REVIEW

Carol B. Sheridan, MD Nicholas Zyromski, MD Samer Mattar, MD

Department of Surgery Indiana University School of Medicine Indianapolis

ht D rsonal u ig opyr For pe C

a FIGURE 1 n He only and conquer Divide e owd se A helpful technique in constructing the
hand-sewn GI anastomosis is the divide and conquer approach, placing the first in the row of posterior sutures in the center of the suture line. (Illustration by Molly Borman)

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IN THIS ARTICLE
Comparing the inverting and everting techniques
P 71

How to always do a safe anastomosis

It comes down to controlling factors that are either patient- or surgeon-related.
discourse on the principles of a safe anastomosis is best begun with some definitions. The word anastomosis comes from the Greek anastomo, which means to furnish with a mouth. Stedmans Medical Dictionary defines anastomosis as an operative union of two hollow or tubular structures.1 We will focus on the gastrointestinal (GI) anastomosis. However, these principles can also apply to vascular, urologic, and biliopancreatic anastomoses as well. For an anastomosis to be safe, it must cause no harm to the patient. It must be

How to construct a hand-sewn GI anastomosis

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Recommendations for best practices

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free of the potential complications that can occur when a surgeon creates an anastomosis. A safe anastomosis should: Not leak. Cause no persistent bleeding. Cause no stricture of the lumen. Create no risk for internal hernia. An ideal anastomosis should also be easy to construct, be consistently reproducible, and be easy to teach. Gastrointestinal anastomoses are, in essence, wounds, and so are governed by factors that influence wound healing. These factors are either patient- or surgeonCONTEMPORARY SURGERY

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related, the latter embracing the technical aspects of creating a safe anastomosis.

TABLE 1

Patient factors that may contribute to failure of a GI anastomosis

Local bacterial contamination Inflammation Shock and hypoperfusion states Diabetes mellitus Chronic steroid use Poor nutritional status Malignancy

Patient-related factors
The most common patient factors (TABLE 1 ) are characteristics the patient brings to the operating room. The surgeon must take these factors into account when deciding to create an anastomosis, and can even minimize them. All patients should receive appropriate preoperative intravenous antibiotics immediately before the operation. Although no evidence has suggested further doses in the patient who does not carry an ongoing infection, many surgeons continue antibiotics for 24 hours postoperatively.2 Any patient in a volume-depleted state should receive adequate fluid resuscitation before, during, and after the operation. Monitor the standard end points of volume resuscitation, including vital signs and urine output, to guide management.

oxygenation and healing. However, overcoming the negative effects of the catabolic state or the impact of chemoradiation therapy on healing may be difficult. In an emergency operation, the surgeon may not have the opportunity to optimize the patient. Two examples are the patient in septic shock from peritonitis with an ischemic perforation of the small bowel, or in hypovolemic shock with gunshot wounds to the torso resulting in multiple penetrating injuries of the small bowel. Control nutritional factors Often the safest anastomosis for this The hyperglycemic patient should have patient is during the second-look operablood sugars controlled preoperatively, tionthe clip-and-drop technique. This and may require an insulin drip immedi- is essentially a staged anastomosis in a preately postoperatively to maintain euglyce- carious environment.5,6 Gross bacterial or fecal contamination mia. The patients overall nutritional status is also critical to wound and anastomotic poses another hazardous setting, as in perihealing. The patient at increased risk for a tonitis from perforated diverticulitis. In this postoperative complication fits any of the case, resection with an immediate ostomy and anastomosis at a second operation following profiles: several months later is the right choice. Involuntary loss of more than 10% of body weight over the last 6 months. Involuntary loss of more than 5% of Technical factors The technical factors that contribute to a body weight over the last month. Low serum albumin levels (less than safe anastomosis apply in a global fashion (TABLE 2, P 70 ), regardless of its location 3.5 g/dL).3 Consider preoperative supplemental within the GI tract, the choice of suture or nutrition for the malnourished patient, stapling device, or approach (laparoscopic preferably enterally, for at least 7 days or open). before the operation.4 Ensure adequate local blood supply The availability of adequate tissue perfuOptimize the resection For the patient with an underlying GI sion through an uncompromised local malignancy, ensure appropriate resection blood supply may be the most critical techwith negative margins to optimize tissue nical factor for creating the anastomosis.
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FAST TRACK

Perioperative identication and appropriate treatment of patient factors can minimize their negative effects on anastomotic healing.

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FAST TRACK

When suturing the bowel, pass the needle perpendicular to tissues, taking bites that include the submucosa.

ways: either full-thickness in avascular areas, or by simply scoring the mesenteric peritoneum on both sides. Selectively dividing mesenteric vessels may also result Adequate local blood supply in additional length, but this must be done Elimination of tension judiciously to avoid ischemia. Hemostasis Lastly, the apex or crotch of a Gentle and precise handling of tissues side-to-side anastomosis is an area under greater stress than the rest of the Closure of mesenteric defects anastomotic line. A recent study of func Close inspection tional end-to-end stapled anastomoses in pigs demonstrated significantly higher Be aware of the mesenteric vascular supply bursting pressures for anastomoses butto the bowel segment undergoing resection, tressed with a stitch at the apex versus and follow known vascular distributions. unbuttressed anastomoses.7 Placing a Carefully examine the vascular seromuscular crotch stitch at this site arcade supplying the intestine, and palpate can reinforce the anastomosis. the mesenteric pulse adjacent the selected resection line. Before creating the anas- Achieve hemostasis tomosis, observe the divided ends of the The anastomotic line, whether hand sutured or stapled, must be hemostatic. A bowel for signs of ischemia. Bleeding mucosa at the cut ends of the hematoma at the anastomosis can interbowel is a reassuring sign of adequate per- fere with healing and lead to disruption fusion. Re-resect bowel ends that appear and leak. Bleeding can also persist into the dusky or congested back to a well-perfused lumen of the bowel leading to postoperaarea. When aligning an anastomosis, take tive intraluminal hemorrhage. To avoid this, inspect the lumen before care to prevent twisting the mesentery, as this will compromise the blood supply of complete closure. It is preferable to avoid stapling across the mesentery, but if necesthe completed anastomosis. sary, this can be done with a vascular load. Suture ligation or cautious electrocautery Eliminate tension All gastrointestinal anastomoses should can control bleeding at a staple line, but be created so the union between the two one must be mindful to avoid ischemia to ends of bowel is free of tension. Adequate the bowel wall. mobilization of the adjacent bowel is the most important maneuver to ensure a ten- Handle tissue gently and precisely sion-free anastomosis. This is crucial for As with any operation, gentle tissue hancolonic anastomoses, often requiring the dling is paramount. When suturing the division of attachments to the retroperi- bowel, use atraumatic graspers and pick toneum. For example, when performing a up the tissue only when necessary to prelow anterior resection, the surgeon must vent crushing injury from the forceps. Pass often take down the splenic flexure of the needle perpendicular to tissues, taking the colon to allow the proximal colon to bites that include the submucosa. Here, minimize lateral movement to drop into the pelvis to avoid tension on the avoid tissue shearing. When using a stapler, colorectal anastomosis. Occasionally a shortened mesentery ensure passage of the prongs into the true will pose a problem in joining the two ends. lumen. This avoids creating a false passage One way to increase mesenteric length in the bowel wall. An inverting technique is without compromising the blood supply is probably preferable, but an everting anasto create stepladder transverse incisions tomosis, which minimizes exposed mucoalong the mesentery. This can be done two sa, is likely safe as well (BOX ).
TABLE 2

Technical factors that contribute to a safe GI anastomosis

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Safe anastomosis
Follow the adage approximate, do not strangulate to avoid ischemia of the bowel wall at the anastomosis. For handsutured anastomoses, do not pull or tie down too tightly. For stapled anastomoses, use the correct staple height for the tissue thickness. Too short and ischemia may result; too long, and bleeding or leaking may occur. The common staple height for the small bowel and colon is 3.5 mm. For the thicker stomach, 4.8 mm is typical.

Comparing the inverting and everting techniques

Closing mesenteric defects

Close all mesenteric defects to prevent an internal hernia. Carry out closure with your choice of running or interrupted sutures. Proceed carefully to avoid taking excessively large bites of the mesentery, which can compromise the mesenteric blood vessels or cause bleeding. The need for closure of very large mesenteric defects is debatable. The chance of herniation leading to obstruction or strangulation in this setting is minimal.

he use of an inverting versus the everting technique for apposition of bowel wall layers has spawned much debate. In the 1800s, Lembert, Halsted, and others advocated an inverted, serosa-to-serosa union for bowel anastomosis to protect against leakage or infection. Since the advent of the surgical stapler, the need for an inverting anastomosis became controversial. Advocates of the hand-sutured everting bowel anastomosis pointed out the relative simplicity and decreased risk of bowel lumen narrowing with this technique compared with the inverting anastomosis. Animal experiments in the 1960s and 1970s demonstrated no difference in healing strength and leak rates between the two approaches in the presence of normal peritoneal defenses.27-31 On the other hand, authors have proposed that exposed mucosa at the suture line of the everting anastomosis can serve as a nidus for infection and promote increased adhesion formation. CBS, NZ, SM

a watertight union. Pay special attention to areas where staple lines overlap. These are potential points of weakness.10

Testing the anastomosis To test anastomoses to the anus or rectum and esophagus or stomach, use air insufRoux-en-Y anastomosis Special anastomoses, such as the Roux-en- flation with the anastomosis under irrigaY gastrojejunostomy and hepaticojejunos- tion fluid to check for bubbles. Endoscopic tomy, carry greater potential for herniation. inspection is another option. Oversew The Roux limb can lead to hernia spaces at areas that may be compromised with seromuscular sutures. Gross failure of the three locations: anastomosis calls for taking it down and At the defect through the transverse creating a new one. No patient should mesocolon (in retrocolic fashion). leave the operating room with a failed test At the space between the transverse of a foregut anastomosis. colon or transverse mesocolon and However, in a colorectal anastomosis, the jejunal mesentery of the Roux the situation may arise where the anastolimb (Petersens defect). motic integrity is a concern but any revi At the jejunojejunostomy. Closing these spaces can prevent an sion would be imprudent or impractical. internal hernia, although some surgeons Options here include a diverting colostomay elect to not close Petersens defect my or ileostomy. The latter is an excellent owing to the relatively low incidence of option, as it is easy to create and reverse with a second operation.11 herniation at this site in some series.8,9

FAST TRACK

A special anastomosis, such as the Roux-en-Y gastrojejunostomy, carries greater potential for herniation.

Inspecting the anastomosis

At the completion of a GI anastomosis, inspect the finished product carefully. Closely observe suture or staple lines circumferentially for gaps or failure to create
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Making a safer anastomosis

As surgeons, we are always searching for ways to decrease complications and optimize outcomes. We follow with a distillation of the literature on this topic.
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How to construct a hand-sewn GI anastomosis

hese steps illustrate the construction of an antecolic pylorojejunostomy in a patient undergoing pancreaticoduodenectomy for ampullary adenocarcinoma. First, laterally place stay sutures to approximate the pylorus and jejunum (FIGURE 2 ). Next, place a posterior row of silk sutures. A helpful technique is to divide and conquer, placing the first suture in the center of the suture line and continuing in

this fashion until the entire posterior row of silk sutures has been placed (FIGURE 3 ). Remove the staple line from the pylorus with electrocautery and create a jejunotomy of commensurate length in the jejunum (FIGURE 4 ). Healthy mucosa demonstrates excellent perfusion of the bowel. Leaving all the tails of the silk sutures in situ greatly facilitates exposure when creating the jejunostomy.

FIGURE 2 Lateral sutures

FIGURE 3 Center-row sutures

FIGURE 4 Remove staple line

Laterally place stay sutures to approximate Place the posterior-row sutures in the the pylorus and jejunum. center of the suture line.

Remove the staple line from the pylorus with electrocautery and jejunotomy.

FAST TRACK

Studies have shown no difference in complication rates between hand-sutured and stapled GI anastomoses, except in the ileocolic location.

MALPRACTICE MINUTE

Multiple operations follow delayed diagnosis of leak See P 52 and submit your verdict at: contemporarysurgery.com 72

Hand-sutured or stapled approach The data comparing these two approaches is frequently conflicting. Meta-analyses of randomized controlled trials of handsutured versus stapled esophagogastric, ileocolic, ileoanal, and colorectal anastomoses exist.1216 However, only one has demonstrated a difference, having found significantly fewer anastomotic leaks among stapled ileocolic anastomoses.13 This poses an argument for the stapled technique for ileocolic anastomosis. These data have shown no difference or have been inconclusive as regards to other areas in the GI tract. Although all surgeons should be proficient in more than one method of creating an anastomosis, a surgeon should perform the anastomosis utilizing a technique he or she is most comfortable with. Material costs may also influence this decision. Single- versus two-layer anastomosis Although a two-layer technique is the standard and would seemingly provide
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added security, a single-layer anastomosis is conceivably cheaper, faster, and may reduce both ischemia to the bowel edges and lumen narrowing. A recent meta-analysis found similar leak rates between the two techniques. From an economic viewpoint, a singlelayer anastomosis might offer a slight advantage.16 The meta-analysis was limited by the number and quality of available randomized controlled trials. To drain or not to drain Placement of a surgical drain at the anastomosis site may avoid fluid collections, prevent hematomas, and permit identification and management of potential anastomotic leaks. However, prospective studies and a meta-analysis have been inconclusive that routine placement of drains in colorectal surgery decreased complications or the need for reintervention.18,19 Unfortunately, few studies have examined drainage for
CONTEMPORARY SURGERY

Safe anastomosis

Next, cut the tails of the posterior-row silk sutures, leaving one stitch intact to facilitate placement of the inner layer of 3-0 Vicryl sutures. Use two 3-0 Vicryl sutures to create the inner layer of the anastomosis. Place these immediately adjacent to one another and the final silk suture of the posterior layer cut (FIGURE 5). Create the inner layer of the anastomosis with a running technique. Run the first 3-0 Vicryl suture along

the back wall of the anastomosis, and the second suture around the anterior wall, utilizing a Connell stitch for the anterior wall (FIGURE 6 ). Finally, create the outer layer of the anterior layer of the interior wall with interrupted silk sutures utilizing seromuscular bites (FIGURE 7 ).

CBS, NZ, SM FIGURE 7 Outer-layer sutures

FIGURE 5 Inner-layer sutures

FIGURE 6 Connell stitch

Place the inner layer of 3-0 Vicryl sutures immediately adjacent to one another.

Use a Connell stitch for the second suture around the anterior wall.

Use interrupted silk sutures utilizing seromuscular bites to create the outer layer.

upper GI anastomoses, so evidence-based recommendations are lacking in this setting.20 Buttresses Applying fibrin glue to an intestinal anastomosis may act as a sealant and decrease leak rates. Animal data have supported this beneficial effect.21,22 Prospective studies of bariatric surgery have demonstrated decreased leak rates from gastro-jejunal and jejunal-jejunal anastomoses reinforced with fibrin glue.23-25 Additionally, no adverse affects of fibrin glue application have been reported. Staple-line reinforcement materials, including bovine pericardium and expanded polytetrafluoroethylene (ePTFE), were initially used in thoracic surgery for lung resection. Their success in decreasing stapleline bleeding and air leaks from the lung has led to their application in GI surgery. Completely absorbable staple-line reinforcements are also available. These
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include products made from polyglycolic acid: trimethylene carbonate and cellulose. Animal studies of these materials have supported their application to increase anastomotic bursting pressure. Human studies, mainly uncontrolled trials, have demonstrated potential benefit for decreasing staple-line bleeding and leak rates.25 One must balance the increased cost of using either fibrin glue or staple-line reinforcement materials against their potential benefit.
Disclosure
The authors did not disclose any affiliations.

FAST TRACK

Animal data have supported the application of brin glue to act as a sealant on an intestinal anastomosis.

References
1. Spraycar M, ed. Stedmans medical dictionary, 26th ed. Baltimore, MD: William and Wilkins; 1995. 2. Dellinger EP, Gross PA, Barrett TL, et al. Quality standard for antimicrobial prophylaxis in surgical procedures. The Infectious Diseases Society of America. Infect Control Hosp Epidemiol. 1994;15:182-188. 3. Sacks GS, Kudsk KA. Nutritional support in the critically ill. In: Cameron JL, ed. Current Surgical Therapy, 8th ed. Philadelphia, PA: Elsevier Mosby; 2004.

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Evidence-based best practice recommendations P 74. 73

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Recommendations for best practices in creating a GI anastomosis

1. Ensure an adequate blood supply, eliminate tension, maintain hemostasis, and handle tissues gently. Level of evidence: 5Expert opinion without explicit critical appraisal, or based on physiology, bench research or rst principles.32 2. Use an inverting (serosa-to-serosa), or an everting, with minimal exposed mucosa, technique. Level of evidence: 5 3. Close mesenteric defects to avoid internal hernia. Level of evidence: 5 4. Consider a stapled technique for ileocolic anastomoses; elsewhere in the GI tract either a hand-sutured or stapled anastomosis may be employed. Level of evidence: 1aSystematic review (with homogeneity) of randomized clinical trial32 5. A single-layer anastomosis is an acceptable technique. Level of evidence: 1a

15. Lustosa SA, Matos D, Atallah AN, Castro AA. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database of Systematic Reviews. 2001;(3):CD003144. 16. MacRae HM, McLeod RS. Handsewn vs stapled anastomoses in colon and rectal surgery: a meta-analysis. Dis Colon Rectum. 1998; 41:180-189. 17. Shikata S, Yamagishi H, Taji Y, Shimada T, Noguchi Y. Single- versus two-layer intestinal anastomosis: a meta-analysis of randomized control trials. BMC Surgery. 2006;6:2. 18. Jesus EC, Karliczek A, Matos D, Castro AA, Atallah AN. Prophylactic anastomotic drainage for colorectal surgery. Cochrane Database of Systematic Reviews. 2004;(4): CD002100. 19. Yeh CY, Changchein CR, Wang JY, et al. Pelvic drainage and other risk factors for leakage after elective anterior resection in rectal cancer patients: a prospective review of 978 patients. Ann Surg. 2005;241:9-13. 20. Petrowsky H, Demartines N, Rousson V, Clavien P-A. Evidence-based value of prophylactic drainage in gastrointestinal surgery. A systematic review and meta-analysis. Ann Surg. 2004;240:1074-1085. 21. Bonanomi G, Prince JM, McSteen F, Schauer PR, Hamad GG. Sealing effect of fibrin glue on the healing of gastrointestinal anastomoses: implications for the endoscopic treatment of leaks. Surg Endo. 2004;18:1620-1624. 22. Kanellos I, Mantzoros I, Goulimaris I, Zacharakis E, Zavitsanakis A, Betsis D. Effects of the use of fibrin glue around the colonic anastomosis of the rat. Techniques in Coloproctology. 2003;7:82-84. 23. Silecchia G, Boru CE, Mouiel J, et al. Clinical evaluation of fibrin glue in the prevention of anastomotic leak and internal hernia after laparoscopic gastric bypass: preliminary results of a prospective, randomized multicenter trial. Obesity Surg. 2006;16:125-131. 24. Sapala JA, Wood MH, Schuhknecht MP. Anastomotic leak prophylaxis using vapor-heated fibrin sealant: report on 738 gastric bypass patients. Obesity Surg. 2004;14:35-42. 25. Liu CD, Glantz GJ, Livingston EH. Fibrin glue as a sealant for high-risk anastomosis in surgery for morbid obesity. Obesity Surg. 2003;13:45-48. 26. Yo LS, Consten EC, Quarles van Ufford HM, Gooszen HG, Gagner M. Buttressing of the staple line in gastrointestinal anastomoses: overview of the new technology designed to reduce perioperative complications. Dig Surg. 2006;23:283-291. 27. Mellish RW. Inverting or everting sutures for bowel anastomoses. An experimental study. J Ped Surg. 1966;1:260265. 28. Ravitch MM, Canalis F, Weinshelbaum A, McCormick J. Studies in intestinal healing: III. Observations on everting intestinal anastomoses. Ann Surg.1967;166:670-680. 29. Rusca JA, Bornside GH, Cohn I, Jr. Everting versus inverting gastrointestinal anastomoses: Bacterial leakage and anastomotic disruption. Ann Surg. 1969;169:727-735. 30. Hearn D, Cohn I Jr. Inverted versus everted gastrointestinal anastomoses: The role of the everted mucosa in anastomotic breakdown. Am Surg. 1970;36:728-730. 31. Abramowitz HB, Butcher HR. Everting and inverting anastomoses. An experimental study of comparative safety. Am J Surg. 1971;121:52-56. 32. Jones RS, Richard K. Office of Evidence-Based Surgery charts course for improved system of care. Bull Am Coll Surg. 2003;88(4):11-21.

CBS, NZ, SM
4. Campos AC, Meguid MM. A critical appraisal of the usefulness of perioperative nutritional support. Am J Clin Nutr. 1992;55: 117-130. 5. Park WM, Gloviczki P, Cherry KJ, et al. Contemporary management of acute mesenteric ischemia: Factors associated with survival. J Vasc Surg. 2002;35 445-452. 6. Lee JC, Peitzman AB. Damage-control laparotomy. Curr Opin Crit Care. 2006;12:346-350. 7. Goto T, Kawasaki K, Fujino Y, et al. Evaluation of the mechanical strength and patency of functional end-to-end anastomoses. Surg Endosc. 2007;21:1508-1511. 8. Cho M, Pinto D, Carrodeguas L, et al. Frequency and management of internal hernias after laparoscopic antecolic antegastric Roux-en-Y gastric bypass without division of the small bowel mesentery or closure of mesenteric defects: review of 1400 consecutive cases. Surg Obes Relat Dis. 2006;2:87-91. 9. Garza E Jr, Kuhn J, Arnold D, Nicholson W, Reddy S, McCarty T. Internal hernias after laparoscopic Roux-en-Y gastric bypass. Amer J Surg. 2004;188:796-800. 10. Scott-Conner CE. Surgical Stapling: Principles and Precautions. In: Chassins Operative Strategy in General Surgery: an Expositive Atlas, 3rd ed. New York, NY: Springer: 2002;38-43. 11. Bax TW, McNevin MS. The value of diverting loop ileostomy of the high-risk colon and rectal anastomosis. Amer J Surg. 2007;193:585-587. 12. Urschel JD, Blewett CJ, Bennett WF, Miller JD, Young JE. Handsewn or stapled esophagogastric anastomoses after esophagectomy for cancer: meta-analysis of randomized controlled trials. Dis Esophagus. 2001;14:212-217. 13. Choy PY, Bissett IP, Docherty JG, Parry BR, Merrie AE. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database of Systematic Reviews. 2007;(3):CD004320. 14. Lovegrove RE, Constantinides VA, Heriot AG, et al. A comparison of hand-sewn versus stapled ileal pouch anastomosis (IPAA) following proctocolectomy: a meta-analysis of 4183 patients. Ann Surg. 2006;244:18-26.

FAST TRACK

Evidence supports the use of the single-layer technque and stapled technique for ileocolic anastomosis.

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