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| ORIGINAL RESEARCH REPORT |
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| Year : 2021 | Volume
: 18
| Issue : 3 | Page : 161-167 |
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Training trends and practice pattern of intestinal anastomosis among Nigerian Postgraduate Trainees: A cross-sectional survey
Olanrewaju Samuel Balogun, Emmanuel A Jeje, Oluwole Ayoola Atoyebi
Department of Surgery, College of Medicine, University of Lagos, Lagos, Nigeria
| Date of Submission | 06-Jan-2021 |
| Date of Acceptance | 10-Jul-2021 |
| Date of Web Publication | 23-Aug-2021 |
Correspondence Address:
Dr. Olanrewaju Samuel Balogun
Department of Surgery, College of Medicine, University of Lagos, Lagos
Nigeria
 Source of Support: None, Conflict of Interest: None  | Check |
DOI: 10.4103/jcls.jcls_2_21
Background: The concept of mentor-mentee skills learning in surgical education has been the bedrock of training and knowledge acquisition over many years. Techniques of intestinal anastomosis are one of the fundamentals skills to be mastered in the early career of trainees in surgery. This study aims to evaluate the training trends and current practice of intestinal anastomosis amongst Nigerian postgraduate trainees. Methods: A cross-sectional survey using a self-administered questionnaire was conducted on surgical trainees who attended the 2020 annual revision course of the National Postgraduate Medical College in Lagos. Results: Response rate was 74.1%. The age range of respondents was 29–52 years with a mean 35.5 ± 4.6 years. Majority of the respondents had their future career interest in general surgery and were in the second (43.3%) and third (38.3%) postgraduate year in surgery. Nontraumatic emergency abdominal conditions (71.7%) were the most common indication for gastrointestinal anastomosis. Majority of the respondents practice prophylactic use of bowel preparation and nasogastric tube placement for elective colorectal procedures. Two-layer anastomosis using synthetic absorbable suture was favored by most respondents. This was the technique of choice regardless of the segment of the bowel involved in the anastomosis. Fifth postoperation day was the most preferred time for the commencement of oral intake. Twenty respondents gave an estimated anastomotic leak rate of 0%–10% and this was attributed to systemic factors by 71.7% of the respondents. Two-third of respondents rated their current anastomotic skills as good even though 86.7% of respondents desired further formal training in intestinal anastomosis. Conclusion: Nontraumatic emergency abdominal conditions were the most common indication for intestinal anastomosis. The traditional two-layer anastomosis with synthetic absorbable sutures was favored over other anastomotic techniques. Majority would commence oral feeding on 5th day postoperation. Self-rated anastomotic leak reported by a third of respondents was ≤10%.
Keywords: Anastomosis, intestinal, Nigeria, surgery, training
How to cite this article:
Balogun OS, Jeje EA, Atoyebi OA. Training trends and practice pattern of intestinal anastomosis among Nigerian Postgraduate Trainees: A cross-sectional survey. J Clin Sci 2021;18:161-7 |
How to cite this URL:
Balogun OS, Jeje EA, Atoyebi OA. Training trends and practice pattern of intestinal anastomosis among Nigerian Postgraduate Trainees: A cross-sectional survey. J Clin Sci [serial online] 2021 [cited 2023 May 28];18:161-7. Available from: https://www.jcsjournal.org/text.asp?2021/18/3/161/324401 |
| Introduction | |  |
Successful surgical practice can be judged on the premise of good outcomes with minimal adverse events. Intestinal anastomosis is one of the fundamental techniques in surgery and one of the earliest procedures to be learned in the career of a trainee surgeon. The art of restoring continuity of the bowel requires adherence to some laid down scientific principles for a successful outcome. The choice of pattern and technique of intestinal anastomosis appears to be highly variable among Surgeons. The anastomotic technique of choice may be influenced by the learning experience and level of exposure of the surgeon.
A good mastery of intestinal anastomosis is essential because complications resulting from poor technique can lead to significant morbidity and even mortality. The mortality rate for an anastomotic leak in the literature typically is in the 10% to 15% range.[1],[2],[3] Despite the perceived perfect situation such as "perfect patient," healthy bowel and meticulous technique, some anastomoses continue to leak resulting in significant morbidity and mortality (e.g., 22% mortality in patients with a leak vs. 7.2% mortality in those without).[1],[4] While there are so many techniques of intestinal anastomosis as described in the literature, there is currently no ideal technique for intestinal anastomosis devoid of complications.
The development of surgical staplers has revolutionized the art of bowel anastomosis.[5] Intestinal staplers have advantages in terms of speed of execution and performance of anastomosis in "hard to reach" cavities of the body like the deep pelvis.[5],[6] While some experts had reported superiority of stapling for leak-proof bowel anastomosis, some authorities believe that leak rates are not different for hand-sewn and stapled anastomoses.
Simulation-based learning for intestinal anastomosis has become a compliment of postgraduate surgical education in some developed countries in the last decades.[7],[8] Simulation offers a balance between the acquisition of skills and patients' safety. Simulation for intestinal anastomosis is an integral part of the basic surgical skills (BSS) course and was rated as the most useful BSS skills in a report by Ezeome et al.[9] Most surgical simulations in existence are conducted outside the operating room environment and may provide a more efficient method of skills acquisition than the traditional learning through exposure to surgical cases.[8] Surgical simulation is still not widely available in most developing countries in the Sub-Saharan Africa.[10] Hence, there is a high possibility that surgeons will adopt and practice the anastomotic technique that works for them while trainees may likely imbibe the technique(s) that have been seen to work well for their trainers. Consequently, variation in the techniques of performing intestinal anastomosis is expected among Surgeons. The practice pattern of intestinal anastomosis amongst the surgeons in the Nigeria is not known. We aimed to determine the process of skills acquisition and practice of intestinal anastomosis amongst some resident doctors in Nigerian postgraduate training centers. This is to document the training trend and practice pattern of intestinal anastomosis in comparison to the contemporary surgical practice.
| Methods | | |
A cross-sectional survey, using a pretested, self-administered questionnaire was conducted on Nigerian Postgraduate Surgical trainees who attended the annual surgical revision course of the Nigerian Postgraduate Medical College in surgery which held at the National Orthopedic Hospital, Igbobi/Lagos University Teaching Hospital, Lagos between March 9 and 23, 2020. Approval to conduct this study was obtained from the Ethics Committee of the Lagos University Teaching Hospital. Idi-Araba. Lagos. For data analysis, the content of the questionnaire was divided into themes as follows:
- The demographic and professional characteristics of the residents.
- Indications and types of intestinal anastomosis experienced
- Preoperative preparation of patients
- Intraoperative considerations
- Postoperative care and self-assessment of the outcome after intestinal anastomosis.
Respondents who declined participation and poorly completed questionnaires were excluded from the study.
Data analysis
Responses, as obtained from the respondents were recorded in the study and pro forma and entered into a Microsoft excel 2016 spreadsheet. The study data were subsequently exported into Data analysis was done using IBM Statistical Packages for Social Sciences(SPSS)for Windows, version 23.0, IBM Corp., Armonk, NY, USA. Categorical data were expressed in proportions and demonstrated with appropriate frequency tables, charts, and figures. Continuous variables were expressed in mean and standard deviation.
| Results | | |
Demographic characteristics and future career interests of the respondents
Sixty out of 81 postgraduate residents in attendance completed the questionnaire. This gave a response rate of 74.1%. There were 57 (95%) males and 3 (5%) females. with male-to-female ratio of 19:1. The mean age of the respondents was 35.5 ± 4.6 years; range was 29–52 years. Fifty-six respondents (93.3%) were from Federal/State Teaching Hospital, 3 respondents (5%) were from Federal Medical Centers and 1 respondent (1.7%) was from the General hospital. [Figure 1] shows the distribution of the respondents from the 6 Geopolitical zones of the country. The highest proportion of respondents in the survey was from the South-South geopolitical zone of the country. Majority of the respondents were in the 2nd year (43.3%) and 3rd year (38.3%) of their postgraduate training in surgery [Figure 2]. Future surgical specialty of interest in 56 out of 60 residents surveyed is as shown in [Figure 3]. General surgery (25%), urology (23%), and neurosurgery (20%) were the most preferred surgical careers. | Figure 1: Distribution of training institutions of the respondents according to the Geopolitical Zones of Nigeria
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Current indications and pre-operative preparation for intestinal anastomosis as reported by the respondents
Nontraumatic abdominal surgical emergencies (71.7%) were the most common indication for intestinal anastomosis. Elective abdominal procedures constituted 20% of all indications and trauma-related indications 6.7%. [Table 1] depicts the various types of intestinal anastomosis experienced by the respondents. Duodeno-jejunal anastomosis (21.7%) was the most common upper gastrointestinal anastomosis seen by the respondents. Jejuno-jejunal/Jejunoileal anastomosis (81.7%) was the most common lower gastrointestinal anastomosis experienced by the respondents. Fifty-five respondents (91.7%) currently practices bowel preparation using laxatives and antibiotics before elective colorectal anastomosis. The same proportion of respondents (91.7%) also reported the use of prophylactic nasogastric tubes after bowel anastomosis.
Intestinal anastomotic skills acquisition and anastomotic technique practice
Intestinal anastomotic skills acquisition was from multiple sources. Thirty-five respondents (58.3%) acquired their anastomosis skills from the supervising consultants, 31 respondents (51.7%) learned intestinal anastomosis working with the senior residents. Other modalities of learning included surgical videos in 15 respondents (25%). Only four respondents (6.7%) acquired intestinal anastomosis skills from BSS course.
The preferred instruments for bowel resection prior to intestinal anastomosis vary among the respondents. Using a scalpel to divide bowel was favored by 24 respondents (71.7%) and scissors by 10 respondents (16. 7%). Only one respondent preferred to use intestinal staplers. No specific choice was indicated by the remaining 25 respondents.
Double-layer intestinal anastomosis consisting of continuous inner-layer and interrupted outer-layer was the method of choice in 23 respondents (38.3%). Double-layer interrupted sutures were the method of choice in 6 respondents (10%). Double-layer continuous sutures were preferred by 7 respondents (11. 7%). Fifteen respondents (25%) practiced single-layer extra mucosal interrupted sutures. Intestinal anastomosis using single-layer extra mucosal continuous sutures was the technique of choice in 10 respondents (16. 7%). Fifty-four respondents (90%) indicated they would use the same anastomotic technique for small and large bowel. With regards to the choice of sutures for intestinal anastomosis, Polyglactin (VicrylR) was the suture of choice in 48 respondents (80%) for intestinal anastomosis. In managing bowel diameter disparities during intestinal anastomosis, 44 respondents (73.3%) use Cheatle's split maneuver, two respondents (3.3%) indicated halving technique as the method of choice. There was no response from the remaining 16 respondents. Only 11 respondents (18.3%) had experience with the use of surgical staplers for intestinal anastomosis. Twenty-four respondents (40%) had experience with air leak test after colorectal anastomosis. Seven respondents (11.7) had experienced the use of methylene blue for the leak proof test after colorectal anastomosis.
Postoperative care and outcome after intestinal anastomosis
Fifth postoperation day was the most preferred time for the commencement of oral intake as indicated by twenty respondents (33. 3%). This was followed by patients feeding at 3rd day postoperation in 15 respondents (25%) and 4th day postoperation in 9 respondents (15%). Only 2 respondents (3.3%) fed their patients 24 h postoperation. The favorite sign for commencement of oral intake was the presence of bowel sounds (38.3%), passage of flatus (30%), and passage of stool (16.7%).
When asked to estimate their self-reported leak rate after intestinal anastomosis. Only a minority of respondents answered this question. An estimated leak rate of between 0% and 10% was reported in 20 respondents. Reported risk factors for intestinal anastomosis are as shown in [Table 2]. Forty-three respondents (71.7%) were of the opinion that systemic factors were major causes of intestinal anastomotic leak. Anastomotic leak was attributed to poor technique in 24 respondents (40%). | Table 2: Risk factors for anastomotic leak according to the training experience of the residents
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Self-rating of success rate and desire for training in intestinal anastomosis
Only 7 respondents (11.7%) reported their intestinal anastomosis skills level as excellent while 40 respondents (66. 7%) rated their skills as good and 9 respondents (15%) rated theirs as average. In all, 52 (86.7%) of 60 respondents desired formal training in intestinal anastomosis.
| Discussion | | |
Intestinal anastomosis is performed to restore continuity following resection of a segment of bowel for various indications from trauma to neoplastic processes. Techniques for performing bowel anastomosis have been developed since 19th century.[11] Early methods of bowel anastomosis were reportedly fraught with significant morbidity and mortality. However, in the last 200 years, a better understanding of the anatomy of various layers of the gastrointestinal tract coupled with advancement in suture technology have led to better outcomes after intestinal anastomosis.[12] In addition, the development of staplers for restoring bowel continuity now enables surgeons to complete the procedure in a shorter time.
This survey represented the opinion of 60 residents in surgery majority of who were in the first 3 years of residency training in surgery. These are doctors in their early formative years rotating through various surgical specialties in preparation for the qualifying Part 1 examination to become Senior residents. Senior residents are expected to spend most of their training years in a particular specialty. Anastomotic skills acquisition is an important component of the training of doctors in general surgery and urology. These were the most common area of career interest of the respondents.
More than two-thirds of indications for gastrointestinal anastomosis in this survey were for nontraumatic abdominal emergencies. Nontraumatic surgical conditions of the abdomen requiring emergency surgery include intestinal obstruction and nontraumatic perforations. The bulk of surgical workload for intestinal anastomosis reported in emergency settings in this survey supported the report that about 60% of surgeries in low- and middle-income countries are performed as emergencies.[13] A large volume 1-year retrospective audit from Ethiopia revealed that emergency surgical operations constituted 57.4% of all operations.[14] Onyemaechi et al.[15] in Enugu reported that acute abdomen constituted the majority of cases of nontraumatic emergency admissions.
Most respondents had multiple sources from which they acquired their anastomotic skills, of these, the traditional learning from the consultant during live procedures which were done as emergencies was the principal means of intestinal anastomosis skills transfer. Learning from the BSS program is not widely available in many training institutions in Nigeria at this time. Similar to Ezeome's report on BSS,[9] very few respondents had attended formal training on the intestinal anastomosis. It is arguable whether learning in an emergency setting would yield a better performance compared to that of elective surgery or via surgical simulation of the BSS. This survey also revealed that majority of learning and practice of gastrointestinal anastomosis were on pathologies involving the jejunum ileum colon and rectum. This suggests pathologies requiring bowel resection and anastomoses were more common in the lower gastrointestinal tract. These include bleeding, perforation, and obstruction.
Bowel preparation had long been practiced in elective colorectal surgery. Over the last 3 decades, the utility of routine bowel preparation before elective colorectal surgery had been questioned in several prospective studies and meta-analyses.[16],[17],[18],[19] Prophylactic bowel preparation is no longer considered beneficial in colorectal surgery.[19] There was a report that elective bowel preparation may be associated with increased anastomotic leak.[19] However, the majority of respondents indicated the use of bowel preparation before colorectal anastomosis as a necessary prophylaxis against adverse outcomes. Similar findings were reported in large scale surveys from the United States in 2003 where over 99% of surgeons surveyed used mechanical bowel preparation for elective colorectal surgery.[19] This response was seen as a gap between evidence and practice.[18] However, there is paucity of local evidence to justify continued use of bowel preparation in our setting for elective colorectal surgery. Bowel preparation in elective colorectal surgery may be appropriate in resource-challenged settings where facilities to manage morbidity of anastomotic leaks from an unprepared bowel are very limited. In a like manner, the current evidence does not recommend the routine use of nasogastric tube before elective colorectal procedures.[20],[21] This was still being practiced by the majority of respondents.
Two-layer hand-sewn anastomosis using interrupted or continuous polyglactin sutures was the most common techniques respondents were exposed to in their trainings. This method of choice was used regardless of the segment of the gastrointestinal tract being anastomosed. The main difference between the majority's preference for the 2-layer anastomosis and the traditional 2-layer anastomosis as described in the literature was in the choice of outer layer sutures. The choice of outer seromuscular layer in the traditional method was the nonabsorbable suture such as silk[22] rather than absorbable polyglactin suture reported by most respondents. Over the years, there have been proponents or single-layer anastomosis with continuous or interrupted sutures. Many comparative studies on single versus double-layer anastomosis have failed to show any statistically significant difference in outcome of the two techniques.[22],[23] A randomized controlled trial by Burch et al.[22] reported that single-layer anastomosis required less time to perform and cost less than any other method.
Bowel disparities may be encountered in anastomosis involving different segments of the gastrointestinal tract or in the setting of intestinal obstruction due to dilation or edema of the proximal bowel. Correction of bowel circumference disparities in needed to ensure an equivalent circumference of bowel loops is anastomosed between the proximal and distal bowel. Varying techniques of handling bowel disparities have been described in the literature. These include halving techniques, anastomosis of wider bowel end to the side of the narrower end, side-to-side anastomosis and Cheatle's maneuver (split or slit).[24] Cheatle's split which involves an extension of circumferential incision to was the preferred method in most respondents. A large volume case-controlled study by Picklemann et al.,[25] found no difference in outcome between end-to-side, side-to-end, or side-to-side anastomosis in small and large bowel resections. Randomized control trials comparing surgical outcome of Cheatle's split and other methods of handling bowel disparities are potential studies for future research work.
An important finding of this survey is the low experience of respondents in the use of surgical staplers. Mechanical gastrointestinal stapling is not routinely practiced in many Nigerian Hospitals.[26] High cost of intestinal staplers and human training requirements needed to achieve proficiency in their use are probably responsible for the low experience of the respondents in stapled bowel anastomosis.
The tradition of fasting patients till 5th day postoperation was to allow resolution of postoperative ileus. The presence of bowel sounds, passage of flatus (usually at 5th postoperation day), and bowel movement were clinical indicators for resumption of oral intake. Early feeding was thought to be associated with prolonged ileus, anastomotic failure, intestinal obstruction, and aspiration pneumonia.[27],[28] About a third of respondents in this survey practice postoperative feeding of patients on 5th day after surgery. A quarter of respondents indicated feeding of patients at 3rd postoperation day. The most common indicator of readiness for oral intake among the respondents was the presence of bowel sounds. There were reports of feasibility and safety of early oral feeding (from 24 h after surgery) in many prospective studies and meta-analyses.[25],[27],[28],[29] Paucity of local studies and guidelines on early feeding and reluctance to change are possible reasons early feeding is yet to be adopted in the local practice of the respondents.
The response to self-reported leak rate was poor although the most common quoted figure of up to <10% leak rate was within the range in many studies. Less than half of the respondents were familiar with intraoperative air leak test is used to assess integrity of colorectal bowel anastomosis. There were multiple responses to factors affecting leak rates. To most respondents, systemic factors followed by poor anastomotic techniques were adjudged the most common reasons for anastomotic leaks.
A self-rating of excellent grade in bowel anastomosis in a minority of respondents in this survey could be a reflection of their year of experience in surgical training which could also be the reason why 86% of respondents desired further training in intestinal anastomosis. In accordance to the findings of this survey, we recommend that the traditional pattern of training in gastrointestinal anastomosis should be supplemented by participation of surgical trainees in the BSS course. More time and resources should be allocated to the intestinal anastomosis module of the BSS course for a more enriching experience. A dedicated anastomosis course that teaches both hand-sewn and stapled anastomosis and perioperative care would also be of great impact on the learning experience of the residents.
| Conclusion | | |
This survey shows the predominant learning and practice of intestinal anastomosis as experienced by the residents in Nigerian training institution was from the supervising consultants during emergency operation. The traditional two-layer technique was preferred over one-layer anastomosis by most respondents. Experience with intestinal staplers was low. Majority of postoperation feedings was at 5th day after surgery. Self-reported leak rates in minority of respondents were ≤10%. Only a minority of the respondents rated their anastomotic skills as excellent. Majority of the respondents desired further training in intestinal anastomosis.
Limitations
The responses from the survey are those of a sample of resident Doctors participating in the annual revision course and hence cannot be generalized to be representative of all residents in training in Nigeria. Recall bias may have affected some of the responses in this survey.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | Nesbakken A, Nygaard K, Lunde OC. Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg 2001;88:400-4.  |
| 2. | Bokey EL, Chapuis PH, Fung C, Hughes WJ, Koorey SG, Brewer D, et al. Postoperative morbidity and mortality following resection of the colon and rectum for cancer. Dis Colon Rectum 1995;38:480-6. |
| 3. | Docherty JG, McGregor JR, Akyol AM, Murray GD, Galloway DJ. Comparison of manually constructed and stapled anastomoses in colorectal surgery. West of Scotland and Highland Anastomosis Study Group. Ann Surg 1995;221:176-84. |
| 4. | Goulder F. Bowel anastomoses: The theory, the practice and the evidence base. World J Gastrointest Surg 2012;4:208-13. |
| 5. | Fain SN, Patin CS, Morgenstern L. Use of a mechanical suturing apparatus in low colorectal anastomosis. Arch Surg 1975;110:1079-82. |
| 6. | Sonoda T, Verdeja JC, Rivadeneira DE. Stapler access and visibility in the deep pelvis: A comparative human cadaver study between a computerized right angle linear cutter versus a curved cutting stapler. Ann Surg Innov Res 2011;5:7. |
| 7. | Olson TP, Becker YT, Mcdonald R, Gould J. Association for Academic Surgery. A simulation-based curriculum can be used to teach open intestinal anastomosis. J Surg Res 2012;172:53-8. |
| 8. | Jensen AR, Wright AS, McIntyre LK, Levy AE, Foy HM, Anastakis DJ, et al. Laboratory-based instruction for skin closure and bowel anastomosis for surgical residents. Arch Surg 2008;143:852-8. |
| 9. | Ezeome ER, Ekenze SO, Ugwumba F, Nwajiobi CE, Coker O. Surgical training in resource-limited countries: Moving from the body to the bench – Experiences from the basic surgical skills workshop in Enugu, Nigeria. Trop Doct 2009;39:93-7. |
| 10. | Campain NJ, Kailavasan M, Chalwe M, Gobeze AA, Teferi G, Lane R, et al. An evaluation of the role of simulation training for teaching surgical skills in sub-Saharan Africa. World J Surg 2018;42:923-9. |
| 11. | Chen C. The art of bowel anastomosis. Scand J Surg 2012;101:238-40. |
| 12. | Nandakumar G, Stein SL, Michelassi F. REviEWS anastomoses of the lower gastrointestinal tract. Nat Rev Gastroenterol Hepatol 2009;6:709-16. |
| 13. | McCord C, Ozgediz D, Beard JH and Haile T Debas. General surgical emergencies.In: Debas HT, Donkor P, Gawande A, Jamison DT,Kruk ME,Mock CN ed(s). Essential Surgery: Disease Control Priorities. 3rd ed. Washington, DC. The World Bank.201.p 61-75. |
| 14. | Gebresellassie HW, Tamerat G. Audit of surgical services in a teaching hospital in Addis Ababa, Ethiopia. BMC Res Notes 2019;12:678. |
| 15. | Onyemaechi NO, Urube SU, Ekenze SO. Pattern of surgical emergencies in a Nigerian tertiary hospital. Afr Health Sci 2019;19:1768-77. |
| 16. | van Geldere D, Fa-Si-Oen P, Noach LA, Rietra PJ, Peterse JL, Boom RP. Complications after colorectal surgery without mechanical bowel preparation. J Am Coll Surg 2002;194:40-7. |
| 17. | Guenaga KF, Matos D, Castro AA, Atallah AN, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2003:CD001544. doi: 10.1002/14651858.CD001544. Update in: Cochrane Database Syst Rev. 2005;(1):CD001544. PMID: 12804412. |
| 18. | Eskicioglu C, Forbes SS, Fenech DS, McLeod RS, Best Practice in General Surgery Committee. Preoperative bowel preparation for patients undergoing elective colorectal surgery: A clinical practice guideline endorsed by the Canadian Society of Colon and Rectal Surgeons. Can J Surg 2010;53:385-95. |
| 19. | Wille-Jørgensen P, Guenaga KF, Matos D, Castro AA. Pre-operative mechanical bowel cleansing or not? An updated meta-analysis. Colorectal Dis 2005;7:304-10. |
| 20. | Bauer VP. The evidence against prophylactic nasogastric intubation and oral restriction. Clin Colon Rectal Surg 2013;26:182-5. |
| 21. | Vinay HG, Raza M, Siddesh G. Elective bowel surgery with or without prophylactic nasogastric decompression: A prospective, randomized trial. J Surg Tech Case Rep 2015;7:37-41. |
| 22. | Burch JM, Franciose RJ, Moore EE, Biffl WL, Offner PJ. Single-layer continuous versus two-layer interrupted intestinal anastomosis: A prospective randomized trial. Ann Surg 2000;231:832-7. |
| 23. | 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;6:2. |
| 24. | |
| 25. | Pickleman J, Watson W, Cunningham J, Fisher SG, Gamelli R. The failed gastrointestinal anastomosis: An inevitable catastrophe? J Am Coll Surg 1999;188:473-82. |
| 26. | Adisa AO, Olasehinde O, Arowolo OA, Alatise OI, Agbakwuru EA. Early experience with stapled gastrointestinal anastomoses in a Nigerian hospital. Niger J Surg 2015;21:140-2. [Full text] |
| 27. | Ng WQ, Neill J. Evidence for early oral feeding of patients after elective open colorectal surgery: A literature review. J Clin Nurs 2006;15:696-709. |
| 28. | Petrelli NJ, Cheng C, Driscoll D, Rodriguez-Bigas MA. Early postoperative oral feeding after colectomy: An analysis of factors that may predict failure. Ann Surg Oncol 2001;8:796-800. |
| 29. | Fanaie SA, Ziaee SA. Safety of early oral feeding after gastrointestinal anastomosis: A randomized clinical trial. Indian J Surg 2005;67:185-8. |
[Figure 1], [Figure 2], [Figure 3]
[Table 1], [Table 2]
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