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Delcio Matos Suzana Angélica Silva Lustosa
Sao Paulo Med J/Rev Paul Med 1999; 117(3):99-100.
Handse wn or staple d colore ctal anastomosis?
Or how e vide nce base d is surgical practice ?
Respo nding to increasing demands fo r co st-effectiveness relatio n a recent rando miz ed trial which co mpared the co st o f stapled and hand-sutured anasto mo sis in the g astro intestinal tract, has co ncluded that stapled anasto mo sis are no t efficcient and sho uld be reserved fo r individual indicatio ns.1 Ho wever, o ne can admit that in the g eneral surg ical practice, preference fo r stapler is so o ve rw he lming tha t c o st-e ffe c tive ne ss a p p ro a c h is b e ing ne g le c te d sinc e the first anasto mo tic machine has been fired. As a matter o f fact mo st surg eo ns do no t reg ard this as an issue o f co ncern and as a result it has no t been c o nsidered a s a ma jo r study endpo int in the literature.2
Taken into acco unt that health care co st is g etting even mo re wo rriso me, any interventio n in this area has to be so undly based. To save reso urces is impo rtant no t o nly fo r develo ped co untries b ut a lso a nd ma inly fo r develo ping o ne s, w he re fina nc ia l b urd e n is to o hig h.3 Therefo re, o ne must pursue the best available scientific evidence in o rder to suppo rt decisio ns, o therwise it takes the risk o f being restricted by fina nc ia l pressure. Purc ha sers o f a na sto mo tic devices are well aware o f this matter.
So far mo st o f the research in co lo rectal surg ery lack o f the best epidemio lo g ical evidence
which take us to infer o n the limitatio n to use the co nclusio ns o f these studies in o rder to g uide decisio ns. Surg eo ns tend to take theirs decisio ns based o n series repo rt o r specialist o pinio n which are no t co nsidered first level quality o f evidence. The so called unwilling ness o f the surg eo n to perfo rm rando miz ed co ntro lled trials has to be vanished o nce and fo r all. Ho w co uld we do it? Just b y d o ing w e l d e sig ne d ra nd o miz e d co ntro lled trials, even with the restrictio n o f this kind o f research in the surg ical area. A systematic review o f these trials may be the final answer to research questio n, just in case o f sample siz e being the pro blem.
Syste ma tic re vie w with ho mo g e ne ity o f rando mized co ntro lled trials o n therapy has been reg a rded a s to p level evidenc e.The extent to w hic h surg ic a l p ra c tic e is sup p o rte d b y satisfacto ry scientific evidence is currently under investig atio n. The first co nclusio n o f these studies is that the majo rity o f surg ical treatment canno t be subjected to rando miz ed co ntro lled trials and that it will be necessary to develo p better metho ds o f categ o riz ing the no n rando miz ed evidence suppo rting treatment cho ice.4
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Sao Paulo Med J/Rev Paul Med 1999; 117(3):99-100.
a va ila b le is insuffic ie nt to sho w supe rio rity o f sta ple d to ha ndse w n te c hniq ue .2 So until b e st e vide nc e c a n b e sho w n, the c ho ic e o f w hic h te c hniq ue ha s to b e use d ma y b e b a se d o n the surg e o n e x p e rie nc e a nd the b e st judg e me nt.
REFERENCES
1. Izbicki JR, Gawad KA, Quirrenbach S, Ho sch SB, Breid V, Kno efel WT. Can stapled anasto mo sis in viscera surgery still be justified? a pro -spective, rando mized and co ntro lled study o f co st-effectiveness o f handsewn and stapled anasto mo ses. Chirurg, 1998;69:725-34.
2. Lusto sa, SAS. Stapled o r handsewn co lo rectal anasto mo sis? sys-tematic review and metanalysis. Master thesis (in Po rtuguese). UNIFESP - Esco la Paulista de Medicina, 1999.
3. Attalah, AN. The Co chrane Co llab o ratio n in the Third Wo rld. Edi-to rial. Rev Paul Med, 1998;116:1693.
4. Ho wes N, Chagla L, Tho rpe M, McCullo sh P. Surgical practice is evi-dence based. Br J Surg, 1997;84:1220-23.
Delcio M a tos
Dean o f Po stg raduate G astro entero lo g ical Studies and Head o f Co lo rectal Surg ery, UN IFESP - Esco la Paulista de Medicina.
Suza na Angélica Silva Lustosa
