Bowel resection with anastomosis is a cornerstone procedure in general surgery, performed for a wide spectrum of pathologies including intestinal tumors, obstructions, traumatic injuries, and perforations [1]. The success of this procedure hinges on creating a secure, well-vascularized, tension-free anastomosis to restore intestinal continuity. The two principal techniques for achieving this are the conventional hand-sewn (HS) method and the mechanical stapled (ST) anastomosis [2]. The HS technique, using either absorbable or non-absorbable sutures, is the time-honored standard, offering complete control to the surgeon but being relatively time-consuming and dependent on surgical skill [3]. In contrast, linear and circular stapling devices promise a quicker, standardized, and technically simpler anastomosis, especially in anatomically confined spaces like the deep pelvis [4]. The purported benefits of stapling include reduced operative time, less tissue handling, and potentially lower leakage rates, though these advantages are balanced against significantly higher costs and the need for specific training [5]. The choice between techniques often rests on surgeon preference, institutional protocol, and patient-specific factors. While numerous studies have compared these methods, findings regarding postoperative recovery and complication rates remain heterogeneous [6-8]. Some meta-analyses suggest equivalence, while others indicate advantages for staplers in specific contexts. This study aimed to provide a contemporary, prospective, randomized comparison of HS and ST bowel anastomosis in a tertiary care center in Central India, focusing on pragmatic outcomes like operative efficiency, recovery milestones, hospital stay, and complication profiles, to inform evidence-based surgical decision-making.

Study Design and Setting This prospective, randomized, comparative study was conducted in the Department of General Surgery at the ESIC Model Hospital and Occupational Disease Centre, Indore, India, over one year from April 2023 to March 2024. The study protocol was approved by the Institutional Ethics Committee and Scientific Review Committee. Participants Patients aged 18-65 years undergoing elective or emergency gastrointestinal surgeries requiring bowel anastomosis for benign or malignant conditions were eligible. Exclusion criteria included age <18 or >65 years, pregnancy, coagulopathy or anticoagulant therapy, history of radiotherapy/chemotherapy, and surgeries specifically involving the colorectum, stomach, or pancreas. Patients unwilling to provide informed consent were also excluded. Sample Size and Randomization The sample size calculation was based on a pilot study, targeting a detection of a significant difference in operative time. Using convenience sampling, 50 patients were enrolled and randomly allocated into two equal groups (n=25 each) via computer-generated random numbers: Group A (HS Anastomosis) and Group B (ST Anastomosis). Surgical Technique All patients received standard preoperative antibiotics and underwent exploratory laparotomy. The diseased bowel segment was resected. In Group A, a two-layer, inverting, hand-sewn anastomosis was performed using sutures per the operating surgeon’s preference. In Group B, anastomosis was performed using appropriate linear stapling devices (e.g., GIA stapler) as per the surgical requirement. All procedures were performed by qualified surgeons experienced in both techniques. Data Collection and Outcome Measures Data were collected using a pre-tested proforma. Primary outcomes included operative duration (skin-to-skin) and postoperative recovery parameters: time to return of bowel sounds, first passage of flatus and stool, day of mobilization, removal of Ryle’s tube, and initiation of oral feeding. Secondary outcomes included postoperative hospital stay, time to return to regular activities/work, and complications such as anastomotic leak (clinical or radiological), surgical site infection (SSI), wound dehiscence, burst abdomen, enterocutaneous fistula, and mortality. Statistical Analysis Data were analyzed using IBM SPSS Statistics Version 22. Continuous variables were presented as mean ± standard deviation and compared using the unpaired t-test. Categorical variables were expressed as numbers and percentages and analyzed using the Chi-square test or Z-test for proportions. A p-value of <0.05 was considered statistically significant.

Baseline Demographics Fifty patients were equally distributed between the HS and ST groups. The groups were well-matched in terms of age (HS: 44.24 ± 11.84 years vs. ST: 43.04 ± 15.32 years, p=0.758) and sex distribution (Male: 68% in both groups, p=1.000), indicating successful randomization. Table 1: Baseline Demographic Characteristics of the Study Groups Characteristic Hand-Sewn Group (n=25) Stapled Group (n=25) p-value Mean Age (Years) 44.24 ± 11.84 43.04 ± 15.32 0.758 Sex, n (%) 1.000 - Male 17 (68%) 17 (68%) - Female 8 (32%) 8 (32%) Operative and Recovery Outcomes The mean operative duration was significantly shorter in the ST group (2.30 ± 0.50 hours) compared to the HS group (2.86 ± 0.39 hours) (p=0.001). Table 2: Comparison of Operative Duration and Key Recovery Milestones Outcome Measure (Mean ± SD) Hand-Sewn Group Stapled Group p-value Operative Duration (hours) 2.86 ± 0.39 2.30 ± 0.50 0.001 Return of Bowel Sounds (POD) 4.76 ± 1.33 4.24 ± 1.69 0.233 Passage of Flatus (POD) 4.76 ± 1.33 4.24 ± 1.69 0.233 Passage of Stool (POD) 9.24 ± 1.45 8.84 ± 1.77 0.387 Mobilization Started (POD) 3.96 ± 0.98 3.00 ± 0.76 0.001 Oral Feeding Started (POD) 8.28 ± 1.34 6.96 ± 1.37 0.001 Hospital Stay (Days) 16.92 ± 11.16 11.84 ± 4.35 0.039 Return to Work (Days) 56.88 ± 21.66 44.44 ± 17.35 0.031 POD: Postoperative Day; SD: Standard Deviation Postoperative recovery of intrinsic bowel function (return of sounds, flatus, stool) was similar between groups. However, milestones influenced by patient activity and clinical protocol favored the ST group: they mobilized earlier (POD 3.0 vs. 3.96, p=0.001), started oral feeds sooner (POD 6.96 vs. 8.28, p=0.001), had a shorter hospital stay (11.84 vs. 16.92 days, p=0.039), and returned to regular activities faster (44.44 vs. 56.88 days, p=0.031). Postoperative Complications and Mortality There was no statistically significant difference in the overall spectrum of anastomotic and wound-related complications between the two groups. Table 3: Comparison of Postoperative Complications Complication Hand-Sewn Group (n=25) Stapled Group (n=25) p-value None 18 (72%) 17 (68%) 0.756 Burst Abdomen 2 (8%) 1 (4%) 0.548 Enterocutaneous Fistula 1 (4%) 0 (0%) 0.312 Surgical Site Infection 1 (4%) 5 (20%) 0.081 Wound Dehiscence 3 (12%) 2 (8%) 0.638 One mortality (4%) occurred in the HS group due to septic complications from an enterocutaneous fistula, whereas there was no mortality in the ST group; this difference was not statistically significant (p=0.312).

This prospective randomized study demonstrates that stapled bowel anastomosis offers significant advantages in operative efficiency and several key postoperative recovery parameters over the conventional hand-sewn technique, while maintaining a comparable safety profile. The most consistent finding across literature and confirmed in our study is the significant reduction in operative time with staplers [9, 10]. The mean difference of approximately 34 minutes in our series is clinically relevant, as it translates to reduced anesthesia exposure, less fluid shift, and potentially lower infective risk from prolonged cavity exposure. This efficiency is particularly valuable in emergency settings or for patients with poor physiological reserve. While the return of intrinsic bowel motility (sounds, flatus) was similar, the stapler group achieved significant early advantages in mobilization and oral feeding. This discrepancy suggests that factors beyond anastomotic technique, such as reduced overall tissue trauma, shorter anesthesia, and possibly greater surgeon confidence in the staple line's integrity, may lead to more aggressive early rehabilitation and feeding protocols [11]. This directly contributed to the significantly shorter hospital stay (5 days shorter on average) and faster return to regular activities (12.5 days earlier) in the ST group—outcomes of paramount importance to patients and healthcare systems. Our complication rates were comparable between groups, aligning with studies by Avtar et al. [3] and Sarkar et al. [12] which found no significant difference in anastomotic leak or major morbidity. The single mortality in the HS group was related to a fistula, but the small sample size precludes definitive conclusions about mortality. Interestingly, Surgical Site Infection (SSI) was numerically higher in the ST group (20% vs. 4%), though not statistically significant (p=0.081). This trend, noted in some studies [13], warrants investigation—whether it relates to foreign body (staple) reaction, different tissue handling, or is merely a chance finding in a small sample. The primary limitation of our study is its modest sample size from a single center, which may affect the generalizability of findings and the power to detect differences in rare complications like clinical anastomotic leak. The lack of long-term follow-up excludes assessment of chronic issues like anastomotic stricture. Furthermore, cost-analysis, a critical factor in resource-limited settings, was not performed. The higher cost of stapler cartridges remains a significant disadvantage, as highlighted by Parmar et al. [14], and must be weighed against the benefits of shorter hospital stay.

This study concludes that stapled intestinal anastomosis is superior to the hand-sewn technique in reducing operative time and accelerating postoperative recovery, as evidenced by earlier mobilization, oral feeding, hospital discharge, and return to normal activities. Both techniques are safe, with comparable rates of major anastomotic complications. Therefore, stapled anastomosis is a highly effective and efficient alternative, especially where reducing surgical time and enhancing recovery are priorities. The choice of technique should be individualized, considering the surgical site, patient factors, surgeon expertise, and institutional cost constraints. Larger, multicenter studies with long-term follow-up and formal cost-benefit analyses are recommended.

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