2. TO KNOW THE INDICATIONS OF RESECTION
AND ANASTOMOSIS.
GENERAL PRINCIPLES AND RECENT
ADVANCES.
COMPLICATIONS OF THIS PROCEDURE.
PREVENTION AND TREATMENT OF THE
COMPLICATIONS.
3. Surgical removal of all or part of an organ,
tissue, or structure.
WHAT IS ANASTOMOSIS ?
Intestinal anastomosis is a surgical
procedure to establish communication
between 2 formerly distant portions of the
intestine. This procedure restores intestinal
continuity after removal of a pathological
condition affecting the bowel.
4. Broadly divided into 2 categories:
I. Restoration of bowel continuity following
resection of diseased bowel.
II. Bypass of unresectable diseased
bowel.
5.
6. Bowel gangrene due to vascular compromise.
Malignancy.
Benign conditions (eg. intestinal polyps).
Infections (eg. tuberculosis complicated with
stricture or perforation).
Traumatic perforations.
7. Inflammatory bowel disease, ulcerative colitis,
or Crohn’s disease that is refractory to
medical therapy or associated with
complications (eg. bleeding, perforation,
toxic megacolon, dysplasia/carcinoma.)
Hirschprung’s disease.
8. Locally advanced tumor causing luminal
obstruction.
Metastatic disease causing intestinal
obstruction.
Poor general condition or condition that
prevents major resection.
9. Local
■ Good blood supply.
■ No tension on suture line
■ Inverting anastomosis with appropriate
suture
■ Accurate apposition and suture technique
■ Avoidance of tissue damage by clamps.
10. ■ Bowel preparation (and avoidance of
spillage)
■ Antibiotic prophylaxis
■ Maintenance of good perfusion and tissue
oxygenation during anaesthesia (correction of
shock)
■ Adequate nutritional attention
■ Adequate resectional margins (cancer or
inflammatory bowel disease)
■ Avoidance of chemotherapy/radiotherapy
11. Most of the strength of the bowel wall resides
in the submucosa.
However, Serosa (i.e., the visceral
peritoneum) holds sutures better than either
the longitudinal or the circular muscle layer.
12. Collagen is the single most important
molecule Content highest in submucosa.
A critical stage in collagen formation is:
Hydroxylation of proline hydroxyproline
fibril cross-linking
maturity of the collagen
Vitamin C
overall strength of
the scar tissue
13. A dynamic process that depends on the
balance between collagen synthesis and
collagenolysis.
Degradation of mature collagen begins in the
first 24 hours.
Predominates for the first 4 days.
By 1 week, collagen synthesis is the dominant
force.
14. The bursting pressure of anastomoses has
often been used to gauge the strength of the
healing process.
reaching 60% of the strength of the
surrounding bowel by 3 to 4 days and 100%
by 1 week.
Collagen synthetic capacity is relatively
uniform throughout the large bowel but less
so in the small intestine
15. Intestinal anastomosis can be performed by:
Hand-sewn technique using absorbable /
non-absorbable sutures.
Stapling devices.
16. Sutured anastomosis (hand-sewn technique)
- commonly used because of the availability
and affordability of suture materials and
familiarity with the procedure.
Stapling definitely reduces the operative time
and facilitated the ease of doing the
procedure, especially in low colorectal
anastomosis.
17. An anastomosis may be either
a. end-to-end.
b. end-to-side.
c. side-to-side.
18.
19. The bowel ends must be brought together
without tension.
The all-layers continuous inner suture can be
undertaken with a double-ended suture to
help to keep the anastomosis even, going
from the middle posteriorly to the lateral
edge on each side.
The double-ended suture can then be tied in
the middle (on the anti-mesenteric side of
the bowel).
20.
21.
22.
23.
24. The line of transection in the bowel is oblique
rather than perpendicular.
The blood supply to the small bowel is such that
the antimesenteric border of the bowel can
become ischemic if the vascular arcade supplying
the edge of the resected bowel is transected
perpendicularly.
Secondly for transecting the bowel in an oblique
rather than a perpendicular line is that an oblique
transection will give a larger anastomosis and
reduce the incidence of stricture formation.
25.
26.
27.
28.
29. Suture bites should be 3-5mm deep and 3-
5mm apart depending on thickness of
bowel.
Suture material size 2/0-3/0,
absorbable,mounted on round bodied
needle.
Bowel of similar diameter is essential for
end to end anstomosis
In major size discrepancy, side- to-side or
end-to-side anastomosis is preferable.
Atlast, mesentry should always be closed to
avoid internal hernia.
30. Segments of bowel to be united have no
interruption of blood supply.
Size discrepancy can be tackled.
DISADVANTAGES-
More suture lines involved.
More degree of stasis and bacterial
overgrowth.
31. Stapling devices were first used successfully
by Hümer Hültl, in Hungary.
Give strong predictable suture lines, with
minimal tissue necrosis.
Allow access to difficult areas.
32. Three different types of stapler are commonly
used:
Transverse anastomosis (TA) stapler
Gastrointestinal anastomosis (GIA) stapler
Circular or end-to-end anastomosis (EEA)
stapler
33. Simply provides two row of staples for a
single transverse anastomosis.
Useful for closing bowel ends.
34.
35. Two detachable limbs.
Each limb can be introduced into bowel
loops,then limb reassembled and fired.
Two row of staples alongwith division of the
septum between the rows.
36.
37.
38. Commonly used in esophagus and low rectum.
Stapling head/anvil is introduced into one end of
bowel, secured with purse string suture.
Body/shaft of device is introduced via rectum in
low rectal anastomosis or via an enterotomy
elsewhere and secured with purse-string suture.
Head is reattached to the shaft and two ends of
bowel approximated till a green signal window
appear.
stapler is fired.
39. It is important to assess the integrity of
anastomosis by examining the doughnuts of
tissue for completeness
40.
41.
42. Titanium staples are ideal for tissue apposition
because
they provoke only a minimal inflammatory
response.
provide immediate strength to the cut
surfaces during the weakest phase of healing.
43. Use of Stapling devices needs familiarity with
the instrument.
Technical failure during operation.
Grossly much expensive then sutures
Size of the device is a concern too.
More compromise of blood supply to
anastomotic site due to two rows of staples in
an interlocking manner.
Requires seromuscular suture sometime to
make tension free anastomosis
44. Principle of compression anastomosis
consists of two opposing rings
trapping the cut ends of the
transected bowel with subsequent
ischemia and eventual sloughing of
the trapped bowel, thus releasing the
rings into the fecal stream.
45. Valtrac™ BAR
AKA-2 by Kanshin et al
Compression anastomotic clip
Endoluminal compression anastomotic ring -
EndoCAR
Magnamosis
46. Anastomotic leak
Fistula formation
Bleeding
Wound infection
Anastomotic stricture
Prolonged functional ileus,
especially in children
47. Anastomotic leak is the most feared early
complication of intestinal anastomosis.
Any systemic or local factor that causes delay
in the transition from the inflammatory phase
to the fibroplasia phase can result in poor
healing and anastomotic leak.
48. 1. Faecal fistulas to the skin or vagina or bladder.
2. Fever > 38 °C with septicaemia.
3. Radiological signs of anastomotic leakage.
4. Also an intraperitoneal abscess or peritonitis in the
presence of an anastomotic leak.
IF ANY ONE OF THE ABOVE CRITERIA PRESENT-
DIAGNOSIS
Müller, 1994
49. Technical aspects:
Blood supply
Tension on the suture line
Mechanical bowel preparation
50. Location in the gastrointestinal
tract:
◦ Pancreaticoenteric
◦ Colorectal
◦ Above the peritoneal reflection
◦ Below the peritoneal reflection
51. LOCAL FACTORS-
Septic enviornment.
Fluid collections.
BOWEL RELATED FACTORS-
Radiotherapy/chemotherapy
Compromised distal lumen
53. 12. Vitamin c, iron, zinc, cysteine deficiency
13. Stapler related complications-
Forceful extraction of the stapler
Tear caused by anvil
Failure of stapler to close
54. Loss of integrity of anastomosis and leakage of
intestinal content may occur in 3 ways-
Leakage may be diffuse throughtout the
peritoneal cavity(uncontrolled leak).
Formation of enterocutaneous
fistula(controlled leak)
May be walled off by omentum, abdominal
wall, contiguous loops of bowel, pelvic wall or
adhesions from prior operations( sealed leak)
56. Fistulous track into urinary bladder or vagina
forming enterovescical or enterovaginal
fistula
Spontaneous discharge from fistula leading to
pyuria or fecaluria, and problems related to
loss of intestinal content and perifistula
skin,malnutrition.
Organisms responsible are-
enterobacteriaceae, non group A
streptococci, bacteroides species
59. Contrast material extravasation is considered as
a direct sign of leak
Indirect signs considered as suggestive of leak
are:
disproportionate postoperative
pneumoperitoneum
progressive increase in the gas volume;
intracavitary fluid collections, with or without
fluid or contrast material level inside;
significant amount of fluid in the subphrenic
and/or perihepatic spaces
60. Choice of Suture Material- PGA
(absorbable )
monofilament and coated braided
sutures represent an advance beyond
silk and other multifilament materials.
The ideal suture material-one that
causes minimal inflammation and
tissue reaction while providing
maximum strength during the lag
phase of wound healing.
61. Perianastomotic tissue oxygen
tension was significantly less with
continuous sutures than with
interrupted sutures.- (animal
models)
No data regarding superiority of
one upon another in humans
62. Traditionally, double-layer anastomoses have
been considered more secure.
Microscopic areas of necrosis and sloughing
of the tissues incorporated in the inner layer
as a result of strangulation.
63. single-layer anastomoses take less
time to create,cause less narrowing of
the intestinal lumen.
more rapid vascularization and
mucosal healing
increase the strength of the
anastomosis (as measured by the
bursting pressure) in the first few
postoperative days.
64. Improved postoperative return of milestones.
Still surgeons should favor double-layer
anastomoses when
tissues are very edematous or friable,
Tissue under tension,
lie in highly vascular areas (e.g., the
stomach).
65. Greater support and improved blood supply
to the healing tissues associated with
stapling.
Stapling shorten operating time, especially
for low pelvic anastomoses.
NO DIFFERENCES in clinical and subclinical
leakage rates, length of hospital stay,or
overall morbidity IN EITHER OF THE
METHODS.
66. Recent studies shows it might have
detrimental effect on healing by causing
immune changes in bowel mucosa and
inflammatory changes that interfere with the
healing process.
Most surgeons would agree that:-
Much easier to operate on an empty bowel.
Decreases chances of faecal contamination.
67. Eversion-lower bursting pressure, slower
healing and more severe inflammation.
Inversion - greater anastomotic strength, less
luminal narrowing, and less edema and
inflammation.
INVERSION IS AN AESTHETIC ONE: AN
INVERTED ANASTOMOSIS ALWAYS LOOKS
NEATER.
68. Increased incidence of respiratory
tract infections after routine gastric
decompression.
Important to remain alert to the
potential for gastric dilatation, which
can develop suddenly and without
warning.
69. Must in emergency operations for peritonitis
or trauma in which it was necessary to close
or anastomose damaged or inflammed bowel.
Other cases – depends on surgeons decision.
increase in the incidence of anastomotic
dehiscence after the placement of
perianastomotic drains for more than 24-
48hrs due to increased infections.
70. Highest leak rate in distal rectum 6 to 8 cm
from anal verge.
More complications in esophagus due to lack
of serosa.
More complications in pancreato-enteric
anastomosis.
71. Selectively used protective colostomy does
not prevent the development of anastomotic
leak but when it happens -colostomy reduces
the mortality and morbidity.
Reduces peri-anastomotic contamination and
re-operation rate.
But deprives colon of short chain fatty acids
resulting in exclusion colitis and delay in
epithelisation of anastomosis due to altered
collagen synthesis.
72. Angigenesis inhibitor-targets VEGF.
USED in cases of metastatic colorectal cancer
alongwith IFL (irinotecan, 5-FU, leucovorin)
Also compromises healing of colonic
anastomosis leading to
o Dehiscence of anastomosis
o Colocutaneous fistula.
may occur after 2 years post-surgery.
73. Adequate exposure.
Gentle handling of tissue.
Aseptic precautions.
Meticulous and careful
dissection.
Adequate mobilisation for a
tension-free anastomosis.
74. Correct placement of sutures
or staplers.
Matching lumina of two
organs to be connected.
Preservation of blood supply
to the ends of bowel to be
anastomosed.
75. In elective cases nutritional support
for 5-7 days pre-operatively specially
in mal-nourished.
In patients receiving BEVACIZUMAB,
delay elective surgery for atleast 4-
8weeks post-chemotherapy ( three
half lives- 60days).
In patients who are candidates for BZB
therapy-evaluation using fine slice
CECT scan,colonoscopy.
76. Better to avoid anastomosis in-
Hemodynamically unstable
Immunocompromised
Nutritionally depleted
Fecal peritonitis
Edematous,ischaemic bowel.
A LEAK MAY PROVE FATAL IN THIS CASES
77. SUSPICION OF AN LEAK EVEN BEFORE
DIAGNOSIS SHOULD BE MANAGED PROMPTLY.
Immediate resuscitation.
Correction for third space loss and Intestinal
content losses.
NPO again ,if orally started.
Infected surgical wound should be drained.
BLOOD TRANSFUSION if required.
Broad spectrum antibiotics.
78.
79. Diffuse peritonitis
Intra-abdominal hemorrhage
Suspected intestinal ischemia
Major wound disruption or evisceration
Reoperation is always associated with
significant mortality and morbidity.
Poor prognosis must be explained to
the patient.
80. In critically ill patients or with fecal
peritonitis:
Anastomosis is taken down.
Ends of bowel are stapled.
Peritoneal lavage is performed.
Incision is left open.
81. 2nd look laparotomy with stoma formation is
performed after 24-48 hrs (once patient is
stabilised).
In other small intestinal anastomosis leaks,
ends of bowel are delivered as stomas.
In colon, proximal end is brought out as
colostomy and distal end is closed or
bought out as mucous fistula.
82. In rectum,proximal end as stoma and distal
end is closed.
Diverting stoma is not enough for colorectal
anastomosis.
Omentoplasty is an option for management
of the leak and prevents spontaneous fistula
formation in colorectal cases.
Omentoplasty – covering the bowel with
greater omentum.
83.
84. ENTEROCUTANEOUS FISTULA –
Presents with triad of sepsis,fluid and
electrolyte imbalance, malnutrition.
Fistula in general classified-
Anatomically:-
INTERNAL FISTULA- Enteroenteric,
enterovescical, enterovaginal.
EXTERNAL FISTULA- Enterocutaneous fistula
86. PRESENTATION-
Sepsis is prominent feature.
Hypovolemia
Electrolyte imbalance
Malnutrition.
In proximal small bowel fistula,output is high,
fluid loss ,electrolyte imbalance &
malabsorption is profound.
87. Distal and colonic fistulas,output is
low and dehydration,acid-base
imbalance & malnutrition is are
uncommon.
Effluent dermatitis due to corrosive
effects of intestinal content causing
irritation,maceration,excoriation.
88. Combined effort from surgeon, nutritionist,
enterostomal therapist, radiologist.
Prevention of leak formation.
Resuscitation
TPN
Electrolyte correction.
Antibiotics therapy
Drainage of abscess and wound infections
89. Adequate nutrition by TPN.
Trace elements and vitamin supplements.
Somatostatin- reduces secretions,reduces
output.
FISTULOCLYSIS- infusion of nutrition directly
through the fistula into the bowel distal to it.
Provided -more than 75cm of healthy bowel
present distally.
Safer and less expensive than TPN
Prevents atrophy of bowel distal to fistula.
90. Protection of peri-fistula skin is by:
Barriers- zinc
Oxide cream
Sealants
96. 90% OF ECF closes spontaneously after 4-
6weeks if sepsis is controlled.
Definitive closure surgically requires a waiting
period of 8-12 weeks with sepsis
controlled,nutrition provided and skin is
protected.
SIMPLE FISTULA- short tract, single fistula,
small enteral opening.--- can be closed by
12weeks
97. COMPLEX FISTULA-With long tract, associated
with other int. fistula, large abscess cavity,other
unfavourable factors---can be closed after 6-12
months.
In Crohn’s disease- infliximab is used to aid
closure of fistulous tract.
Fistula is excised->continuity of gi tract
reestablished->freshly made anastomosis
wrapped with omentum->laparotomy incision
closed primarily with or without synthetic mesh.
98. Bleeding may manifest in the immediate
postoperative period as either hemorrhagic
aspirate from the nasogastric tube,
hematemesis, melena, or bleeding from an
intra-abdominal drain.
Patients with bleeding should be aggressively
managed with correction of coagulopathy (if
present) and blood transfusion.
99. Intraoperative anastomotic site bleeding is
characterized by blood in the intestinal lumen
distal to the anastomosis.
In such circumstances, the anterior layer of the
sutures is opened and both layers are examined
for evidence of any bleeding.
Once the bleeding site is identified, it can be
controlled by hemostatic sutures.
Conversion to stoma is preferred in patients with
hemodynamic instability.
100. Wound infection occurs when there is
uncontrolled spillage of intestinal contents
during anastomosis.
It is managed by removing a few skin sutures
and ensuring proper drainage of pus.
Superficial surgical site wound infection does
not require treatment with systemic
antibiotics.
101. Anastomotic stricture is a late complication of
intestinal anastomosis.
The risk of anastomotic stricture is marginally
increased after end-to-end anastomosis,
especially when performed using a stapled
technique.
Managed conservatively, If this fails surgical
revision might be required.
102. Well-nourished patient with no
systemic illness
No fecal contamination, either within
the gut or in the surrounding
peritoneal cavity .
Adequate exposure and access Well-
vascularized tissues .
Absence of tension at the anastomosis
Meticulous technique
103. Leaks are common.
Maintain high index of suspicion
Manage aggressively and safely.
Leaks are better avoided than
treated.
Over meticulous surgery is harmful.
Stick to basic principles of surgery
with smooth handling of tissues and
better pre-op preparation.
