Stapled versus Hand Sewn Anastomoses in Patients with Small Bowel Injury: A Changing Perspective Jonathan D. Witzke, MD, James J. Kraatz, MD, Jeffery M. Morken, MD, Arthur L. Ney, MD, Michael A. West, MD, PhD, Joan M. Van Camp, MD, Richard T. Zera, MD, PhD, and Jorge L. Rodriguez, MD Introduction: Recent studies indicate that trauma patients with hollow viscus injuries requiring anastomosis who are managed with stapling have a higher rate of complications than do those in whom a hand-sewn anastomosis is used. We un- dertook this study to determine whether this finding applied to patients with small bowel trauma at our institution. Methods: Records of patients with small bowel injuries were retrospectively reviewed. Demographics, severity of in- jury, injury management, and outcome data were collected. Results: Patients who had their small bowel injuries managed by hand-sewn re- pair versus resection and stapled anasto- mosis demonstrated a nonsignificant de- crease in overall complication rate (35% vs. 44%) and rate of intra-abdominal complication (10% vs. 18%). Yet the rate of intra-abdominal abscess formation was significantly lower with hand-sewn repair than with resection and stapled anastomo- sis (4% vs. 13%). However, when hand- sewn primary repairs were excluded from the analysis and injuries that required re- section and either stapled or hand-sewn anastomosis were compared, there was a similar overall complication rate (41% vs. 41%) and rate of intra-abdominal compli- cations (17% vs. 21%). Conclusion: The rate of intra-ab- dominal complications did not differ sig- nificantly between patients requiring small bowel resection and reanastomosis managed by either a stapled or hand-sewn technique. In our experience, surgical sta- pling devices appear to be safe for use in repairing traumatic small bowel injury. J Trauma. 2000;49:660 –666. T he role of stapling devices in surgery has continued to expand over the last 30 years. 1–4 Their performance in elective gastrointestinal surgery has been documented, and numerous published reports have found that stapling devices performed as well as, if not better, than conventional suture methods in elective surgery. 5–9 In the setting of trauma, their ease of use has made them invaluable tools in the expedient management of hollow viscus injuries. Al- though stapling devices are generally regarded as safe, Brundage et al. 10,11 recently reported a multi-institutional trial showing that the use of staples for repair of bowel injuries was associated with a significantly increased rate of intra-abdominal complications in trauma patients with hollow viscus injuries. The definition of anastomosis was somewhat ambiguous, because no clear-cut distinction was made be- tween primary enterotomy repairs and resection with anasto- mosis. In addition, this work included anastomoses at all levels of the gastrointestinal tract. To our knowledge, there is no data regarding safety and efficacy of primary repair or resection of the injury and anastomosis in the management of traumatic small bowel injuries. Therefore, we undertook this study to assess if there is an increased rate of complications associated with primary repair or resection of the injury with stapled small bowel anastomoses relative to patients in whom a hand-sewn anastomosis was used in our institution. MATERIALS AND METHODS Patients sustaining traumatic small bowel injury were identified from the Hennepin County Medical Center (HCMC) Trauma Registry. Patients with a small bowel injury who died within 24-hours after injury or patients whose medical records were inadequate were excluded from analy- sis. Patients who had a small bowel injury repaired had their medical record retrospectively reviewed. Demographic, se- verity of injury, injury management, and outcome data were collected. Because some patients had more than one type of anastomosis, the data were analyzed at both the levels of the patient and the individual anastomosis. Initially, patients were categorized into two groups: Group I, which included all patients whose injuries were repaired by the staple technique, and Group II, which included all patients whose injuries were repaired by a hand-sewn technique. Furthermore, a subgroup analysis was performed to assess the effect of primary repair of the injury to patients that underwent resections of the injury either with stapled or hand-sewn anastomoses. For this analysis patients were categorized into three groups: the SA group, representing injury managed by resection and stapled anastomosis; the HA group, comprising injury managed by resection and a hand-sewn anastomosis; and the PR group, composed of small bowel injuries managed by primary re- pair. Six patients had multiple anastomoses in which both Submitted for publication September 24, 1999. Accepted for publication June 21, 2000. Copyright © 2000 by Lippincott Williams & Wilkins, Inc. From the Department of Surgery, Hennepin County Medical Center affiliated with the University of Minnesota Medical School, Minneapolis, Minnesota. Presented at the 59th Annual Meeting of the American Association of Trauma, September 16 –18, 1999, Boston, Massachusetts. Address for reprints: Jorge L. Rodriguez, MD, Department of Surgery, Hennepin County Medical Center, 701 Park Avenue, Minneapolis, MN 55415 The Journal of TRAUMA  Injury, Infection, and Critical Care 660 October 2000