BOWEL ANASTOMOSIS( overview )
SUDJATMIKO
DIGESTIVE DIVISION – DEPARTMENT OF SURGERY
DR SOETOMO GENERAL HOSPITAL
SURABAYA
1st Surabaya Gastrointestinal and Emergency Surgery
Surabaya, May 19 –20th 2017
INTRODUCTION
• The word anastomosis comes from the Greek ‘ ana’ without , and ‘stoma’ a mouth.
• The intestinal anastomosis is the surgical connection of separate bowel to form a continous chanel.
• Worldwide intestinal resection and anastomosis performed over billion annually
• Bowel anastomoses are common problem in both elective and emergency surgery
• Various complication can be assosociated with anastomosis after the surgeries
• The anastomotic methode and devices are invented with the purpose to perfect the result.
HISTORY
• Suture have been used for at least 4000 years ago.
• Egyptian used linen and animal sinew to close wounds
• In 1826, Antoine Lembert, serosal apposition
• 1867, Joseph Lister concept of asepsis
• Cushing and Connel continous inverting suture
• In 1882, Halsted, idea that collagen in the submucosal layer was main factor responsible for the resistance of anastomosis
• Halsted recommended single layer aposition anastomosis
• 1892, Murphy Button was first popular anastomosis stapling prototype
• In 1893 detected approximated 52 different technique intestinal suture
• 1908, Humer Hultl (Hungary) and 1924, Petz invented modern stapling
• 1970 stapling introduce as bowel anastomosis
• 1985, Thomas G Hardy, biofragmentable anastomotic ring (sutureless anastomosis)
Chen C , Scandinavian Journal of Surgery 2012; 101; 238-240.
Chellamani KP at al. J. Acad. Indus. Rev. Vol (12) May 2013
INDICATION
• Restoration continuity following resection of bowel disease i.e
- perforation - gangren- malignancy - radiation enteric- infection, stricture- benign condition, polip, intusuception
• Bypass of unresectable bowel disease- advanced tumor causing luminal obstruction- metastatic disease
• Congental anomalies- ie. Intestinal atresia
• Bilio-pancreatic diversion
ANATOMY
• The wall of small intestine comprises :
- The mucosa
- The submucosa- Muscularis
- The serosa
• The submucosa layer provide :
- Blood vesel
- Lymphatics
- Nerves• The importanly of the submucosal layer
- is holding layer which must be included in
any suturing technique
HISTOLOGY
• Submucosal layer contains high content of collagen fibers which provide the tensile strength of the bowel
• Collagen is the most important molecule in determining intestinal wall strength
INTESINAL VIABILITY
The standard clinical criteria :
- Colour
- Peristaltic motility
- Arterial pulsation
The technique to increase accuracy of the viability :
- Doppler ultrasound
- Thermistor thermometry
- Intrvenous fluorescence (ei. ICG)
Clinical examination is at least as effective as other techniques
White D. [email protected]
ANASTOMOTIC HEALING
• Early (lag) phase (0 – 4 days )
- there acut inflamation response- no intrinsic cohesion
• Proloferation phase (3 – 14 days)
- fibroblast proliferation –> collagen formation- matrix metalloproteinase (MMP) -> collagen
degradation
• Maturation phase- period of collagen remodeling
- hydroxilation of prolene become hydroxy prolene.
- increase stability and strength of the anastomosis
Chen C. Scandinavian Journal of Surgery 2012;101: 238-240
PATIENTS HEALING FACTORS AFFECTING ANASTOMOSIS HEALING
World J Gastrointestinal Surg 2012 Sept 27;4(9): 208-13
TEHNICAL FACTORS AFFECTING ANASTOMOTIC HEALING
World J Gastrointest Surg. 2012 September 27, 4(9): 208-213
BOWEL ANASTOMOSIS
BOWEL ORIENTATION
- end to end
- end to side
- side to side
BASE OF THE NUMBER OF LAYER
- single layer
- double layer
TYPE OF SUTURE
- interrupted
- continous
TECHNIQUE
- Hand sewn
- Stapling technique
- Compression ( sutureless)
TECHNIQUE ANASTOMOTIC
METICULOUS TECHNIQUE
- adequate resection margin- appropriate suture
- inverting edge
- tension free - ensuring patency
- negosiating caliber cheating
cut back
oblique division
side to side anastomosis
end to side anastomosis
- closure of mesenteric defect
THE CHOICE OF THE ANASTOMOTIC
Must be consider :
• Diameter of the bowel ends
• Edema
• Contamination
• Accesibility and site of anastomosis
• Available time
• Equipment
• Underlying pathology
ANASTOMOTIC SUTURE
• Interrupted or continous
• Single or two layer
• End to end or side to side or combination
• Extramucosal or full-thickness
• Size of and spacing between each suture
• Various suture material
SINGLE VS DOUBLE LAYER ANASTOMOSIS
SINGLE LAYER TECHNIQUE• Single layer has potential advantage in reduce operating time, less ischaemic,
less tissue necrosis and less narrowing intestinal lumen
• Single layer technique is used better in extra peritoneal rectum.
• No evidence an increasing risk of anastomosis leak in single layer
• It has been shown that single layer interrupted suture are reliable for all gastro-
intestinal anastomosis
TWO LAYER TECHNIQUE• Narrowing of lumen is hardly problem and takes time longer
• No evidence two layer anastomosis better than one layer
• Two technique is used in stomach, duodenum and smal intestine
• Meta-analysis study ; there no evidence that two layer anastomosis
reduce the rate post-operative leaks
The excelent result obtain by some surgeon are probably of surgeon experties rather than the technique
SUTURE MATERIAL
Ideal suture material is one that elicits little to inflamatory response, while maintaning strength of the anastomosis during the lag phase of healing
SUTURE MATERIAL
J. Acad. Indus. Res. Vol. 1(12) May 2013
PROPERTIES OF DIFFERENT ABSORBABLE SUTURE
WJMER. Vol 3: Issue 1, 2013
SURGICAL SUTURE
J. Acad. Indus. Res. Vol. 1(12) May 2013
Burch JM et al. ANNALS OF SURGERY. Vol.231, No. 6: 832-837
Dandi PP at al. Int J Res Med Sci 2015 Aug; 3(8); 2099-2104
INVERSION or EVERSION
Has long been a controversial• INVERSION
- inverting ignore of accurate opposing clean cut tissue- narrowing anastomosis- Halsted proposed an interupted extra mucosal technique
low leakage rate ( 1.3% to 6.0% )
• EVERSION- lower bursting pressure- slower healing- more severe inflamation- higher rate of feces fistula formation- high potentially adhesion
INTESTINAL STAPLING DEVICE
• Potential reduction in operative time
• Faster learning curve than hand-sewn technique
• More costly
• Making popular with trainee
But as surgeon one should be familiar with booth techniques
SUTURE or STAPLER ?
• Suturing and stapling have equally good result• Stapler fascilitated rapid anastomosing
- Stapler easier and rapidly in low rectal anastomosis- but anastomosis easier to suture eq. bilio-digestive
anastomosis• Stapler more easily joint bowel with varying size• Stapler disadvanted in increasing expense but advanced of
speed• Stapling has benefit on critically ill patient• There is no evident that stapler are safer than suture• The choice is up to the surgeon experience and preference
Carol EH at al ; Chasin’ operative surgery in general surgery, 4th edit, Springer 2014: 39-44
STAPPLING vs SUTURING
Several case series and RCT showed :No significant different in :
- Anastomotic leaks- Morbidity or mortality
in anastomosis throughout gasrtointestinal tract
Goulder F, Bowel anastomoses : The theory, the practice and the evidence base; World J Gastrointestinal surg 2012 Sept 27;4(9):208-13
Fatek IS. Asian PacJ Cancer Prev. 15 (13), 5427-5431
STAPLERS EQUIPMENT
STANDARD CHECKLIST AFTER ANASTOMOSIS
• Any tension
• Any rotation
• Viability / vascularity
• Patency
• Are the doughnut complete
• Leak test
• Need for defunctioning
DISEASE AND SYSTEMIC FACTOR ASSOCIATED WITH POOR ANASTOMOTIC HEALING
• Anemia• Diabetes mellitus• Previous irradiation• Previous chemotheraphy•Malnutrition with hypoalbuminemia• Vitamin deficiencies
Bozzeti F. Br,J Surgery 2002; 89: 1201- 1202
ANASTOMOTIC LEAK (AL)
• The pathofisiology of AL remain unclear
• Probaly to the undetermined healing process.
• Difficult to conclude which factor are essential preventing AL
• The conclusion are mainly base on reduction in AL rate or increasing in bursting pressure
• Essential factors that lead disruptive healing process
- older age
- male gender
- malnutrition
- operative time
Joana WA; BMC Gastorenterology (2015); 15: 180
PRINCIPLES OF SUCCESSFUL INTERESTING ANASTOMOSIS
TECHNICAL FACTOR
- Adequate blood supply
- Tension free
- Minimized contamination
- Meticulous technique
PATIENT-RELATED FACTORS
- Malnourished
- Chronic steroid use
- Diabetes mellitus
- Malignancy, prior chemo-radiation
- Hypotension / Shock
- Emergency surgery
EQUIPMENT FACTOR
MURPHY’S BUTTON
• Introduce by Dr. John Benyamin Murphy in 1892
Valtrac BAR(Biofragmented Anastomosis Ring)
• Introduceed in 1985 by Thomas Hardy et al.
• Double segmented ring composed of polyglycolic acid and barium sulphate
SUTURELESS ANASTOMOSIS
Marano et al. BMC Surg 2012, 12 (Supl1) 527
So which is the better outcome ?
THE SUCCESSFUL OUTCOME OF INTESTINAL ANASTOMOSIS
• Patients optimatization
• Depend on personal experiece and preference
• Respective of the of the technique used
• Principle of a successful outcome include
- meticolous tehnique
- good vascular supply
- appropriate suture
- tension free repair
• Good post operative care
THE FUTURE STUDIES
•Constructing safe anastomosis
•Raising burst pressure
•Reducing the leakage rate
CONCLUSION
• Anatomotic technique have greatly improve over the past two centuries
• All anastomoses, no matter how technically creation, can fail.
• A complicated anastomosis is associated with increasing morbidity, length of hospital stay, mortality and costly.
• Successfull bowel anastomosis is attributed to adequate knowledge in intestinal healing, patient optimization, meticulous surgical technique and good post operative care.
• The future studies are constructing safe anastomosis, raising burst pressure and reducing the leakage.
• One of the most important determinant of outcome in bowel anastomosis is carefull attention to detail.
• It was suggestion the surgeon could chose the technique base on their own experience and preference
