The arT of bowel anasTomosis

Document Sample
The arT of bowel anasTomosis Powered By Docstoc
					Scandinavian Journal of Surgery 101: 238–240, 2012

The arT of bowel anasTomosis

C. Chen1
1   Department of Surgery, Yale University School of Medicine, New Haven, CT, U.S.A.


anastomotic techniques have greatly improved over the past two centuries, and postop-
erative complications have fallen accordingly. factors contributing to anastomotic failure
include location and systemic diseases such as sepsis and hemorrhagic shock. factors
that have not demonstrated any difference in outcome include stapled versus hand sewn
anastomosis, continuous versus interrupted sutures, and single versus two layer anasto-
mosis. successful intestinal anastomosis necessitate adequate exposure and access, gen-
tle tissue handling, absence of tension and distal obstruction, hemodynamic stability
with adequte tissue oxygenation, and meticulous surgical technique.
Key words: Bowel anastomosis; history; surgical technique; anastomotic leak; suturing; colorectal surgery

INTroDUCTIoN                                             Although the Murphy Button described in 1892 was
                                                         the first popular stapling prototype (3), further prog-
An intestinal anastomosis becomes necessary when a       ress was not remarkable until the early 1960’s when
segment on the gastrointestinal tract is resected for    the Institute for Experimental Apparatus and Instru-
benign or malignant indications and gastrointestinal     ments in Moscow developed a group of instruments
continuity needs to be restored. The art of bowel        capable of performing gastrointestinal tract anasto-
anastomosis dates back into the 19th century. Nicho-     mosis (4). However, these instruments were cumber-
las Senn’s review (1844–1908, Chicago) performed in      some and required individual staples be inserted by
1893 detected approximately 60 different techniques      hand prior to each use. Several further engineering
for intestinal suture, which he attributed to the “an-   feats, including ravitch’s introduction of a modified
cient and modern methods,” followed by an addi-          form of the russian stapling device and advent of
tional 33 “recent methods” of suturing bowel (1).        biofragmentable anastomosis rings in 1985 led to the
Within the past 200 years, gastrointestinal anastomo-    resurgence of sutureless anastomosis around the
sis has been transformed from a life-threatening ven-    world (4–5). Even today, intestinal anastomosis can
ture into a safe and routinely performed procedure.      be performed in a variety of ways; the specific tech-
Among these advances was the transition to scientif-     nique is usually a function of surgeon preference.
ically-based medicine, chiefly the knowledge of the
importance of serosa apposition introduced by An-
toine Lembert (1802–1851) in 1826 (2) and the concept    FACTorS IN ANASToMoTIC HEALINg
of asepsis proposed by Lord Joseph Lister (1827–1912)
in 1867 (3). Additional modern advancement in bowel      In 1882, Halsted was already drawing attention to the
anastomosis included the advent of stapling device.      idea that the collagen content in the submucosal layer
                                                         was the main factor responsible for the resistance of
                                                         anastomosis (6). The process of intestinal anastomotic
                                                         healing is similar to wound healing elsewhere in the
  Charlie Chen, M.D.
                                                         body and can be divided into (A) acute inflammatory
  Department of Surgery                                  (lag) phase, (B) proliferative phase, and (C) remodel-
  Yale University School of Medicine                     ing or maturation phase. A critical stage in collagen
  20 York Street                                         formation is the hydroxylation of proline during mat-
  New Haven, CT 06510, U.S.A.                            uration phase to hydroxyproline, which gives the
  Email:                           molecule its structural strength. The bursting pres-
                                             The art of bowel anastomosis                                        239

sure of an anastomosis is often used to gauge the            thesis, and eventual anastomotic disruption. Severe
strength of the healing process. This pressure has           malnutrition has also been shown to decrease tissue
been found to increase rapidly in the early postop-          collagen and thus decrease bursting pressure. resec-
erative period, reaching 60% of the strength of the          tions for Crohn’s disease appear to carry a significant
surrounding bowel by three to four days and 100%             risk of anastomotic dehiscence from 2–12% (12).
by one week (7). For the purpose of a bowel anasto-          Smoking was found to be associated with an in-
mosis, it is important to keep in mind that the serosa       creased risk of anastomotic leakage, as was heavy
(i.e. the visceral peritoneum) holds suture better than      alcohol consumption (13). Inverting the cut edges of
the musclar layers of bowel. The absence of a perito-        bowel in colorectal surgery is also of importance. In
neal layer makes anastomosis of the thoracic esopha-         one study, the rate of fecal fistula formation was far
gus and the rectum below the peritoneal reflection            higher in the group that had everted suture anasto-
technically more difficult than anastomosis of the in-        mosis (43%) than in the group with inverted suture
traperitoneal segments of the intestine. In addition,        anastomosis (8%) (14). In animal studies, everted
the stomach and the small bowel are more vascular-           anastomosis have increased leaks and adhesion for-
ized than the esophagus and the large bowel and              mation (15). recent studies have also suggested that
consequently tend to heal more rapidly.                      hypothermia can result in vasoconstriction, tissue hy-
                                                             poxia, and reduced bacterial killing – all of which can
                                                             lead to increased infection and leakage rates (16).
FACTorS IN ANASToMoTIC FAILUrE                                  For elective anastomosis of the colon and rectum,
                                                             it is traditional to cleanse the large bowel prior to
Failure of an anastomosis with leakage of intestinal         surgery. The rationale being that decreasing the bac-
contents is one of the most significant surgical com-         terial load in the large bowel facilitates anastomotic
plications. reported failure rates range from 1 to 24%,      healing and minimizes the consequences of anasto-
depending on what type of anastomosis was per-               motic leakage. recent studies have questioned this
formed and whether the operation was an elective or          approach, and there is increasing evidence that a
an emergency procedure (8). An anastomotic leak in-          bowel preparation may not be essential and that it
creases the morbidity and mortality associated with          may actually be harmful. A Finnish randomized pro-
the operation: it can double the length of the hospital      spective study published in 2000 was first to indicate
stay and increase the mortality by threefold (9). Signs      that patients with bowel preparation had no benefit
and symptoms suggestive of an anastomotic leak in-           in leak, infection, or restoration of bowel function
clude postoperative (usually between days four to            rates (17). Subsequent studies have showed that rates
seven) abdominal pain or peritonitis, fever, leukocy-        of both anastomotic leakage and wound infection
tosis, and tachycardia, all of which can point to de-        were actually significantly higher in the patients re-
velopement of systemic inflammatory response syn-             ceiving bowel preparation compared to those that did
drome (SIrS) or sepsis. In the elderly, chest pain and       not (18). This may be related to the change in native
new-onset arrhythmias may be the first sign of leak.          intestinal flora after bowel preparation.
An abdominal X-ray showing free air or a CT scan
with pneumoperitoneum and significant free fluid or
inflammatory changes around the anastomosis are               ANASToMoTIC TECHNIqUES
suggestive of an anastomotic failure. A localized
anastomotic leak that is not associated with peritoni-       The two most commonly used anastomotic tech-
tis or significant systemic sepsis can be managed with        niques are: (A) handsewn sutured anastomosis and
percutaneous or open drainage of the abscess, how-           (B) stapled anastomosis. Prospective, randomized tri-
ever anastomotic leaks associated with peritonitis or        als have not demonstrated any differences between
systemic manifestation of sepsis require a laparotomy        stapled and hand-sewn anastomosis in terms of in
and either revision of the anastomosis if feasible or        leakage rates, length of hospital stay, or overall mor-
fecal diversion proximally or at the site of the anas-       bidity (19). However, controversy remains regarding
tomosis.                                                     which of the two methods of creating an anastomosis
   Factors contributing to anastomotic failure include       yields better clinical outcomes. Intestinal segments
location and systemic factors. As a rule, for any given      can be sewn together with various suture materials.
technique the location of the anastomosis does not           The ideal suture material is one that causes minimal
significantly influence the overall leakage rate. There        inflammation and tissue reaction, while providing
are two exceptions to this general rule. First, low an-      maximum strength during the lag phase of wound
terior rectal anastomosis are associated with higher         healing. Popular choices include polyglactin, poly-
leakage rates ranging from 12–19% (10). Second,              dioxanone, and silk. There is little difference between
esophageal anastomosis are associated with leakage           absorbable and nonabsorbable sutures with respect
rates of about 3% when stapled technique is used             to the strength of the anastomosis. Either continuous
(11). Systemic factors including sepsis, anemia, dia-        and interrupted sutures can be used in performing an
betes mellitus, previous irradiation or chemotherapy,        intestinal anastomosis. No randomized trials have
malnutrition, vitamin deficiencies, steroid use, and          addressed the question of whether interrupted su-
certain disease conditions like Crohn’s disease are          tures have a significant advantage over continuous
associated with poor anastomotic healing and in-             sutures; however, retrospective reviews have not
creased anastomotic leak rates. Septic shock can lead        demonstrated any advantage of one method over the
to impaired tissue perfusion, decreased collagen sys-        other (20). Double layered anastomosis typically con-
240                                                                C. Chen

sist of an inner layer of continuous or interrupted                     06. Halsted WS: Circular structure of the intestine: an experimen-
absorbable sutures and an outer layer of interrupted                        tal study. Am J Med Sci 1887;94:436–461
                                                                        07. Hesp F, Hendriks T, Lubbers EJ: Wound healing in the intesti-
absorbable or nonabsorbable sutures. Single layered                         nal wall: a comparison between experimental ileal and co-
anastomosis consist of one layer of interrupted or                          lonic anastomoses. Dis Colon rectum 1984;24:99
continuous absorbable sutures. A 2006 meta-analysis                     08. Matthiessen P, Hallbook o, rutegard J, et al: Defunctioning
analyzing 670 patients concluded that there was no                          stoma reduces symptomatic anastomotic leakage after low
                                                                            anterior resection of the rectum for cancer: a randomized mul-
evidence that two-layer anastomosis yielded a lower                         ticenter trial. Ann Surg 2007;246:207–214
rate of postoperative leakage than single-layer anas-                   09. Fielding LP, Stewart-Brown S, Blesovsky L, et al: Anastomotic
tomosis (21).                                                               integrity after operations for large-bowel cancer: a multicentre
                                                                            study. BMJ 1980;281:411–414
                                                                        10. Karanjia ND, Corder AP, Bearn P, et al: Leakage from stapled
                                                                            low anastomosis after total mesorectal excision for carcinoma
CoNCLUSIoN                                                                  of the rectum. Br J Surg 1994;81:1224–1226
                                                                        11. orringer MB, Marshall B, Iannettoni MD: Eliminating the cer-
Anastomotic techniques have greatly improved over                           vical esophagogastric anastomotic leak with a side-to-side
                                                                            stapled anastomosis. J Thorac Cardiovasc Surg 2000; 119:277–
the past two centuries, and postoperative complica-                         288
tions have fallen accordingly. The principles of suc-                   12. Post S, Betzler M, Ditfurth B, et al: risks of intestinal anasto-
cessful intestinal anastomosis are: well nourished                          moses in Crohn’s disease. Ann Surg 1991;213:37–42
patient with no systemic illness, no fecal or purulent                  13. Sorensen LT, Jorgensen T, Kirkeby LT, et al: Smoking and alco-
contamination, adequate exposure and access, gentle                         hol abuse are major risk factors for anastomotic leakage in
                                                                            colorectal surgery. Br J Surg 1999;86:927–931
tissue handling, well vascularized tissues, absence of                  14. goligher J, McAdam W: A controlled trial of inverting versus
tension and distal obstruction, approximation of well                       everting intestinal suture in clinical large bowel surgery. Br J
vascularized cut ends of the bowel, and meticulous                          Surg 1970;57:817
surgical technique. After any anastomosis a close vi-                   15. Abramowitz HB, Butcher Hr: Everting and inverting anasto-
                                                                            moses: An experimental study of comparetive safety. Am Jr
sual inspection of the entire circumference of the                          Surg 1971;121:52–56
anastomosis should be performed. one of the most                        16. Witte MB, Barbul A: repair of full-thickness bowel injury. Crit
important determinants of outcome after intestinal                          Care Med 2003;31:S538–46
anastomosis is careful attention to detail.                             17. Miettinen, PJ, Laitinen ST, Makela JT, et al: Bowel preparation
                                                                            with oral polyethylene glycol electrolyte solution vs. no prep-
                                                                            aration in elective open colorectal surgery: Prospective, ran-
                                                                            domized study. Dis Col rectum 2000;43:669–675
rEFErENCES                                                              18. Bucher P, gervaz P, Morel P: Should preoperative mechanical
                                                                            bowel preparation be abandoned? Ann Surg 2007;245:662
01. Senn N: Enterorrhaphy; its history, technique and present sta-      19. Docherty Jg, Mcgregor Jr, Akyol AM, et al: Comparison of
    tus. JAMA 1893;21:215–235                                               manually constructed and stapled anastomoses in colorectal
02. Lembert A: Memoire sur l’enterorraphie avec description d’un            surgery. West of Scotland and Highland Anastomosis Study
    precede nouveau pour pratiquer cette operation chirurgicale.            group. Ann Surg. 1995;221:176–184
    rep gen D’Anat Physiol Pathol Clin Chir 1826;2:100–107              20. Koruda MJ, rolandelli rH: Experimental studies on the heal-
03. Lister J: on the antiseptic principle in the practice of surgery.       ing of colonic anastomoses. J Surg res 1990;48:504–515
    BMJ 1867;2:246–248                                                  21. Shikata S, Yamagishi H, Taji Y, et al: Single versus two- layer
04. Forde KA, McLarty AJ, Tsai J, et al: Murphy’s button revisited:         intestinal anastomosis: a meta-analysis of randomized con-
    Clinical experience with the biofragmentable anastomotic ring.          trolled trials. BMC Surg 2006;6:2
    Ann Surg 1993;217:78–81
05. ravitch MM, Brown IW, Daviglus gF: Experimental and clin-
    ical use of the Soviet Bronchus Stapling Instruments. Surgery       received: July 18, 2012
    1959;46:1,97                                                        Accepted: August 13, 2012

Shared By: