***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    Input: Stapler and manual sutures in rectal end-to-end anastomoses were compared in a controlled trial . The following results were obtained : For the analysis the cases naturally separated into three groups , A ( manual suture ) , B ( planned stapler suture ) and WD ( " withdrawn " cases , from both groups , in which continence could be maintained only with a stapler suture ) . The distribution of the WD cases in dependence on localization and sex varied significantly from groups A and B , while A and B remained comparable , in spite of the WD cases . The analysis of the date showed no , or only slight , clinical differences . In a comparison of the two stapler groups B and WD , significantly more suture dehiscences , colocutaneous fistulae and post-operative disturbances in bladder function were found in group WD . As a general conclusion we can state that : In comparable anastomosis localizations it is possible to achieve almost the same clinical results with both suture techniques . With a circular stapler it is , however , technically possible to perform rectum resections in cases in which this was not previously possible , particularly in men with a narrow pelvis and a stale pelvic floor . To what extent this still is an advantage after the local recurrences are taken into consideration remains to be seen A total of 145 consecutive patients receiving a colorectal anastomosis were r and omized to ‘ test ’ or ‘ no test ’ once the anastomosis had been completed . Anastomotic testing was performed with the pelvis filled with saline and the rectum distended by sigmoidoscopic insufflation of air . Any leaks demonstrated were oversewn . A water‐soluble contrast enema was performed on the tenth postoperative day . Seventy‐four patients were r and omized to ‘ test ’ and 71 to ‘ no test ’ but one patient was withdrawn from each group leaving a total of 143 for analysis . The two groups were well matched for age , sex , diagnosis and operative details . Eighteen ( 25 per cent ) air leaks were detected and repaired in the ‘ test ’ group . After operation there were three ( 4 per cent ) clinical leaks in the ‘ test ’ group and ten ( 14 per cent ) in the ‘ no test ’ group ( Fisher 's exact test , P = 0.043 ) . There were eight ( 11 per cent ) radiological leaks in the ‘ test ’ group and 20 ( 29 per cent ) in the ‘ no test ’ group ( P = 0.006 ) . Intraoperative air testing and repair of colorectal anastomoses significantly reduces the risk of postoperative clinical and radiological leaks In a r and omized prospect i ve clinical trial one layer and two layer techniques have been compared in 92 patients undergoing colorectal anastomosis .  The results were assessed radiologically by barium studies on the tenth postoperative day . There was no significant difference in the incidence of anastomotic breakdown with either technique when the anastomosis was performed above the pelvic peritoneal reflection . When the anastomosis was situated below the pelvic peritoneum the incidence of dehiscence was significantly greater when a two layer technique was used BACKGROUND Although used widely for supraperitoneal anastomoses , circular stapled anastomoses have never been proved better than h and -sewn anastomoses . In the one prospect i ve controlled trial that studied these anastomoses specifically , the only significant difference found was that there were more clinical ly obvious leakages with the circular stapled variety , but not in the overall clinical and roentgenologic leakage rates . METHODS One hundred fifty-nine consecutive patients ( 88 men and 71 women , mean age 65.8 + /- 12.1 years ) were r and omized to undergo  h and -sewn ( n = 74 ) or circular stapled ( n = 85 ) supraperitoneal colorectal anastomosis after left colectomy .  RESULTS Patient demographics were similar in both groups .  Overall mortality was 1.3 % ( 2 of 159 ; one in each group ) . No statistically significant difference ( NS ) was found in the rate of early complications , including anastomotic leakage ( 4 of 74 versus 6 of 85 ) in the h and -sewn and stapled anastomoses , respectively ) . Mishaps ( n = 10 ) and hemorrhage ( n = 5 ) occurred in the stapled group only . Stapled anastomoses took an average of 8 minutes less to perform ( p < 0.001 ) , but this time gain did not significantly influence the overall duration of operation ( identical median times ) . The median duration of hospitalization was 13 and 14 days , respectively ( NS ) . At 8 months there were 2 of 74 strictures in the h and -sewn group and 4 of 85 strictures in the stapled group ( NS ) . CONCLUSIONS According to these results , there seems to be no advantage of routine or regular use of stapling instruments for supraperitoneal colorectal anastomosis The merits of stapled versus h and sewn anastomosis were evaluated in a prospect i ve r and omized study of 60 patients undergoing resection for rectal cancer . The analysed factors included the time required for construction of anastomosis , post operative complications , local recurrence , disease free state and survival .  H and sewn anastomosis was performed in two layers with 3/0 silk in 30 cases and the stapled anastomosis with EEA staplers in 30 cases . The anastomosis time averaged 24 minutes in the suture group and 16 minutes in the stapling group . Five post-operative complications occurred in each group . Six patients of the h and sewn group developed local recurrence as a first sign of treatment failure compared to four patients in the stapled group . The average time of study was 41 months . No significant difference was found in the overall survival pattern of the two groups One hundred and eighteen patients undergoing low colorectal anastomoses  were r and omly allocated to reconstitution by either single layer interrupted extramucosal sutures or circular staple gun . In the 60 patients undergoing sutured anastomosis there were 2 ( 3 per cent ) clinical leaks and 4 ( 7 per cent ) radiological leaks , and no failures of the 58 patients who underwent stapled anastomosis  there were 4 failures , 7 ( 12 per cent ) clinical leaks , 14 ( 24 per cent ) radiological leaks and 1 death .  Stapled anastomoses were more than ten times as expensive as sutured anastomoses and there were no savings in time or numbers of associated colostomies . An interrupted extramucosal suture technique remains the ultimate st and ard for low colorectal anastomosis Among the numerous anastomotic techniques after colonic resection , the mechanical sutures using staplers have been credited with a lower incidence of anastomotic leakage than h and -sewn anastomoses . This hypothesis has been tested in two multicentre , prospect i ve , r and omized trials after right hemicolectomy for carcinoma and after left colectomy with colorectal anastomosis .  After right hemicolectomy , the stapled anastomosis using the GIA and TA staplers appeared to be superior to all h and -sewn anastomoses . This superiority was not apparent after left colectomy followed by colorectal anastomosis . Although the leakage rate of stapled anastomoses was similar to h and -sewn anastomoses , they carry a high rate of intra-operative mishaps . Furthermore , the stapler does not permit a lower anastomosis in this study . Finally , the overall cost of a stapled anastomosis is superior to the cost of an h and -sewn anastomosis A prospect i ve r and omized study of 1004 patients is reported , comparing surgical stapling and manual suturing techniques in the construction of gastrointestinal anastomoses . The incidence of clinical leaks was similar between the two groups ( sutured 3·2 per cent , stapled 4·7 per cent ; P = 0·22 ) , while for radiological leaks the incidence was significantly higher in the sutured group ( 12·2 per cent versus 4·1 per cent , P<0·05 ) . Stapling instruments afforded significantly quicker anastomoses , mean(s.e.m . ) 28·1(0·7 ) versus 14·3(0·5 ) min ( P<0·001 ) , and quicker operations , 115·5(2·4 ) versus 103·8(2·2 ) min ( P < 0·001 ) . The two groups were found to be comparable in other respects such as operative mortality , requirements for blood transfusion , incidence of infective complications , recovery of gastrointestinal function and postoperative hospital stay A r and omized , prospect i ve study should be done to evaluate any new procedure or instrument . Our experience with the  end-to-end anastomosis ( EEA ) stapler suggests that an anastomosis can be created in a shorter time than is required for the traditional h and -sewn technique . This difference is even greater when the anastomosis is technically difficult and located deep within the pelvis . There appears to be little difference in the security of a h and -sewn anastomosis compared with that of stapled anastomosis .  Postoperative complications appear similar . With the stapler , however , there is an increased risk of intraoperative complications that are not apparent with the traditional h and -sewn technique . These include rectal tears and anastomotic defects . It appears that the EEA stapler can save as many as 12 percent of rectums that otherwise might have to be removed because of technical inability to perform an anastomosis The merits of mechanical versus manual anastomosis were evaluated in a prospect i ve study of 48 patients undergoing resection of colonic or rectal cancer . The analyzed factors included the time required for construction of the anastomosis , the length of hospital stay , the cost/benefit ratio and complications . The anastomosis was manually performed with monolayer polyglactin 910 sutures in 24 cases and mechanically with an E.E.A. stapler in 24 . The anastomosis time averaged 14 min in the suture group and 14.3 min in the stapling group , and the respective hospitalization times were 16 and 17 days . The mean cost was 48,000 lire in the manual , and 200,000 lire in the mechanical group . Four complications occurred in each group . Apart from the cost , no intergroup difference was statistically significant 
    Output:
    
REVIEW ER 'S CONCLUSIONS The evidence found was insufficient to demonstrate any superiority of stapled over h and sewn techniques in colorectal anastomosis , regardless of the level of anastomosis