Bowel Anastomoses For MIS Procedures

Richard L. Whelan, MD

St. Luke’s Roosevelt Hospital

New York, N.Y.

2012 MISS Meeting, Salt Lake City

Whelan Disclosures• Ethicon Endosurgery • Olympus Corporation • Atrium Corporation• Convatec• Hooters Restaurants• Coca Cola Corporation • Frito Lay• Hospital Vending Machine Corporate Council

(who support lengthy operations)

What does “MIS” Mean?

• Laparoscopic (no extraction incision) ?

• Laparoscopic-assisted (extraction incision) ?

• Hand-assisted ?• Hybrid (part laparoscopic, part open) ?

• SILS ?

• Robotic ?

• NOTES ?

Number of Splinter MIS Methods is Growing

• Each new method has a group of devoted proponents who have mastered the method

• In their hands it works well• Each splinter method handles certain

aspects of colorectal resection differently• It is now harder to give a general talk on

some topics because what is said will not apply to all MIS methods

This Talks Comments Apply to the Following Methods:

• Laparoscopic (no extraction incision)

• Laparoscopic-assisted (extraction incision)

• Hand-assisted

What Are You Comfortable Doing?• In the end, the surgeon must be comfortable

with the method selected• If you want to learn a new method then:

– Read about it, watch videos, talk/visit with surgeons who use the method

– Consider doing the first few cases with someone in your area who has experience

• What you hear at this conference must be considered in the context of your skill set and your MIS experience

Types of Bowel Anastomoses

• Stomach to small bowel

• Small bowel to small bowel

• Small bowel to colon

• Colon to colon

• Colon to rectum

• Colon to anus

Types of Anastomoses

• End to End

• Side to Side– Isoperistaltic vs Anti-peristaltic

• End to Side

• Pouch formation + anastomosis– Ileal– colonic

Means of Rejoining the Bowel

• Staplers– Circular EEA, linear GIA stapler, TA-staplers

• Hand-sewn• Combination

– Stapled off bowel end & hand sewn side to side anastomosis

– Stapled anastomosis reinforced with sutures

• Pressure (seldom used)

– Murphy button

– Niti method

Colorectal Anastomoses After Laparoscopic Bowel Resection

• Bariatric / Upper GI and MIS General surgeons:– Staplers– Hand-sewn methods

• Colorectal surgeons– Rely on staplers predominately – In general, few intracorporeal hand-sewn ‘moses.– Need to be comfortable sewing intracoporeally

Sigmoid & Low Anterior Resection

• Almost all distal L anastomoses done in the same manner (double stapled circular EEA):– Specimen exteriorized via lower abdominal

extraction incision

– Extracorporeal pursestring and anvil placement

– Intracorporeal docking of anvil and firing of stapler

Laparoscopic-Assisted Sigmoid & Low Anterior Resection

Hand-assisted LAR

Exteriorization of Specimen

Placement of Anvil in Proximal Bowel

EEA Anastomosis

Stapled EEA Anastomosis

Leak Test After EEA Anastomosis

• Alerts surgeon as to presence of leak

• Choices:– Rigid procto with anastomosis submerged– Flexible sig + mosis submerged (CO2 for insufflation of

bowel)– Bulb syringe injected air/betadine in rectum

• If leak found suture reinforcement of anastomosis then retest

• ? Need for proximal stoma if leak found or doughnuts incomplete (must check doughnuts)

Circular EEA Anastomosis

• Proper stapler size– If too big, anvil won’t fit– If too small, then the

“doughnut” may be too bulky

• Must clear mesentery • Is anus strictured or

narrowed? • Must consider colon &

rectal diameters• Largest size possible

Factors That Impact Distal Left Anastomotic Healing

• Level of the anastomosis (how low?)

• Blood supply– Unusual anatomy (vessel origin, marginal art.)– Division IMA at origin or more distal

• Tension flexure takedown• Abnormal tissue

– Neoadjuvant RT/chemo– Inflammatory bowel disease

• Critical co-morbidities (cardiac, vascular)

How to Avoid Leaks For Sigmoid/LAR Anastomoses

• Splenic flexure takedown in great majority

• Carefully assess & understand the arterial anatomy

• Carefully assess vascularity of proximal end when placing dougnut

• Use sizers to make sure that stapler can be inserted to proximal end of Hartmann’s pouch

Sigmoid Resection for Diverticulitis

• Preserve IMA (which improves blood supply)

• Devascularize specimen in mid- mesentery• Preserves pelvic autonomic nerves• Danger here is leaving distal rectosigmoid

colon and subsequent difficult stapler insertion (to reach proximal end of Hartmann’s)

• Can partially mobilize in presacral plane (without detaching or dividing all attachments in order to preserve nerve supply)

Fully Laparoscopic Anastomosis• Transanal extraction of specimen• Transanal introduction of EEA Anvil• Placement of anvil in proximal bowel

– Anvil into bowel end and then endoloop– Anvil spike exits side of proximal bowel and

stapler used to close the bowel end

• Close open end of Hartmann’s pouch• Insert stapler transanally• Docking of anvil and firing of stapler

Coloanal Anastomosis

• Mucosectomy (Lone star retractor)– After TME to levators (breakthrough tricky)– TATA (done at start of case)

• Need fully mobilized proximal colon – Flexure takedown– IMA at aorta and IMV proximal to L colic

• Handsewn colon to anoderm anastomosis• +/- colonic J Pouch• Has clear functional implications

Ileocolic and Colo-colic AnastomosesIntracorporeal vs. Extracorporeal

• Majority done extracorporeally

• Can be safely done intracorporeally

• Latter is harder to accomplish, may add time to operation

• Is extraction incision size appreciably smaller for intracorporeal method? For most probably not.

• Does it matter ? Not been well studied. There is little comparative data.

Ileal to Transverse Colon Anastomosis: The Problem

• The length of the Middle Colic Artery is highly variable

• In some patients it is very short and will not easily reach outside via small extraction incision

• In obese patients with a thick abdominal wall this can be a big problem

• Intracorporeal anastomosis makes most sense in the very obese population

Right Hemicolectomy: Standard Periumbilical Extraction Incision

Takeoff of Middle colic vessels

Extraction Incision

Right Hemicolectomy: Extraction Incision in Obese & Short Mesentery Patients

Takeoff of Middle colic vessels

Right Hemicolectomy Epigastric Extraction Site

Takeoff of Middle colic vessels

Extracorporeal Anastomosis

• Two side to side stapling methods– Remove specimen first, then anastomose

• Disadvantage: 3 crossing staple lines usually

– Make anastomosis with bowel still in continuity (Barcelona Method)

• Advantage: avoid 3 staple lines & fewer cartridges• Disadvantage: less sound oncologically ?

• GIA 75 (or 80 mm) stapler used for both

Extracorporeal Ileocolic Anastomosis

Intracorporeal Anastomoses

Summary• Numerous ways to skin a cat• Before using new method fully investigate & learn

about the technique (video/talk/observation). Mentor, if possible.

• There are nuances to each method• Must be comfortable with method chosen• Good assistant and considerable colon experience

prior to LAR / TME• Divert proximally if concerned about distal L

anastomosis

Conditions Necessary for Anastomotic Healing

• Adequate blood supply

• Lack of tension

• Technically “sound” anastomosis

• Healthy, non-diseased bowel ends

Risk Factors for Anastomotic Leaks• Level of the anastomosis (< 6 cm) ** ++

• Neoadjuvant RT / chemo **

• Perioperative cardiac event *

• Other co-morbidities (lung, liver, DM)+

• Male gender ?

• Smoking, excessive ETOH ?• Double stapled method (vs handsewn) ^ ^^

*Lyall et al. Colorectal Dis 2003;9:801-7. **Heald RJ et al. Dis Col Rectum 1981;24:437-44. +Chessin et al. J Amer Coll Surg 1997;185:105-13. ++Vignali et al. J Amer Coll Surg 1997;185:105-13. ^ Mac Rae HM et al, Dis colon Rectum. 1998 ^^ Lustosa SA et al. , Sao Paulo Med J. 2002.

Cochrane Review of Literature 2005

Main findings regarding laparoscopic method:– Length of stay 1.5 days shorter– Incidence of wound infection lower (4.6% vs.

open 8.7%, p=0.002)

– No difference in anastomotic leak or abscess rate

– Mortality similar– Quality of life better up until POD 30

How to Decrease Leak Rate: Blood Supply

• Must determine each patient’s anatomy

• Check for anatomic variations (common)

• Vascular anatomy largely determines resection margins

• When possible, palpate pulses, check for bleeding (extracorporeal anastomoses)

• Does patient have atherosclerosis, DM ?

• Prior Aortic aneurysm (is IMA open) ?

Anastomotic Leaks

• The bane of the GI surgeons existence• They occur regardless of the construction method• Extraperitoneal bowel anastomoses have higher

leak rates (no serosa)– Rectum– Esophagus

• Types of leaks– Clinical– Radiologic (usually asymptomatic)

Anastomotic Morbidity: Not Just Leaks

• Abscesses (without documented leak)• Fistulas can develop (abscess or leak

related)• Rate of pelvic infection = leak +

abscess– Abscess and collection rate not always

given– Literature hard to assess for this reason

• No uniform complication reporting system in place

Incidence of Clinical Leaks After Open LAR

Series N No. Leaks %

Karanjia et al ’94 219 24 11

Zaheer et al ’98 291 16 5

Enker et al ’99 681 8 1.2

Law et al ’00 196 20 10.2

Marijnen et al ’02 1861 214 11.5

Leester et al ’02 249 16 6.4

Wong NY et al ’05 1066 41 3.8

Gastinger et al ’05 2729 390 14.3

Chessin et al ’05 210 8 3.8

Lyall et al ’07 87 10 11.5

Anastomotic Leak After Laparoscopic Colectomy

Trial # pts. % leak

Franklin ‘96 191 0 Gellman et al ‘96 104 1.9 Lumley et al ‘97 200 2.5 Fielding et al ‘97 285 2.5 Kockerling et al ‘99 949 4.5 Lacey et al ‘97 116 0.9 Regados et al ‘98 146 2.7

Level of Devascularization for Left Sided Colorectal Resections

• In cancer setting:– IMA at origin (+ IMV) best colon mobility

OR – Sigmoidal artery, distal to left colic takeoff

• Diverticular disease:– Mid-mesenteric division preserves IMA blood

supply to rectum– Also protects pelvic nerves– Downside: rectum not as well mobilized

Splenic Flexure Mobilization

• For vast majority of left sided resections

• Medial mobilization of mesentery

• Detach omentum • Can detach base of

distal transverse mesocolon

• Provides better vascularized colon

Prevention of Leak: Splenic Flexure Mobilization

• Lower leak rate when descending colon used for anastomosis (vs sigmoid)

• 15 % with takedown vs 31 % *

• Less tension

• Well accepted that flexure should be mobilized for vast majority of LAR’s

* Karanja ND et al. Br J Surg 1994;81:1224-6.

Tension: Rectal Mobilization (for LAR)

• To level of pelvic floor (levators)

• TME (circumferential dissection)

• Preserve nerves• Full mobilization

increases the “reach” of the remaining rectum

Laparoscopic Technique Points for Sigmoidectomy and LAR

• Check mobility of proximal bowel intracorporeally prior to exteriorization (will it reach to rectum?)

• Select proximal transection point intracoroporeally. Must consider bowel:– Mobility – Blood supply

• Use loop suture to mark transection site • Once bowel is exteriorized it is hard to

determine what will reach

Technique Point: Choosing Site of Incision for

Specimen Extraction

• Make sure proximal bowel will reach wound and can be exteriorized:

• Obese lower abdominal wall is thick

• Pfannenstiel’s incision can be placed too low

• May be difficult to put in EEA anvil if bowel cannot be well exteriorized

LAR: Exteriorization of Proximal Bowel

Incision too low in this patient !!

Colon will not reach

LAR: Exteriorization of Proximal Bowel

Incision made higher

Colon reaches

After Rectal Transection Insert EEA Sizers Into Hartmann’s Pouch

• If you cannot fully insert sizer to Hartmann linear staple line: – Rectal mesentery may not be adequately

cleared from linear staple line• Carefully clean 1-11/2 cm of posterior & lateral wall

– Peritoneum covering the rectum anteriorly & laterally may impair stapler insertion

• Score peritoneum in several places

• Do further dissection / mobilization and then re-insert

Anastomosis: Orientation of Mesentery

• Avoid twist of mesentery

• Follow free cut edge of the mesentery proximally AND

• Follow anti-mesenteric surface of bowel as well

• Easier to twist bowel when working laparoscopically

Testing Anastomotic Integrity

• After rectal transection ?

• After circular stapled anastomosis

• Method:– Flexible sigmoidoscope with CO2 insufflation– Proctoscope– Bulb syringe (if desperate)– Air pumped into rectum & fluid in pelvis OR– Betadine solution into rectum with dry pelvis

Technique Point: After Anastomosis, Prior to Completion:

• Medial to lateral methods leave mesenteric windows

• Small bowel can get trapped under mesentery or in window

• Want free edge of colon mesentery directly overlying retroperitoneum

• Small bowel underneath the free mesenteric edge will increase tension & can decrease the blood supply

Proximal Diversion of Fecal Stream

• Limits consequences of leaks

• Choice of diversion:– Colostomy

• Less output • Harder to close• Larger stoma, bulky

– Ileostomy• Higher output • Smaller, less bulky• Easier to make and close

• Loop stomas most commonly made

Proximal Diversion: Preop Mark Possible Stoma

Locations• Mark sites with patient sitting in chair

– Avoid skin creases and deep folds– Keep 4 fingerbreadths away from umbilicus– Mark on right and left

• Place port at stoma, if possible

• Place other ports at least 4-5 cm away

Low Anterior Resection:Site Chosen for Loop Ileostomy

Planned ileostomy site

Umbilicus

Low Anterior Resection:Port Site Locations: Option 1

Low Anterior Resection:Port Site Locations: Option 2

Impact of Diversion at Time of LAR

• Prospective study, n= 2,729 patients• 881 patients diverted at initial op• Leaks (+ stoma = 14.5%; - stoma = 14.2%) • Lowers chance of requiring laparoscopy /

laparotomy (3.6 vs 14.2 % in non-diverted pts)

• Lower mortality (0.9 vs 2% in non-diverted, p=0.0310)

• Morbidity of closure (ileostomy, 22.4% vs colostomy, 15.4%, p=0.031)

* Gastinger et al Br J Surg 2005;92:1565-6.

Anastomotic Reinforcement

• Types of reinforcing materials:– Fibrin glue, fibrinogen, (“paint” anastomosis)– Polyglycolic acid/trimethylene carbonate,

random fiber (absorbable)– L-lactic acid-co-epsilon-caprolactomne

(absorbable)– Small intestinal submucosa (bioprosthesis)– Bovine pericardium & collagen strips (semi-

absorbable)– PTFE (non-absorbable)

Anastomotic Reinforcement

• Most involve “sleeve” that is slid onto stapler (GIA and for EEA)

• Incorporated into the anastomosis

• Absorbable materials gone in ~ 6 months

• Goal is to decrease leaks and hemorrhage

• Limited data available, thus far

• Absorbable appears better than non-absorbable

Anastomotic Reinforcement: Summary of Studies

• Pig study, SB stapled anastomosis: greater bursting pressure in submucosa bioprosthesis reinforced group*

• Rabbit study, hand sewn ‘mosis, polyglycolic acid mesh: higher bursting strength**

• Human study, 30 pts, no leaks or bleeding noted. Appeared safe +

*Downey DM, et al. Obes Surg. 2005 Nov-Dec;15(10):1379-83. **Raboff W, et al. Am Surg. 1994 Oct;60(10):721-7. +Franklin ME, et al. Surg Laparosc Endosc Percutan Tech 2005;15(1):9-13.

Anastomotic Reinforcement: Summary

• Being used commonly in US for gastric bypass to limit bleeding

• Being used for colorectal anastomoses• Will be hard to show significantly decreased

leak rate without doing large randomized, multicenter study

• What are the oncologic implications? (tumor cell implantation??)

• Does it impact stenosis rate after EEA?• Studies are ongoing.

Low Index of Suspicion: Early Evaluation for Suspected Leak

• Physical exam and careful digital• Abdomen / pelvic CT scan (p/o + rectal contrast)

– Free air, fluid - Extravasation– Collection - Inflammatory changes

• Contrast enema (gastrograffin)– Careful administration of contrast– Via foley cath for low anastomoses

• Transabdominal USG

How to Avoid Leaks: Summary

• Understand vascular anatomy

• Adjust devascularization level to pathology– IMA at takeoff or after left colic takeoff for

cancer– Mid mesenteric transection for diverticulitis

• Utilize well vascularized bowel

• Mobilize flexure

• Mobilize rectum well (neoplasms)

How to Avoid Leaks: Summary

• Determine proximal point of bowel resection intracorporeally

• Choose extraction site carefully

• Tension free anastomosis

• Assess distal left anastomoses (scope, leak test)

• Distal 1/3 rectum, divert routinely

• If in question, divert

Impact of Neoadjuvant Therapy on Leak Rates*

• 87 patients with rectal cancer

• 37 had full course preop Chemo/RT with operation 6-8 weeks later

• 10/87 clinical leaks (11.5%)

• All leaks had neoadjuvant therapy

• 6/10 leak pts had complete clinical response to RT

• CR associated with increased leak rate

* Lyall et al. Colorectal Dis 2007;9:801-7.

Prevention of Leak: Splenic Flexure Mobilization

• Lower leak rate when descending colon used for anastomosis (vs sigmoid)

• 15 % with takedown vs 31 % *

• Less tension

• Well accepted that flexure should be mobilized for vast majority of LAR’s

* Karanja ND et al. Br J Surg 1994;81:1224-6.

Colonic J Pouch

• Some studies found lower leak rates*• Others found no difference

• Better blood supply to pouch apex ?

• Some attribute better results to higher incidence of splenic flexure takedown in J pouch patients.

• Better functional results x 1 year

* Hallbook et al. Ann Surg 1996;224:58-65.

Stenting Anastomoses at LAR With Transanal Tube (to decrease leaks)*

• 50 LAR patients, All EEA

• Transanal tube placed in all at initial op

• Anastomoses checked at 2, 12 weeks via endoscopy

• 2 clinical leaks (4.2%)

• 3 asymptomatic leaks (6.3 %)

• Cannot draw meaningful conclusions

* Sterk et al Zentralbl 2001;126:601-4.

Clinical LAR Leaks: Presentation

• Fever • Tachycardia• Ileus, anorexia (possible nausea

& vomiting)• Abdominal pain and tenderness (often

absent for extraperitoneal anastomoses)• Most result in localized collections and

abscesses in the pelvis • Sepsis may develop

Clinical LAR Leaks: Treatment

• Antibiotics, NPO, observation (small leak, no collection)

• Percutaneous drainage of collection (transabdominal or transgluteal) +/- EUA

• EUA, placement of transanal drain via defect (distal pelvic small collection, small defect)

• Exploratory laparoscopy / laparotomy, drainage of collection, placement of drain, proximal diversion + EUA

In OR, Importance of Exam Under Anesthesia & Direct Transanal

Inspection

• Endoscopy / rigid procto

• Full EUA

• Gain better understanding of the problem

• May be able to drain collection and place drain tube transanally

• In already diverted patients, often all that is needed

• If abdomen opened must also do EUA

What About Stent at Time of Leak?

• Soft or hard stent ?

• Would need to fit snugly yet not decrease blood flow

• Combined with percutaneous drainage

• No data thus far

• University of Missouri study in progress: stenting of esophageal leaks

Impact of Diversion at Time of LAR

• Prospective study, n= 2,729 patients• 881 patients diverted at initial op• Leaks (+ stoma = 14.5%; - stoma = 14.2%) • Lowers chance of requiring laparoscopy /

laparotomy (3.6 vs 14.2 % in non-diverted pts)

• Lower mortality (0.9 vs 2% in non-diverted, p=0.0310)

• Morbidity of closure (ileostomy, 22.4% vs colostomy, 15.4%, p=0.031)

* Gastinger et al Br J Surg 2005;92:1565-6.

Rate of SBO in Diverted vs Non-Diverted LAR Patients *

• N = 210

• All had RT/Chemo

• Diverted at initial op = 119

• SBO– Diverted group = 21%– Non-diverted group = 8 % (p=0.04)

* Chessin et al. J Amer Coll Surg 2005;200:876-82.

Closure of Diverting Stoma after LAR

Series N Retained Stoma %

Nebakken et al ’02 17 5 29.4

Barkley et al ’03 59 5 8

Lefebure et al ’07 52 4 8

LAR Anastomotic Strictures

Anastomotic Strictures: Definitions

• No uniform criteria exists• Cannot pass 2nd finger ?• Cannot pass adult colonoscope ?• Symptomatic narrowing only ?• Poorly tracked and reported• Often noted at time of pre-stomal closure• Asymptomatic ones dx’ed x 1 year or more• Under reported complication

Anastomotic Stricture: Etiology

• Ischemia

• Fibrosis

• Leak related

• Tumor recurrence related

• Radiation related

• IBD related

• Diversion related *

*Graffner HP et al. Dis Colon Rectum 1983;26:87-90.

Incidence of Anastomotic Stricture After LAR

Series N No. Strictures %

Lyall et al’ 87 1 1.1

Chessin et al ’05 210 7 3.3

Joos et al ’98 83 4 4.8

Bailey et al ’03 59 2 3.4

Balik et al ’07 282 50 17.7

Lazuskas et al ’94 108 1 0.9

Miller et al ’96 103 4 3.8

Shimada et al ’96 30 9 30.0

Anastomotic Stricture: Evaluation

• Digital exam• Endoscopic (biopsies to rule out recurrent cancer)

• Contrast fluoroscopic study

• Abdomen / Pelvic CT scan + rectal /p/o contrast– Not ideal to evaluate lumen diameter– In cancer patients needed to rule out

recurrent cancer

Rate of Stricture After Double Stapled EEA Anastomosis*

• 282 patients (sigmoid + LAR)• Routine sigmoidoscopy within 5 months• Stricture defined as inability to pass adult

colonoscope across ‘mosis (diameter 1.2 cm)

• Overall incidence 17.6 % (50 strictures)– EEA #31 = 13.9 %– EEA #28 = 25.8 %

• Vast majority asymptomatic

* Balik et al. Presented at 2007 DDW, submitted for publication

Why Routinely Check Anastomosis Early After LAR ?

• Will detect stenoses• Moderate narrowing can cause symptoms

– Stacking of BM’s, increased frequency– Mild pain– Distension (rarely)

• Will need to be done if patient to undergo colonoscopy in future

• On occasion will find 2-3 mm openings 1-2 years later (may be asymptomatic)

Treatment of Stricture

• Digital (for distal ones)• Metal dilators• Flexible dilators• Balloons (via endoscope or along side scope)

• Division of staple line (extraperitoneal only)

• Re-resection and anastomosis• Diversion (last resort)

Treatment of Distal Stricture• Digital dilatation (if within reach)• Dilators (metal or flexible)

– In office (or OR) by MD at first – At home by patient for difficult cases

• Balloon over wire (TTC or esophageal type)• Cutting across staple line (in 1-4 places)• Circular stapler (total 4 cases reported) *

• Reoperation (rarely)

* Chia et al. Dis Colon Rectum 1991;34:717-9 ** Shimada et al Ann Surg 1996;224:603-8.

Recalcitrant Distal Stenoses

• Option 1: multiple office dilatations or OR EUA and dilatation

• Option 2: teach patient to dilate themselves

• Need to be observed in office doing dilation

• Daily home dilatations often successful in reducing symptoms and avoiding other Rx

• Patients often reluctant (understandably)

Stricture Treatment: Through the Channel Balloon Dilatation

• Works well for majority of strictures beyond reach of finger

• Must be able to see across stenosis• Pass balloon +/- over wire

(1 minute inflation/dilatation, 2-3 inflations/session)

• Balloon size start at 10 mm 12.5 mm• In Columbia series

– 8/25 EEA 31 stenoses required 2 or > Rx– 13/24 EEA 28 stenoses required 2 or > Rx

• Complications = 0 for Columbia series

Treatment of Benign Anastomotic Stricture: Circular Stapler

• Report 1: 3 patients treated *

• Use EEA to resect the stenosis

• With 8-14 mos. follow up, no recurrence noted

• Report 2: single patient **

• Used EEA as well

• Must be able to get anvil above the ‘mosis

* Pabst et al. Dig Surg 2007;24:149-51. **Arak et al. Kurane Med J 2002;49:149-51.

Stenting of Benign Anastomotic Strictures

• Is an option

• No data available for use of stents in patients with benign anastomotic stricture

• Retention rate ?

• Long term function ?

• Erosion

• ? other complications

Resection & Reanastomosis for Stenosis

• Last resort• Carries considerable morbidity and some

mortality• No guarantee of success• Issues of reach, blood supply, tension

remain• Patient must understand that result might

be permanent stoma or serious complications

• Majority of patients accept stoma• Convert ileostomy colostomy (an option)

Stricture Summary

• Look for them

• Routine flexible sigmoidoscopy within 6 months advised

• Dilate to scope diameter (if above finger reach) with balloon

• Distal strictures, dilatation with finger or dilator for most

• Operative treatment for recalcitrant one

Small Intestinal Submucosa (Bioprosthesis) Reinforcement*

• Pig study

• Small bowel anastomoses (GIA)– ½ reinforced– ½ stapled alone

• Bursting strength significantly greater in reinforced group

*Downey DM, et al. Obes Surg. 2005 Nov-Dec;15(10):1379-83.

Polyglycolic acid Mesh: Animal Study *

• Rabbit study (n=22)• Two hand sewn anastomoses per animal• Two layered anastomoses• 1 anastomosis per animal reinforced • Bursting strength determined on POD 4-5• Reinforced anastomoses had significantly higher

bursting strength• Histology: Well-developed layer of fibroblasts

and collagen between the PGAM and bowel wall serosa.

*Raboff W, et al. Am Surg. 1994 Oct;60(10):721-7.

Polyglycolic acid/trimethylene carbonate: Human Study

• 30 patients

• Variety of anastomoses– Ileocolic, 12; colorectal, 15; other, 3

• Median follow up = 7 months

• No leaks, strictures, or bleeding postoperatively

• Appears safe

• 2nd study: 159 colorectal ‘moses (no leaks)* Franklin ME, et al. Surg Laparosc Endosc Percutan Tech 2005;15(1):9-13.

Rate of SBO in Diverted vs Non-Diverted LAR Patients *

• N = 210

• All had RT/Chemo

• Diverted at initial op = 119

• SBO– Diverted group = 21%– Non-diverted group = 8 % (p=0.04)

* Chessin et al. J Amer Coll Surg 2005;200:876-82.

Anastomoses Methods• Circular EEA

– Single staple (2 purse strings)– Double staple

• Side to side stapled (GIA linear stapler)• End to side• Hand-sewn

– Colorectal anastomosis– Coloanal anastomosis (post mucosectomy)

• Pressure induced anastomosis