Bowel Resection and Anastomosis

Dimitri Alexander Petrov, MD
The Operative Review of Surgery. 2023; 1:232-242.

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Table of Contents

Bowel Resection
Bowel Anastomosis
Hand-Sewn vs Stapled Techniques
Indocyanine Green Fluorescence Angiography (ICG-FA/ICGA)

Anastomotic Leak
Other Complications

References

Bowel Resection

Types of Resection

General Principles

  • Ensure Good Blood Supply – Judge Subjectively or Use Doppler/Scintigraphy
  • Ensure Adequate Mobilization and Avoid Tension
  • Angle Transection Line Straight or Somewhat Oblique to Keep Antimesenteric Edge Shorter and Ensure Adequate Blood Supply

Classic Technique

  • Place Non-Crushing Bowel Clamps on Both Sides of the Transection Line
  • Sharply Transect the Bowel Between the Clamps Using a Scalpel
  • Repeat at the Opposite Bowel Margin
  • Transect the Mesentery Using an Electrosurgical Device or by Clamping and Tying
  • Remove Specimen
  • Perform Anastomosis

Linear Stapler Technique (Most Common)

  • Pinch and Thin the Mesentery Just Under the Site of Transection
  • Make a Small Mesenteric Defect at the Site
  • Insert One Jaw of the Stapler Through the Defect
  • Assemble & Fire the Stapler at the Transection Line
  • Repeat at the Opposite Bowel Margin
  • Transect the Mesentery Using an Electrosurgical Device or by Clamping and Tying
  • Remove Specimen
  • Perform Anastomosis

Bowel Anastomosis

General Principles

  • “Strength Layer” of Bowel: Submucosa 1
    • Ensure that the Submucosa is Always Included in the Anastomosis
    • All Layers Add to the Strength
  • Antimesenteric Border is at the Highest Risk for Ischemia – The Vasa Recta Arise from the Most Peripheral Arcades and Do Not Intercommunicate 2
  • Center Side Reconstructions On:
    • Small Bowel: Antimesenteric Border (Limit Ischemia)
    • Large Bowel: Taenia Coli (Adds Strength)
  • Anastomosis Weakest Time Point: 3-5 Days (Breakdown Exceeds Production) 3
    • Bowel Has Increased Collagenase Activity Compared to Skin

Type of Anastomosis

  • End-to-End
    • The End of One Loop is Anastomosed to the End of Another Loop
    • More “Physiologic” in Replication of Normal Gut Motility
  • End-to-Side
    • The End of One Loop is Anastomosed to the Side of Another Loop
    • Generally Considered When There is a Size Mismatch (Small Bowel to Colon, etc.)
  • Side-to-Side
    • Bowel Loops are Oriented Side-to-Side in an Overlapping Fashion
    • The Most Common Technique when Using a Linear Stapler
    • Types:
      • Isoperistaltic: Ends are Approximated to Maintain Similar Directions of Peristalsis
        • Technically More Difficult
      • Antiperistaltic: Ends are Approximated with Opposite Directions of Peristalsis
        • Technically Less Difficult
        • Often Referred to as “Functional End-to-End”

Intraoperative Assessment of Anastomosis Perfusion/Viability

  • Subjective Findings:
    • Bowel Color
    • Observed Pulsatile Blood Flow at the Transected Section
  • Objective Findings:
    • Indocyanine Green Fluorescence Angiography (ICG-FA/ICGA) – Best Studied
      • *See Below
    • Doppler US – Minimal Data
    • Light Spectroscopy – Minimal Data

Anastomosis; (a) End-to-End, (b) End-to-Side, (c) Side-to-Side 4

Side-to-Side Anastomosis; (A) Antiperistaltic, (B) Isoperistaltic 5

Hand-Sewn vs Stapled Techniques

Hand-Sewn Technique

  • Excise Staple Lines if Present
  • Use a Stay Suture to Approximate Both Bowel Ends
  • Create Anastomosis with Full-Thickness Bites Using Absorbable Suture – Techniques are Varied (Interrupted vs Running/Direction of Travel)
  • Consider Seromuscular Lembert Sutures to Buttress as a Second Layer
  • Close the Mesenteric Defect

Linear Stapled Anastomosis (Antiperistaltic Side-to-Side)

  • Traditional Method:
    • Resect the Proximal and Distal Ends
    • Sharply Excise the Antimesenteric Corner of the Resected Ends
    • Place the Two Jaws of the Linear Stapler Through Each Opening
    • Arrange the Jaws Along the Antimesenteric Borders
    • Assemble and Fire the Stapler to Create a Common Channel
    • Consider Placing a Reinforcing Silk Stitch (“Crotch Stich”) at the Inner Junction – The Site of Most Tension
    • Close the Enterotomies – Either with Suture or With Another Staple Load
    • Close the Mesenteric Defect
  • Barcelona Technique:
    • Approximate the Proximal and Distal Ends (Prior to Resection)
    • Make Small Antimesenteric Enterotomies at the Anticipated Ends
    • Place the Two Jaws of the Linear Stapler Through Each Opening
    • Arrange the Jaws Along the Antimesenteric Borders
    • Assemble and Fire the Stapler to Create a Common Channel
    • Use Another Stapler to Amputate the Specimen, Including the Previous Enterotomies
    • Resect the Specimen and Close the Mesenteric Defect
    • *Benefits: Cost-Effective and Only Uses Two Staple Loads (Traditional Uses 4 Staple Loads)

End-to-End Stapled Anastomosis (EEA)

  • *Generally Used for Colorectal or Upper GI Anastomoses
  • Complete the Indicated Bowel Resection
  • The Suture Line of the Proximal End is Resected
  • A Purse-String Suture is Used to Close the Lumen Around an Anvil
    • Can Also Be Brought Out of the Side for an End-to-Side Anastomosis
  • An Assistant Advances the EEA Stapler Through the Anus and Positions Appropriately
  • The Stapler is Opened, Piercing a Guidepost Through the Distal Bowel Wall
  • The Anvil is Attached to the Guidepost
  • The Stapler is then Closed and Fired
  • The Stapler is then Removed Through the Anus and Inspected to Confirm the Presence of Two Rings (“Donuts”) Implying a Complete Anastomosis
  • Consider Performing a Leak Test
    • The Pelvis is Filled with Saline and the Proximal End of the Anastomoses Bowel is Occluded
    • Air is Gently Insufflated Through the Rectum
    • The Pelvis is Inspected for Air Bubbles That Would Indicate a Leak
      • Small Leaks Can Be Repaired Primarily
      • Large Leaks Should Be Taken Down with Repeat Anastomosis

Comparison

  • No Significant Difference in Outcomes Between the Various Techniques 6,7
  • Single-Layer vs Double-Layer Hand-Sewn Anastomoses: 8,9
    • No Difference in Anastomotic Leak Rates
    • Single-Layer are Quicker to Perform
  • Hand-Sewn vs Stapled Anastomoses: 7,10,11
    • No Difference in Anastomotic Leak Rates
    • There are Some Conflicting Data with Strong Views Either Way

Side-to-Side Stapled Anastomosis 12

End-to-End Stapled Anastomosis 13

Indocyanine Green Fluorescence Angiography (ICG-FA/ICGA)

Mechanism/Theory

  • Indocyanine Green (ICG) is a Fluorescent Probe in Response to Near-Infrared (NIR) Light
  • Binds Primarily to Serum Albumin and Other Plasma Proteins
  • Primarily Confined to the Intravascular Compartment with Minimal Leakage
  • Excreted Almost Exclusively into Bile
  • Negligible Toxicity

Administration

  • Timing:
    • Bowel Should Enhance < 60 Seconds
    • Half-Life: 3-5 Minutes
    • Cleared by Liver: 15-20 Minutes
  • Dosing: Poorly Standardized
    • 2-0.5 mg/kg
    • 5-12.5 mg

Imaging Systems

  • Firefly (Intuitive Surgical)
  • SPY Elite (Stryker)
  • PINPOINT (Stryker)
  • IMAGE1 S (Karl Storz)
  • D-LIGHT P SCB (Karl Storz)

Outcomes

  • Colorectal Anastomoses: Possibly Decreased Risk of Anastomotic Leak, Reoperation, and Overall Complications (Debated) 14,15
  • Small Bowel Anastomoses: Insufficient Data

Right Hemicolectomy by ICG-FA; (A) Bowel After Vessel Division with Demarcation, (B) Anastomosis Before ICG, (C) Anastomosis After ICG; (a) Normal Light, (b) NIR, (c) Superimposition of NIR in Green 16

Anastomotic Leak

Leak Rates 17

  • Overall: 2-7%
  • Ileocolic: 1-3% (Lowest)
  • Colocolic: 6-12%
  • Coloanal: 10-20% (Highest)

Risk Factors 18-22

  • Patient Factors:
    • Male Sex
    • Malnutrition (Low Albumin)
    • Obesity
    • High ASA Score
  • Operative Factors:
    • Emergency Surgery (Compared to Elective)
    • Prolonger Operative Time (> 4 Hours)
    • Ischemia/Tension
    • Tumor Size > 5 cm
    • Multiple Stapler Firings
    • Low Anastomosis (< 5 cm from the Anal Verge)
    • Lateral LN Dissection
  • Debated Risk Factors:
    • NSAIDs/Ketorolac (Toradol)
    • Corticosteroids
    • Drains

Presentation

  • Generally Present at 5-7 Days Postoperatively
  • Abdominal Pain
  • Fever
  • Tachycardia
  • Peritonitis
  • Purulent or Feculent Drainage
  • May Present with an Abscess or Gas/Fluid Collection

Complications of Anastomotic Leak

  • Increased Mortality (15-30% vs 2-4%) 23-25
  • Prolonged Hospital Stay 24
  • Increased Risk of Cancer Recurrence 26,27
  • Chronic Presacral Sinus 28
  • Stricture

Diagnosis

  • Most Often Made by CT (Triple Contrast – PO, IV, and Rectal) 29
  • Consider Surgical Exploration if Unstable or Peritoneal
  • Other Options: Contrast Enema or Endoscopy 29

Treatment 30,31

  • Subclinical/Radiographic: Expectant Management
  • Small (< 3 cm) Contained Abscess: Expectant Management and Antibiotics
  • Large (> 3 cm) or Multiloculated Abscess: Percutaneous Drain
    • If Not Feasible or Fails: Surgical Drainage
  • Unstable, Peritonitis, or Free Intraperitoneal Leak: Surgical Repair
    • Major Defects (> 1 cm or One-Third Circumference) Require Resection with Either Revision or Diversion

Other Complications

Bleeding

  • Definitions:
    • Minor Bleeding: Bleeding that Does Not Require Transfusion or Intervention
    • Major Bleeding: Bleeding that Causes Hemodynamic Instability or Requires Transfusion or Intervention (0.5-4.2%)
  • Minor Bleeding is Common and Most Often Stops within 24-48 Hours
    • 50% Will Progress to Major Bleeding 32
  • Treatment: 33-35
    • Initial Management: Supportive Care and Blood Transfusion
    • Persistent Bleeding Requires Endoscopic Intervention
      • May Consider Transanal Operative Interventions for a Low Anastomosis
      • May Consider Angiographic Embolization (Theoretic Risk of Ischemia/Dehiscence)
    • Indications for Surgical Intervention:
      • Early Hemodynamic Instability That Does Not Respond to Aggressive Resuscitation
      • Failure of Endoscopic Management

Stricture

  • Incidence:
    • Overall: 3-30% 36,37
    • Clinically Significant Stricture: 4-10%
  • Risk Factors: Ischemia, Inflammation, Radiation, Leak, or Recurrent Disease 37
  • Stricture After Resection of Malignancy Requires Evaluation of Potential Local Recurrence (CEA, CT, EUS, etc.)
  • General Treatment of Benign Strictures: Repeated Endoscopic Dilation
    • Success Rate: 88-100% 37,38
  • Indications for Surgical Revision:
    • Malignant Strictures without Distant Metastatic Disease
    • Refractory Strictures After Repeated Endoscopic Dilations

Enteric Fistula

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