With the implementation of the DRG payment method, the medical insurance payer no longer pays according to the patient’s actual hospital expenditure, but he now pays according to the related groups, such as type, severity, treatment, and other conditions, of the patient’s disease(17, 18). Under the premise of ensuring patient quality treatment and to save medical costs and reduce economic burden, hospitals need to actively reduce and control treatment costs. In this study, the wedge resection and hand suture groups only needed to apply surgical sutures to complete intestinal anastomosis with low cost, while the stapler group required an expensive stapler and a total of 2 pieces of 80 mm anastomosis nails, making the anastomotic cost higher. Moreover, the wedge resection group needed to suture only part of the intestine transversely without involving the mesangial intestinal wall and blood vessels, among others, while the hand suture anastomosis group required a full-peripheral intestinal anastomosis, needing more sutures in a wider range. Therefore, compared with stapled anastomosis and hand suture anastomosis, wedge resection plus transverse suture was more economical and cost-effective.
Adequate blood supply is the most important factor for establishing intestinal anastomosis(19). As such, the wedge resection plus transverse suture method does not require mesenteric vessel ligation and disconnection or stoma intestinal tube cutting and disconnection, which maximizes the anastomotic blood supply in the most physiological manner while avoiding leaks caused by intestinal ischemia. However, the stapler anastomosis or hand suture end-to-end anastomosis requires cutting the intestinal tube and part of the stoma mesentery, resulting in a certain distance between the closed end of the anastomotic stoma or the common opening and the mesangial margin. Theoretically, this distance should not be greater than 1 cm; otherwise, it would be extremely easy to cause ischemia of the anastomotic stoma or a closed orifice with consequent anastomotic leakage(20). For hand-sewn end-to-end anastomosis, the diameter of the intestine segment at the distal end of the stoma can be significantly reduced owing to its prolonged exclusion; however, the diameter of the two ends is inconsistent, which can also increase the risk of anastomotic leakage or stenosis.
Studies including that of Löffler et al. have observed that stapler anastomosis takes less time than hand suture anastomosis, which makes performing the procedure more conveniently(9, 10). Although the intestinal tube needs to be disconnected in stapler anastomosis, the disconnection of the ostomy intestinal tube and the closure of the common opening are conveniently and quickly completed at one time, which can shorten the time of intestinal tube anastomosis. Meanwhile, the wedge resection used in this study did not require mesenteric blood vessel ligation and intestinal tube disconnection, but it required only trimming of the stoma edge with hand suture transverse suturing later. Although there were few intestinal tubes that needed to be sutured and there was no difference in the operation time when compared to the stapler group, the hand suture anastomosis group required many surgical steps. Compared with the wedge resection group or the stapler group, the operation time required was the longest, which is consistent with the data of this study. This showed that the wedge resection plus transverse suture method and stapler anastomosis are better than hand suture anastomosis in terms of operation time. Although there was no statistically significant difference in terms of intraoperative blood loss among the three patient groups in this study, both stapled and hand suture anastomosis required mesentery ligation, which objectively increases the bleeding risk. By contrast, the bleeding risk of wedge resection is lower, and the safety is higher.
The gastrointestinal motility of the three patient groups recovered to normal after the operation, and the patients experienced release of gas through the anus within 2–3 days; however, the patients who underwent wedge resection plus transverse suture had an earlier postoperative exhaustion time. This may be because the intestine was not disconnected by this method. Moreover, the closure operation was completed in the most suitable way for intestinal physiology, reducing nerve plexus damage in the intestinal wall. After the operation, the intestinal wall of the stoma could still be quickly adjusted using the nerves to promote the peristalsis of the smooth muscle of the small intestine(21). Through correlation analysis, it was found that the postoperative length of hospital stay was mainly related to the operation time, postoperative exhaustion time, and postoperative complications. The longer the duration of operation or the later the postoperative exhaustion, the longer the postoperative length of hospital stay. Furthermore, in the case of serious postoperative complications such as intestinal paralysis, anastomotic leakage, anastomotic bleeding, or anastomotic obstruction, the patient’s postoperative recovery is delayed and a longer length of hospital stay is required, possibly with a required second operation(22). In this study, the patients were able to recover well and were discharged after an average of five days following closure surgery. None of the previously mentioned complications occurred.
The total incidence of postoperative complications (including postoperative abdominal pain, abdominal distension, postoperative fever, and wound infection) in this study was 12.31%. There was no statistically significant difference between the groups, but there was heterogeneity in each study site(23–25). Although there were no significant differences in the incidence among the three groups, the postoperative complication rate of the stapler group or the hand suture anastomosis group was higher than that of the wedge resection group (11.43% and 22.22% vs. 0%, respectively). Another point worth discussing is the rate of secondary operations or rehospitalization, which was mainly a surgical measure taken due to serious postoperative complications, especially the occurrence of anastomotic bleeding or anastomotic obstruction, which cannot be treated with conservative measures. All patients with postoperative complications become better after active treatment.
In previous years, wedge resection was rarely used in the closure of ileostomy, which may have been due to issue about surgical factors causing anastomotic stenosis. We believe that after trimming the edges of the stoma and removing the adhesive skin and tissues, the possibility of postoperative anastomotic stenosis becomes very low when using the transverse suture method following the traditional surgical principle of “longitudinal resection and transverse suture.” Additionally, the anastomotic ring can intraoperatively accommodate a transverse finger for all patients after the intestinal repair is performed, given that no case of postoperative anastomotic stenosis has been attributed to this. In the past, considering the serious adhesion between the stoma and the abdominal wall, it was difficult to separate the normal intestinal tube without damage, and the wedge resection plus transverse suture method was not used. Despite this, for a skilled attending physician or a more senior doctor, it was not a problem to avoid intestinal injury through delicate surgical operations. Therefore, wedge resection plus transverse suture, as a surgical method for ileostomy reversal, is safe and easy to perform, has sufficient advantages for anastomotic blood supply, and it is a surgical method worth exploring.
Despite these findings, the study has certain limitations because the sample size was small and the evidence strength was not high, which may even have promoted selection bias. In the future, there is a need for randomized controlled trials with expanded sample sizes and long-term follow-ups to verify the feasibility and advantages of this surgical method.