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Gastrointestinal anastomoses

• Anastomoses can be fashioned in various ways
  • End-to-end
  • End-to-side
  • Side-to-side
• Anastomoses heal in three phases

Lag phase (day 0-4)

• Acute inflammatory responses occurs
• Anastomosis has no intrinsic strength

Fibroplasia phase (day 3-14)

• Fibroblasts proliferate
• Immature collagen is laid down

Maturation phase (beyond 10 days)

• Collagen is remodelled
• Strength of anastomosis is increased

Factors influencing anastomotic healing

• Anastomotic technique is required to maintain apposition until collagen is laid down
• Anastomoses show serosal healing and require:
  • Maintenance of apposition
  • Good blood supply
  • Tension free
• Anastomotic leak or failure my occur if:
  • Distal obstruction
  • Peri-anastomotic sepsis
  • Per-anastomotic haematoma
  • Hypotension
  • Hypoxia
  • Jaundice
  • Corticosteroids
  • Uraemia
• Any anastomotic technique should:
  • Promote primary healing by accurate alignment of the divided bowel
  • Cause minimal disruption of the local vasculature
  • Incorporate minimum amount of foreign material
  • Not implant malignant cells at the anastomosis
  • Not enhance the risk of metachronous tumours
• No evidence to suggest that hand-sewn are superior to stapled anastomoses

Anastomotic techniques

• Conventional methods
  • Hand-sewn
  • Stapled
• Novel techniques
  • Compression rings
  • Tissue glues

Two layered technique

• Classic teaching of GI anastomoses
  • Inner continuous all layer catgut suture
  • Outer seromuscular interrupted silk
• Produced serosal apposition and mucosal inversion
• Inner layer believed to be haemostatic but also strangulates mucosa

Single layered technique

• Modern teaching of GI anastomoses
• Interrupted seromuscular absorbable (e.g. 3/0 Vicryl on round bodied needle)
• Incorporates strong submucosal layer
• Minimal damage to submucosal vascular plexus

Stapled anastomoses

• Side to side anastomosis with linear staplers (e.g. GIA 60)
• End to end anastomosis with circular devices (e.g. CEEA)
• Stapled anastomoses reduced radiologically detected anastomotic leaks
• Associated with increased rate of anastomotic strictures

Drainage of anastomosis

• Drainage of anastomoses is controversial
• No evidence that the use of a drain reduced leak rate for anastomoses above pelvic brim
• Drain may increase risk of anastomotic leak

Biliary and urological anastomoses

• Always use absorbable sutures

• Nonabsorbable sutures risk stone formation

Vascular anastomoses

• Always use nonabsorbable. 
• Prolene most often used
• 2/0 on aorta
• 4/0 on femoral artery

Bibliography

Bruce J,  Krukowski Z H,  Al-Khairy G,  Russell E M,  Park K G.  Systematic review of the definition and measurement of anastomotic leak after gastrointestinal surgery.  Br J Surg 2001;  88:  1157-1168

Carty N J,  Keating J,  Campbell J,  Karanjia N, Heald R J.  Prospective audit of an extramucosal technique for intestinal anastomosis.  Br J Surg 1991; 78: 1439 - 1441.

Fraser I.   Intestinal anastomosis with a skin stapler: a safe and efficient method in humans.  Br J Surg 1994; 81: 665 - 667.

Irwin S T,  Krukowski Z H,  Matheson N A.  Single-layer anastomosis in the upper gastrointestinal tract.  Br J Surg 1990;  77:  643-644.

Lustosa S A,  Matos D,  Atallah A N,  Castro A A.  Stapled versus handsewn method for colorectal anastomosis surgery.  Cochrane Database Syst Rev 2001;  CD 001825.

Sarin S,  Lightwood R G.  Continuous single-layer gastrointestinal anastomosis:  a prospective audit.  Br J Surg 1988;  155:  611-614.

Steele R J C.  Continuous single-layer serosubmucosal anastomosis in the upper gastrointestinal tract.  Br J Surg 1993;  80:  1416-1417.

Thompson W H F,  Robinson M H E.  One-layer continuously sutured colonic anastomosis.  Br J Surg 1993;  80:  1450-1451.

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