instruments have minimized the occurrence of these problems. A prospective randomized multicenter study by Dochetry and colleagues described 652 patients who were randomized to a sutured n 321 or stapled large bowel anastomosis n 331 between 1985 and 1989. 32 During the study 5 of the 331 patients randomized to a stapled anastomosis had an instrument or technical failure. Intraoperative anastomotic testing was not routinely performed but postoperative radiologic leaks were identified in of the sutured and of the stapled colorectal anastomoses. Clinical anastomotic leakage was evident in of the sutured patients and of the stapled patients. Proper technique is a critical component to obtaining a good anastomosis with a circular intraluminal stapler. To minimize problems the largest diameter stapler that can be accommodated by both bowel ends should be .
