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9 Contemporary Management of the Open Abdomen 245
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the patient’s condition allows and must not be based around the convenience of
theatre staff availability. If an enteroatmospheric fistula develops then the emphasis on management should change according to the SNAP algorithm and referral
to a specialised tertiary referral centre should be considered.
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Anastomotic Techniques for Crohn’s
https://t.me/med1917
Surgery
Antonino Spinelli and Elisa Paoluzzi Tomada
Abstract
Surgery plays a pivotal role in Crohn’s disease treatment. More than 75%
of Crohn’s disease patients will eventually need surgical intervention despite
medical therapy. The surgical approach in Crohn’s disease should follow the
principles of bowel sparing and minimal invasiveness. Optimal timing and
indications for surgery should be defined in a multidisciplinary setting including at least a surgeon, a gastroenterologist, and a radiologist. The stage of
disease, operative map, clinical and drug patient history and conditions are
the main factors to be considered in selecting the ideal surgical strategy.
The most common scenario is ileocecal resection for terminal ileitis. When
considering restorative surgery, different anastomotic techniques have been proposed, and, even after many studies, the debate is open regarding whether a
specific type of anastomosis prevents disease recurrence at the anastomotic
site. A wide lumen side-to-side stapled anastomosis is the most commonly
used technique, but clear evidence is lacking on the advantages of a specific
technique over another. Encouraging results are increasingly reported on the
possible advantages of the functional antimesenteric end-to-end anastomosis
described by Kono et al. in terms of reduced site-specific recurrence. Regarding bowel-sparing approaches, strictureplasties are commonly used in Crohn’s
surgery. Various types of strictureplasty have developed in the past century,
including conventional procedures (i.e. Heinecke-Mickulicz), intermediate procedures (i.e., Finney), and enteroenterostomies (i.e. Michelassi strictureplasty
and its modifications). In the literature over 15 types of strictureplasty techniques have been described. Among Crohn’s disease specific techniques, many
10
A. Spinelli (B) · E. Paoluzzi Tomada
Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4,
20090 Pieve Emanuele, MI, Italy
e-mail: antonino.spinelli@hunimed.eu
Humanitas Research Hospital—IRCCS, Via Manzoni 56, 20089 Rozzano, MI, Italy
© The Author(s), under exclusive license to Springer Nature Switzerland AG 2024
M. Evans e t al. (eds.), Coloproctology, https://doi.org/10.1007/978-3-031-59630-8_10
251
252 A. Spinelli and E. Paoluzzi Tomada
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are currently routine surgical practices, and others remain under investigation.
Future research should aim to identify interrelated factors that could define the
most suitable procedures for the right patient, minimizing bowel resection and
limiting the risk for complications and recurrence.
Keywords
Crohn’s disease•Anastomotic techniques•Intestinal anastomosis•Bowel
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resection
Surgical management•Strictureplasty•Side-to-side anastomosis
End-to-end anastomosis•Stapled anastomosis•Hand-sewn anastomosis
Key Points
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Limited resection and minimally invasive approach.
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Multidisciplinary team should define timing and indications for surgery.
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Wide lumen side-to-side stapled anastomosis is the most commonly used.
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The Kono-S anastomosis may reduce site-specific recurrence.
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A variety of sricturoplasties havebeen described in order to preserve bowel length.
10.1 Surgical Principles in Crohn’s Disease
Crohn’s disease (CD) is an inflammatory bowel disease with a chronic, recurrent,
and often unpredictable pan-intestinal involvement affecting people of all ages
[1, 2]. The disease has a progressive and multifaceted natural course including
various stages that can be characterized as fibro-inflammatory disease, pure fibrotic
disease, fistulising disease, and fistulising disease with abscess formation [3]. The
clinical presentations can be of a wide spectrum, from chronic painful conditions
up to acute situations. Historically, it has been described that up to 3 patients out of
4 are refractory to medical therapy and require surgery within 10 years of diagnosis
[4, 5]. Despite major improvements in medical therapies, this percentage has only
partially decreased, and surgery remains a primary option for many patients.
CD surgical management should follow the principles of bowel sparing and
of minimal invasiveness. In fact, approximately 40% of surgical CD patients
experience clinical disease recurrence after surgery, and a relevant percentage (30–
50%) will undergo additional surgical procedures. From this perspective, minimal
bowel resection with restorative surgery and bowel-sparing procedures should be
considered when planning a surgical operation.
The nature of CD implies that the location of disease activity can impact on
symptoms severity and on surgical strategy. The most commonly affected area is
the terminal ileum, but the entire gastrointestinal tract can be affected. Among
all presentations, perianal CD is associated with a poor prognosis and reduced
patient quality of life [6]. The most common surgical procedure is ileocecal (or
ileocolic) resection with restoration of bowel continuity. A range of anastomotic
techniques have been described. Discussion is active on potential advantages of
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a specific anastomotic type and the impact on postoperative morbidity, anastomotic site-specific recurrence, and reoperation for recurrence. Consensus and
surgical practice show a preference for side-to-side stapled anastomosis [7, 8].
Other common configurations are end-to-end handsewn, end-to-side and sideto-end anastomosis. Concerning postoperative morbidity and short- and longterm results, no clear evidence or high-quality studies i.e. randomized controlled
trials exist to define major differences among the conventional anastomotic techniques. What seems evident is that wide lumen anastomoses are safer and reduce
anastomotic recurrence.
Recently, promising results have been presented after the introduction of the
functional antimesenteric end-to-end anastomosis described by Kono et al. [9].
This innovative handsewn antimesenteric anastomotic technique was conceived
with the aim of reducing the anastomotic recurrence rate—clinical, endoscopic,
and surgical in CD patients. Initial results found an almost nil endoscopic recurrence, and a surgical recurrence below 2% at 5–10 years follow up. These results
prompted the modelling of variations of this anastomotic type (i.e., stapled) and
the fostering of dedicated clinical trials.
The main site of recurrence varies depending on the initial type of surgery
performed. After resection, recurrence presents mostly at the site of anastomosis, whereas, if stricturoplasties are performed, recurrence generally develops at a
different location [10–12].
It is fundamental for CD surgeons to acknowledge the different anastomotic
types and to be familiar with bowel-sparing techniques that can be performed
on fibrotic bowel segments. Stricturing disease is more common in recurrent CD
presentations. Stricturoplasties are a crucial tool for surgeons to maximize bowel
preservation by avoiding resection, and limiting the risk of short bowel syndrome.
There are a variety of options. Stricturoplasties can be categorized into three
classes: Heinecke-Mikulicz like, intermediate procedures, and enteroenterostomies
(Michelassi modifications) [13]. The latter class defines fibrotic bowel segment
rearrangement, with the construction of an entero-entero anastomosis.
The role of the surgeon is challenging, requiring a final call on which type of
procedure is utilized for each segment of diseased bowel. Surgical exploration of
the abdominal cavity and of the entire bowel is a mandatory step in any intervention for CD. In fact, at the time of surgery, an operative map should be created to
customize the surgical treatment to the extent of the disease. In many cases, a combination of ileocecal resection and stricturoplasties is performed [14]. Preoperative
work-up is advisable and may present a fundamental tool for surgeons: magnetic
resonance imaging, for example, is essential to formulate a preoperative surgical
plan, and avoids radiation that may come from the use of computed tomography
[15].
Minimal invasiveness is crucial for CD patients. Since the risk of reoperation
is always present and considering that patients are often very young and care
about the cosmetic outcome, the benefits of minimally invasive surgery are obvious. The laparoscopic approach is defined as the gold standard for CD patients
because of reduced morbidity, shorter hospital stay, less adhesion formation, and
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improved cosmetic outcome compared to the open approach [7, 16]. Laparoscopy
has also proven to be safe and effective in complex and recurrent CD conditions [17–21]. More and more, additional minimally invasive approaches, above
all single-incision and robotic are being implemented in CD surgery. Single-port
surgery in CD is safe and effective, allowing ileocecal resection and eventually
additional stricturoplasties through a single incision and bowel externalization
[22–24]. Following minimal access approaches, an enhanced recovery pathway
should be encouraged for CD patients to foster a rapid return to normal function
[25]. Training of surgeons for these procedures should be implemented and targeted to minimal access approaches considering the specifics of CD surgery (i.e.,
documentation of bowel length, bowel sparing procedures, mesenteric friability)
[26].
Another important factor to be considered is the timing of surgery. It is often
controversial and a matter of multidisciplinary discussion because the available
therapies, the disease course and patients’ preferences must all be considered when
planning the best therapeutic strategy for CD patients. An increasing number of
early surgeries are offered to patients because they could be more cost-effective in
the overall CD patient treatment [27]. Early surgery would allow for a technically
easier procedure, likely in surgery-naïve patients, and for a reduced complication
rate [28]. Evidence supporting this change in practice comes from the LIRIC trial,
the first trial comparing laparoscopic ileocecal resection after failed conventional
medical therapy and anti-TNF therapy. The trial proved that early surgery offers a
similar quality of life [29].
CD surgery has a high rate of postoperative complications and of reintervention. Postoperative complications may be increased by preoperative factors such
as malnutrition, anaemia, immune status, disease activity and phenotype and medical therapy timing. Abdominal sepsis and anastomotic leak may present in up
to 30% of patients undergoing ileocecal resection [30]. Reintervention implies a
major risk for short bowel syndrome (SBS) in CD patients. A length of remnant
small bowel<200 cm, total colectomy, and frequent reintervention (≥3 times) are
factors found to be predictive of the development of SBS in these patients [31].
Planning surgery for CD patients requires defining the appropriate timing and
preoperative optimization with adequate nutritional assessment and support, and
immunomodulating drug discontinuation [32]. To obtain a complete overview of
the disease stage and activity, patient status, expectations and desires, a multidisciplinary approach to every case in a referral centre is strongly recommended [2,
33] to reduce postoperative complications and recurrence.
This chapter will focus on the practical aspects of the spectrum of anastomotic techniques specific for CD surgery. In particular, the anastomotic techniques
used in ileocaecal resections, the main restorative procedures after colectomy
and proctocolectomy, and the most relevant bowel-sparing procedures, namely,
stricturoplasties.
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