Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Intestinal Anastomosis

  • Author: Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS; Chief Editor: Kurt E Roberts, MD  more...
 
Updated: Mar 11, 2016
 

Practice Essentials

Intestinal anastomosis is a surgical procedure to establish communication between two formerly distant portions of the intestine. This procedure restores intestinal continuity after removal of a pathologic condition affecting the bowel.

Indications and contraindications

Indications

Indications for intestinal anastomosis can be broadly divided into two categories: restoration of bowel continuity following resection of diseased bowel and bypass of unresectable diseased bowel. Certain pediatric conditions may also require intestinal anastomosis.

Resection of diseased bowel is performed in the following settings:

  • Bowel gangrene due to vascular compromise caused by mesenteric vascular disease, prolonged intestinal obstruction, intussusceptions, or volvulus
  • Malignancy
  • Benign conditions (eg, intestinal polyps, intussusception, roundworm infestation with intestinal obstruction )
  • Infections (eg, tuberculosis complicated with stricture or perforation)
  • Traumatic perforations
  • Large perforations (traumatic) not amenable to primary closure
  • Radiation enteritis complicated with bleeding, stricture, or perforation
  • Inflammatory bowel disease, ulcerative colitis, or Crohn disease that is refractory to medical therapy or associated with complications (eg, bleeding, perforation, toxic megacolon, dysplasia/carcinoma)
  • Chronic constipation, idiopathic slow transit constipation, or Hirschsprung disease: Subtotal colectomy may be performed when the disease is refractory to medical therapy

Bypass of unresectable diseased bowel is performed in following settings:

  • Locally advanced tumor causing luminal obstruction
  • Metastatic disease causing intestinal obstruction
  • Poor general condition or condition that prevents major resection

Pediatric conditions for which intestinal anastomosis may be required include the following:

  • Congenital anomalies (eg, Meckel diverticulum, intestinal atresia, malrotation with volvulus leading to gangrene, meconium ileus, duplication cysts, Hirschsprung disease)
  • Inflammatory conditions (eg, necrotizing enteritis, enterocolitis, tuberculosis, enteric perforation)
  • Other conditions (eg, intussusception, angiodysplasia, polypoid disease, ascariasis)
  • As a part of other surgical procedures (eg, Kasai portoenterostomy, choledochal cyst, urinary diversions, pancreatic neoplasms)

Contraindications

Contraindications to intestinal anastomosis include conditions in which there is high risk of anastomotic leak, such as the following:

  • Severe sepsis
  • Poor nutritional status (eg, severe hypoalbuminemia)
  • Disseminated malignancy (multiple peritoneal and serosal deposits, ascites)
  • Viability of bowel in doubt
  • Fecal contamination or frank peritonitis
  • Unhealthy bowel condition - Precludes primary anastomosis

Perioperative management

Perioperative management includes the following:

  • Preoperative fluid resuscitation
  • Preoperative antibiotic prophylaxis
  • Placement of nasogastric tube and indwelling urinary catheter
  • Venous thromboembolism prophylaxis

Operative techniques

Adequate exposure and access, gentle handling of the bowel, adequate hemostasis, approximation of well-vascularized bowel, absence of tension at anastomosis, good surgical technique, and avoidance of fecal contamination are tenets of good intestinal anastomosis.

The image below depicts a completed small-bowel anastomosis.

Completed small bowel anastomosis. Completed small bowel anastomosis.

Surgical techniques used in intestinal anastomosis include the following:

  • Incision and exposure
  • Bowel resection
  • Hand-sewn anastomosis (eg, bowel anastomosis, gastrojejunostomy, colorectal anastomosis, esophagogastric anastomosis)
  • Stapled anastomosis (eg, gastrojejunostomy, small bowel anastomosis, colorectal anastomosis, cervical esophagogastric anastomosis)

Postoperative complications

Important complications following intestinal anastomosis include the following:

  • Anastomotic leak
  • Bleeding
  • Wound infection
  • Anastomotic stricture
  • Prolonged functional ileus, especially in children
Next

Background

Intestinal anastomosis is a surgical procedure to establish communication between two formerly distant portions of the intestine. This procedure restores intestinal continuity after removal of a pathologic condition affecting the bowel. Intestinal anastomosis is one of the most commonly performed surgical procedures, especially in the emergency setting, and is also commonly performed in the elective setting when resections are carried out for benign or malignant lesions of the gastrointestinal tract.

A disastrous complication of intestinal anastomosis is anastomotic leak resulting in peritonitis, which is associated with high morbidity and mortality. Proper surgical technique and adherence to fundamental principles is imperative to ensure successful outcome after intestinal anastomosis.

Intestinal anastomosis can be performed by means of a hand-sewn technique that uses absorbable or nonabsorbable sutures or by means of stapling. The former is the more commonly used option because of the availability and affordability of suture materials and the wide familiarity with the procedure. The increased availability of stapling devices for intestinal anastomosis has provided an alternative option to perform a rapid anastomosis. Higher cost, limited availability, and less familiarity are the main drawbacks of these devices. Less common techniques for intestinal anastomosis use compression devices (biofragmentable anastomotic rings), glue (tissue or synthetic), and laser welding.[1, 2, 3, 4]

Intestinal anastomosis in neonatal and pediatric patients may be required for the management of many conditions. Some conditions may necessitate resection of pathology followed by primary anastomosis, whereas other conditions may necessitate delayed anastomosis. Intestinal anastomosis may also be necessary in the management of some nonintestinal anomalies.

Previous
Next

Indications

Indications for intestinal anastomosis can be broadly divided into two categories: restoration of bowel continuity after resection of diseased bowel and bypass of unresectable diseased bowel.

Restoration of bowel continuity after resection of diseased bowel

Resection of diseased bowel is performed in the following settings:

  • Bowel gangrene secondary to vascular compromise resulting from mesenteric vascular disease, prolonged intestinal obstruction, intussusceptions, or volvulus
  • Malignancy
  • Benign conditions, such as intestinal polyps, intussusception, or roundworm infestation with intestinal obstruction
  • Infections, such as tuberculosis complicated with stricture or perforation
  • Traumatic perforations
  • Large perforation (traumatic) not amenable to primary closure
  • Radiation enteritis complicated with bleeding, stricture, or perforation
  • Inflammatory bowel disease (IBD),  ulcerative colitis, or Crohn disease when disease is refractory to medical therapy or associated with complications such as bleeding, perforation, toxic megacolon, or dysplasia/carcinoma
  • Chronic constipation, idiopathic slow-transit constipation, or Hirschsprung disease, for which subtotal colectomy may be performed when the disease is refractory to medical therapy

Bypass of unresectable diseased bowel

Bypass of unresectable diseased bowel is performed in the following settings:

  • Locally advanced tumor causing luminal obstruction
  • Metastatic disease causing intestinal obstruction
  • Poor general condition or condition that prevents major resection

Pediatric conditions

Pediatric conditions for which intestinal anastomosis may be required include the following:

  • Congenital anomalies, such as Meckel diverticulum, intestinal atresia, malrotation with volvulus leading to gangrene, meconium ileus, duplication cysts, and Hirschsprung disease
  • Inflammatory conditions, such as necrotizing enteritis, enterocolitis, tuberculosis, and enteric perforation
  • Other conditions, such as intussusception, angiodysplasia, polypoid disease, and ascariasis
  • As a part of other surgical procedures, such as Kasai portoenterostomy, choledochal cyst, urinary diversions, pancreatic neoplasms
Previous
Next

Contraindications

Intestinal anastomosis is contraindicated in conditions where there is a high risk of anastomotic leak, such as the following:

  • Severe sepsis
  • Poor nutritional status (eg, severe hypoalbuminemia)
  • Disseminated malignancy (multiple peritoneal and serosal deposits, ascites)
  • Viability of bowel in doubt
  • Fecal contamination or frank peritonitis
  • Unhealthy bowel condition (precludes primary anastomosis)
Previous
Next

Technical Considerations

Best practices

Adequate exposure and access, gentle handling of the bowel, adequate hemostasis, approximation of well-vascularized bowel, absence of tension at anastomosis, good surgical technique, and avoidance of fecal contamination are tenets of good intestinal anastomosis.

Procedural planning

Although an inverting anastomosis has been found to be better than an everting anastomosis, there is no difference in complication rates between single-layer and double-layer techniques or between continuous and interrupted anastomosis.

Stapled anastomotic technique has virtually replaced hand-sewn technique for low colorectal anastomosis, and its use in other areas has also increased. Although stapled anastomosis has not yet been proved superior to hand-sewn anastomosis, it has definitely reduced the operating time and facilitated the ease of doing the procedure, especially in low colorectal anastomosis.

Although restoration of bowel continuity is generally preferred, a decision has to be made judiciously in emergency settings. A staged procedure may be preferred for restoration of bowel continuity if the general condition of the patient is not good enough to avoid the complications associated with anastomotic leak.

Complication prevention

An important component of preventing complications related to intestinal anastomosis is to complete preoperative optimization of patients' medical status, including correction of malnutrition with nutritional support and treatment of associated systemic illness. However, this is generally possible only in elective resections, not in emergency situations.

The following can also help prevent complications:

  • Adequate exposure and access
  • Gentle handling of the bowel
  • Adequate hemostasis
  • Approximation of well-vascularized bowel
  • Absence of tension at anastomosis
  • Good surgical technique
  • Avoidance of fecal contamination

It is very important to prevent hypothermia and hypovolemia during surgery, especially in children. Thermal mattresses should be used for thermoregulation, especially for neonates. Fluid loss should be minimized and losses should be adequately replaced. Adequate blood should be arranged.

Previous
 
 
Contributor Information and Disclosures
Author

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS Professor of General and Gastrointestinal Surgery and Senior Consultant Surgeon, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), India

Vikram Kate, MBBS, PhD, MS, FRCS, FRCS(Edin), FRCS(Glasg), FACS, FACG, FIMSA, MAMS, MASCRS is a member of the following medical societies: American College of Gastroenterology, American College of Surgeons, American Society of Colon and Rectal Surgeons, Royal College of Surgeons of England, Royal College of Physicians and Surgeons of Glasgow, Royal College of Surgeons of Edinburgh

Disclosure: Nothing to disclose.

Coauthor(s)

Raja Kalayarasan, MBBS, MS, MCh Senior Resident, Department of Surgical Gastroenterology, GB Pant Hospital, India

Disclosure: Nothing to disclose.

Anup Mohta, MBBS, MS, MCh MAMS, FIMSA, FIAPS, FISPU, Professor and Head, Department of Pediatric Surgery, Chacha Nehru Bal Chikitsalaya and Maulana Azad Medical College, India

Anup Mohta, MBBS, MS, MCh is a member of the following medical societies: Indian Medical Association, Indian Academy of Pediatrics, Association of Surgeons of India, Indian Association of Pediatric Surgeons

Disclosure: Nothing to disclose.

Chief Editor

Kurt E Roberts, MD Assistant Professor, Section of Surgical Gastroenterology, Department of Surgery, Director, Surgical Endoscopy, Associate Director, Surgical Skills and Simulation Center and Surgical Clerkship, Yale University School of Medicine

Kurt E Roberts, MD is a member of the following medical societies: American College of Surgeons, Society of American Gastrointestinal and Endoscopic Surgeons, Society of Laparoendoscopic Surgeons

Disclosure: Nothing to disclose.

Acknowledgements

Acknowledgments

The authors thank their residents at the Department of Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry for help in putting together the images for this article.

The authors also thank Ms. Anahita Kate, VII Semester Medical Student, Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Pondicherry, for her valuable assistance in the preparation of this manuscript.

References
  1. Kaidar-Person O, Rosenthal RJ, Wexner SD, Szomstein S, Person B. Compression anastomosis: history and clinical considerations. Am J Surg. 2008 Jun. 195(6):818-26. [Medline].

  2. Nursal TZ, Anarat R, Bircan S, Yildirim S, Tarim A, Haberal M. The effect of tissue adhesive, octyl-cyanoacrylate, on the healing of experimental high-risk and normal colonic anastomoses. Am J Surg. 2004 Jan. 187(1):28-32. [Medline].

  3. Bae KB, Kim SH, Jung SJ, Hong KH. Cyanoacrylate for colonic anastomosis; is it safe?. Int J Colorectal Dis. 2010 May. 25(5):601-6. [Medline].

  4. Spector D, Rabi Y, Vasserman I, Hardy A, Klausner J, Rabau M. In vitro large diameter bowel anastomosis using a temperature controlled laser tissue soldering system and albumin stent. Lasers Surg Med. 2009 Sep. 41(7):504-8. [Medline].

  5. Nichols RL, Condon RE. Preoperative preparation of the colon. Surg Gynecol Obstet. 1971 Feb. 132(2):323-37. [Medline].

  6. Guenaga KK, Matos D, Wille-Jørgensen P. Mechanical bowel preparation for elective colorectal surgery. Cochrane Database Syst Rev. 2009. (1):CD001544. [Medline].

  7. Bucher P, Gervaz P, Morel P. Should preoperative mechanical bowel preparation be abandoned?. Ann Surg. 2007 Apr. 245(4):662. [Medline]. [Full Text].

  8. James AW, Rabl C, Westphalen AC, Fogarty PF, Posselt AM, Campos GM. Portomesenteric venous thrombosis after laparoscopic surgery: a systematic literature review. Arch Surg. 2009 Jun. 144(6):520-6. [Medline].

  9. Penna M, Knol JJ, Tuynman JB, Tekkis PP, Mortensen NJ, Hompes R. Four anastomotic techniques following transanal total mesorectal excision (TaTME). Tech Coloproctol. 2016 Mar. 20 (3):185-91. [Medline].

  10. Simillis C, Hompes R, Penna M, Rasheed S, Tekkis PP. A systematic review of transanal total mesorectal excision: is this the future of rectal cancer surgery?. Colorectal Dis. 2016 Jan. 18 (1):19-36. [Medline].

  11. Orringer MB, Marshall B, Iannettoni MD. Eliminating the cervical esophagogastric anastomotic leak with a side-to-side stapled anastomosis. J Thorac Cardiovasc Surg. 2000 Feb. 119(2):277-88. [Medline].

  12. Wrighton L, Curtis JL, Gollin G. Stapled intestinal anastomoses in infants. J Pediatr Surg. 2008 Dec. 43(12):2231-4. [Medline].

  13. Trencheva K, Morrissey KP, Wells M, Mancuso CA, Lee SW, Sonoda T, et al. Identifying important predictors for anastomotic leak after colon and rectal resection: prospective study on 616 patients. Ann Surg. 2013 Jan. 257(1):108-13. [Medline].

  14. Barone JE. Abnormal vital signs not a good indicator of anastomotic leaks. Medscape Medical News. March 24, 2014. [Full Text].

  15. Erb L, Hyman NH, Osler T. Abnormal Vital Signs Are Common after Bowel Resection and Do Not Predict Anastomotic Leak. J Am Coll Surg. 2014 Feb 28. [Medline].

  16. Deveney KE, Way LW. Effect of different absorbable sutures on healing of gastrointestinal anastomoses. Am J Surg. 1977 Jan. 133(1):86-94. [Medline].

  17. Burch JM, Franciose RJ, Moore EE, Biffl WL, Offner PJ. Single-layer continuous versus two-layer interrupted intestinal anastomosis: a prospective randomized trial. Ann Surg. 2000 Jun. 231(6):832-7. [Medline]. [Full Text].

  18. Shikata S, Yamagishi H, Taji Y, Shimada T, Noguchi Y. Single- versus two- layer intestinal anastomosis: a meta-analysis of randomized controlled trials. BMC Surg. 2006 Jan 27. 6:2. [Medline]. [Full Text].

  19. Garude K, Tandel C, Rao S, Shah NJ. Single layered intestinal anastomosis: a safe and economic technique. Indian J Surg. 2013 Aug. 75 (4):290-3. [Medline].

  20. Sajid MS, Siddiqui MR, Baig MK. Single layer versus double layer suture anastomosis of the gastrointestinal tract. Cochrane Database Syst Rev. 2012 Jan 18. 1:CD005477. [Medline].

  21. Shandall A, Lowndes R, Young HL. Colonic anastomotic healing and oxygen tension. Br J Surg. 1985 Aug. 72(8):606-9. [Medline].

  22. Lustosa SA, Matos D, Atallah AN, Castro AA. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev. 2001. CD003144. [Medline].

  23. MacRae HM, McLeod RS. Handsewn vs. stapled anastomoses in colon and rectal surgery: a meta-analysis. Dis Colon Rectum. 1998 Feb. 41(2):180-9. [Medline].

  24. Choy PY, Bissett IP, Docherty JG, Parry BR, Merrie AE. Stapled versus handsewn methods for ileocolic anastomoses. Cochrane Database Syst Rev. 2007. (3):CD004320. [Medline].

  25. Getzen LC, Roe RD, Holloway CK. Comparative study of intestinal anastomotic healing in inverted and everted closures. Surg Gynecol Obstet. 1966 Dec. 123(6):1219-27. [Medline].

  26. Goligher JC, Morris C, McAdam WA, De Dombal FT, Johnston D. A controlled trial of inverting versus everting intestinal suture in clinical large-bowel surgery. Br J Surg. 1970 Nov. 57(11):817-22. [Medline].

 
Previous
Next
 
Completed small bowel anastomosis.
Jejunal loop being prepared for antecolic gastrojejunostomy.
Third layer of gastrojejunostomy completed with continuous polyglactin suture. There is no pouting of mucosa.
Gastrojejunostomy completed using interrupted Lembert silk sutures.
Intestinal atresia with dilated proximal loop and narrow distal loop.
Two ends of the bowel after excising the atretic ends. Note the near equal lumen.
Posterior wall of anastomosis completed.
Anastomosis completed with closure of mesentry defect.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.