Intestinal Anastomosis

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Intestinal anastomosis is a surgical procedure performed to establish communication between two formerly distant portions of the intestine. This procedure restores intestinal continuity after removal of a pathologic condition affecting the bowel.

Indications

Indications for intestinal anastomosis can be broadly divided into two categories: restoration of bowel continuity following resection of diseased bowel and bypass of unresectable diseased bowel. Certain pediatric conditions may also require intestinal anastomosis.

Resection of diseased bowel is performed in the following settings:

Bypass of unresectable diseased bowel is performed in following settings:

Pediatric conditions for which intestinal anastomosis may be required include the following:

Contraindications

Contraindications to intestinal anastomosis include conditions in which there is high risk of anastomotic leak, such as the following:

Perioperative management includes the following:

Adequate exposure and access, gentle handling of the bowel, adequate hemostasis, approximation of well-vascularized bowel, absence of tension at anastomosis, good surgical technique, and avoidance of fecal contamination are tenets of good intestinal anastomosis.

The image below depicts a completed small-bowel anastomosis.

Surgical techniques used in intestinal anastomosis include the following:

Important complications following intestinal anastomosis include the following:

Intestinal anastomosis is a surgical procedure performed to establish communication between two formerly distant portions of the intestine. This procedure restores intestinal continuity after removal of a pathologic condition affecting the bowel. Intestinal anastomosis is one of the most commonly performed surgical procedures, especially in the emergency setting, and is also commonly performed in the elective setting when resections are carried out for benign or malignant lesions of the gastrointestinal (GI) tract.

A disastrous complication of intestinal anastomosis is anastomotic leakage resulting in peritonitis, which is associated with high morbidity and mortality. Proper surgical technique and adherence to fundamental principles are imperative to ensure successful outcome after intestinal anastomosis.

Intestinal anastomosis can be performed by means of a handsewn technique that uses absorbable or nonabsorbable sutures or by means of stapling. The former is the more commonly used option because of the availability and affordability of suture materials and the wide familiarity with the procedure. The increased availability of stapling devices for intestinal anastomosis has provided an alternative option for performing a rapid anastomosis. Higher cost, limited availability, and less familiarity are the main drawbacks of these devices.

Less common techniques for intestinal anastomosis use compression devices (biofragmentable anastomotic rings), glue (tissue or synthetic), and laser welding. ^{[1, 2, 3, 4]}

Newer techniques include robotic-assisted methods and magnetic compression anastomosis. In an initial case series from the first trial of the Magnamosis magnetic compression anastomosis device in humans, the device was successfully placed and effectively formed a side-to-side anastomosis (which essentially is a functional end-to-end small-bowel anastomosis). ^[5] No leaks were found in the intermediate follow-up period.

Intestinal anastomosis in neonatal and pediatric patients may be required for the management of many conditions. Some conditions may necessitate resection of pathology followed by primary anastomosis, whereas other conditions may necessitate delayed anastomosis. Intestinal anastomosis may also be necessary in the management of some nonintestinal anomalies.

Resection of diseased bowel is performed in the following settings:

Bypass of unresectable diseased bowel is performed in the following settings:

Pediatric conditions for which intestinal anastomosis may be required include the following:

Intestinal anastomosis is contraindicated in conditions where there is a high risk of anastomotic leakage, such as the following:

The following are essential for good intestinal anastomosis:

Although an inverting anastomosis has been found to be better than an everting anastomosis, there is no difference in complication rates between single-layer and double-layer techniques or between continuous and interrupted anastomosis.

Stapled anastomotic technique has virtually replaced handsewn technique for low colorectal anastomoses, and its use in other areas has also increased. Although stapled anastomosis has not yet been proved superior to handsewn anastomosis, it has definitely reduced the operating time and made the procedure easier, especially in low colorectal anastomosis. However, a 2017 study by Kosuge et al reported that in colonic surgical procedures, a triangulating stapled anastomosis appears to be superior to other stapling methods or handsewn anastomoses with regard to leakage. ^[6]

Although restoration of bowel continuity is generally preferred, a decision must be made judiciously in emergency settings. A staged procedure may be preferred for restoration of bowel continuity if the general condition of the patient is not good enough to avoid the complications associated with anastomotic leakage.

An important component of preventing complications related to intestinal anastomosis is complete preoperative optimization of patients’ medical status, including correction of malnutrition with nutritional support and treatment of associated systemic illness. However, this is generally possible only in elective resections, not in emergency situations.

The best practices listed above can also help prevent complications.

It is very important to prevent hypothermia and hypovolemia during surgery, especially in children. Thermal mattresses should be used for thermoregulation, especially for neonates. Fluid loss should be minimized, and any fluid lost should be adequately replaced. An adequate supply of blood should be arranged.

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Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, MS, PhD, FACS, FACG, FRCS, FRCS(Edin), FRCS(Glasg), FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh, Royal College of Surgeons of England

Disclosure: Nothing to disclose.

Raja Kalayarasan, MBBS, MS Associate Professor, Department of Surgical Gastroenterology, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Disclosure: Nothing to disclose.

Anup Mohta, MBBS, MCh, MS, MAMS, FIMSA, FIAPS, FISPU Director and Head, Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya and Maulana Azad Medical College, Delhi, India

Anup Mohta, MBBS, MCh, MS, MAMS, FIMSA, FIAPS, FISPU is a member of the following medical societies: Association of Surgeons of India, Indian Academy of Pediatrics, Indian Association of Pediatric Surgeons, Indian Medical Association

Disclosure: Nothing to disclose.

A R Pranavi, MBBS Resident Physician, Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Disclosure: Nothing to disclose.

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgments

The authors thank their residents at the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry for help in putting together the images for this article.

The authors also thank Ms. Anahita Kate, VII Semester Medical Student, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, for her valuable assistance in the preparation of this manuscript.

Intestinal Anastomosis

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