A Comparison of Stapled and Handsewn Anastomoses in Patients Undergoing Resection for Dukes' B and C Colorectal Cancer An Analysis of Disease-free Survival and Survival from the NSABP Prospective Clinical Trials NORMAN WOLMARK, M.D., PHILIP H. GORDON, M.D., BERNARD FISHER, M.D., SAMUEL WEIAND, PH.D., HARVEY LERNER, M.D., WALTER LAWRENCE, M.D., HENRY SHIBATA, M.D. Wolmark N, Gordon P, Fisher B, Weiand S, Lerner H, Lawrence W, Shibata H. A comparison of stapled and handsewn anastomoses in patients undergoing resection for Dukes' B and C colorectal cancer: an analysis of disease-free survival and survival from the NSABP prospec- tive clinical trials. Dis Colon Rectum 1986;29:344-350. This study was to assess the effect of stapled colorectal anastomoses on local recurrence, disease-bee survival, and survival following curative resection for Dukes' B and C adenocarcinoma. Data were derived from two randomized prospective trials of the National Surgical Adjuvant Breast and Bowel Project designed to evaluate the efficacy of adjuvant therapy in colorectal cancer. Of 1111 patients with colonic anasto- moses, 255 were stapled mechanically. There were no significant differ- ences in disease-free survival, survival, or local tumor recurrence among patients subjected to stapled or handsewn anastomoses. Of the 181 patients undergoing anterior resection for rectal cancer, 82 anasto- moses were fashioned with staples. No significant disadvantage in disease-free survival, survival, or local recurrence could be attributed to use o[ the mechanical stapling devices. Twelve percent of patients undergoing stapled rectal anastomoses developed a local recurrence as a first sign of treatment failure compared with 19 percent for the handsewn group. No significant differences in the length of distal margins were detectable. The average time on study was 41 months. The use of stapled anastomoses for carcinoma of the colon or rectum is not associated with an adverse effect on long-term outcome. [Key words: Anastomoses, stapled, handsewn; Cancer, colorectal, Survival, disease-free] WITHIN THE PASTDECADE there has been a remarkable increase in the frequency with which stapled anastomoses are performed following bowel resection for colonic cancer. Despite this popularity, little information is available that assesses the influence of this technique on Read at the meeting of the American Society of Colon and Rectal Surgeons, San Diego, California, May 5 to 10, 1985. Supported by USPHS NIH-U10-34212 and an American Cancer Society Grant RC-13. Address reprint requests to Dr. Wolmark: NSABP Headquarters, 3550 Terrace Street, Pittsburgh, Pennsylvania 15261. From the National Surgical Adjuvant Breast and Bowel Project (NS.4BP) Headquarters, Pittsburgh, Pennsylvania tumor recurrence and survival. There are two important putative influences, whereby the use of mechanical sta- pling devices might adversely affect patient outcome exclusive of postoperative sequelae. The first contention suggests that the use of stapling instruments, particularly in the case of carcinoma of the rectum, has led to a compromise in the extent of the operative resection and has resulted in the inappropriate abandonment of abdom- inoperineal resection in favor of sphincter-saving proce- dures. When the perturbation on the management of rectal cancer attributed to the use of the mechanical sta- pling devices is placed into perspective, it must be emphasized that the introduction of these instruments occurred at a time when the retreat from abdominoperi- neal resection was well under way for reasons exclusive of the anastomotic technique employed9 -7 It is clear, how- ever, that the widespread availability of the stapling instruments catalyzed the rapidity with which the sphinc- ter-saving procedure was adopted by surgeons outside the specialty clinics. If one assumes that the numerous retrospective anal- yses attesting to the similarity in disease-free survival between abdominoperineal resection and the sphincter- saving operation are correct, ~-~~ a theoretical negative influence associated with use of the stapling devices must be a result of factors other than those governing the preservation of the anal sphincter per se. This considera- tion places increasing emphasis on the second contention associated with the theoretical adverse effect of the use of mechanical stapling devices, namely, that the staples 344