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10 Anastomotic Techniques for Crohn’s Surgery 255
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10.2 Restorative Surgery Techniques After Bowel
Resection
Surgical resection is indicated in CD patients in cases of ileocaecal disease, in the
presence of localized, symptomatic fistulising and perforated disease, and rarely
in CD in emergent conditions (intra-abdominal abscess not responding to other
therapies, acute peritonitis and massive haemorrhage). In cases of ileocaecal disease surgery is needed, especially in patients who are surgically naïve and without
active inflammation. An essential aspect when considering surgery in CD is always
to be conservative with respect to the amount of bowel resected.
The type of resectional surgery depends on the site of disease activity. Ileocaecal resection, segmental small bowel resections, segmental colectomy, (sub)total
colectomy, and proctocolectomy are all possible surgical options in CD patients.
Frequently, concomitant procedures may be needed in the same operative time.
Restorative procedures in any of these resection types have precise peculiarities,
rates of postoperative complications and risk of recurrence [34]. Regarding upper
gastrointestinal surgery, bypass techniques are described as feasible in CD patients.
10.3 Anastomotic Techniques After Ileocaecal Resection
Ileocaecal resection is the most common operation in CD patients, with terminal
ileitis being the most frequent presentation of active inflammatory disease.
Various anastomotic configurations have been proposed in ileocaecal resection.
The type of anastomosis chosen is defined by the surgeon and the experience of the
centre [35]. Anastomotic techniques vary in terms of conformation and orientation,
and they can be handsewn or stapled and can be performed with extracorporeal or
intracorporeal approaches when minimally invasive surgery is carried out.
Stapled anastomosis is the most commonly employed and has a lower rate of
postoperative morbidity, in both CD and other conditions i.e., reduced anastomotic
leak rate [7, 36, 37]. However, overall, the quality of the evidence is not sufficient
to establish a clear benefit of a single anastomotic technique over another. In particular, the anastomotic configuration has long been considered a critical factor for
recurrence of disease, being the main site of disease recurrence after resection. To
date, the single anastomotic element appearing to have a role in anastomotic site
recurrence is a wide lumen [7, 38]. It is possible that the large diameter of the
anastomotic lumen reduces faecal stasis, bacterial overgrowth, and the risk of wall
ischaemia which in turn could prevent mucosal healing [38]. Mucosal healing is
a main treatment target that seems to reduce anastomotic recurrence [2]. One randomized controlled trial comparing stapled side-to-side and handsewn end-to-end
anastomoses found no differences in terms of endoscopic and symptomatic recurrence rates between the two types of anastomoses [39]. With the aim of reducing
peri-anastomotic recurrence in 2011 a new type of anastomosis was proposed, the
Kono-S configuration, which appears to reduce the recurrence rate [9]. Another
potential factor affecting the recurrence rate may be the role of the mesentery,
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Table 10.1 Anastomotic techniques after ileocaecal resection for Crohn’s surgery
Anastomotic type Characteristics
Side-to-side stapled Wide lumen
Low anastomotic leak rate
Reproducibility
Most commonly performed
End-to-end Ease in endoscopic surveillance
Kono-S Wide lumen
Supporting column
Ease in endoscopic surveillance
Decreased feacal stasis
Reduced endoscopic and surgical recurrence
H-anastomosis Loop diameter mismatch
No comparative data
which has been hypothesized to be a key player in CD pathogenesis and recurrence. Research on the role of the mesentery is investigating, on the one hand, the
exclusion of the mesentery from the anastomosis and a possible decreased recurrence [40]. As an example, the Kono-S anastomosis, with the construction of a
supporting column, could represent a practical example of the exclusion of the
mesentery from the anastomosis and at the same time preserving the mesenterial
function [5]. On the other hand, removal of the mesentery could prevent it from
establishing a vicious inflammatory cycle that could promote recurrence. A practical description of the main anastomotic configurations after ileocaecal resection is
described below. A summarizing table of anastomotic techniques after ileocaecal
resection is displayed (Table 10.1).
10.3.1 Side-to-Side Ileocolonic Anastomosis
Side-to-side anastomosis (SSA) offers high feasibility and reproducibility. This
anastomotic configuration appears to be the most commonly performed. SSA
widespread application in CD is because it allows the option of creating a wide
lumen anastomosis. This is a factor considered to be crucial in reducing the risk
of anastomotic recurrence [38].
The anastomosis can be fashioned extracorporeally or intracorporeally, during
a minimally invasive approach, according to surgeons’ preference and experience.
This will be discussed more extensively later.
The SSA can be stapled or handsewn. Stapled SSA in non-CD conditions is
established to have a reduced postoperative morbidity, particularly with respect to
anastomotic leak rate [41]. However, when only stapled SSA in CD patients is
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considered, the findings are not concordant. In fact, there is only weak quality evidence showing a reduced anastomotic leak rate in CD [41, 42]. Overall, common
consensus favours a stapled SSA [8, 42–46].
At the practical level, the stapled SSA is performed through the apposition
of the ends of the colonic and ileal loops, displayed either in the more common
isoperistaltic configuration or in an anisoperistaltic fashion. Each loop is incised
with electrocautery on the antimesenteric border to create a common channel for
insertion of the stapler. Caution should be given to check that the mesentery is
untwisted and that the anastomosis should maintain a configuration to minimize
tension. The stapler is inserted in the lumen of the loops and the side-to-side anastomosis is created. Then, the breach incision is closed, usually with a suture. When
suturing, in extracorporeal anastomosis, absorbable continuous sutures are used. In
the case of intracorporeal anastomosis, continuous barbed suture technology can
be applied, avoiding the need for continuous tension and knotting.
The isoperistaltic configuration is the most commonly performed (Fig. 10.1). In
the case of an anisoperistaltic configuration, a stapled closure can also be used for
breach closure at the blind end of the loops (Fig. 10.2). Anisoperistaltic SSA is
also referred to as functional end-to-end anastomosis, and this terminology could
cause confusion, as some have reported [47, 48].
In the case of handsewn SSA, longitudinal incisions are performed on both
loops not far from the mesentery, and then either continuous sutures, single or
double layered, or interrupted sutures can be used to complete the anastomosis.
A practical limitation to stapled techniques is the presence of a very thickened and inflamed bowel wall. This could lead the surgeon to opt for a handsewn
technique instead [49].
In terms of endoscopic surveillance after resection, side-to-side anastomosis is
the most difficult for endoscopic navigation. In any orientation, it is fundamental
Fig.10.1 Side-to-side isoperistaltic ileocaecal anastomosis
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Fig.10.2 Side-to-side anisoperistaltic ileocaecal anastomosis
to explore the bowel proximal and distal to the anastomosis for at least 10 cm.
Blind ends, which are fragile and at risk for disease development, must be visualized [50, 51]. Regarding endoscopic surveillance and scoring of disease it has
been increasingly described how the mucosal healing process is different according to anastomotic configuration and to stapled line inversion or eversion toward
the bowel lumen. Inverted stapled lines such as the longitudinal stapled line in
a SSA heal with inflammation and fibrosis. Whereas everted stapled lines such
as the stapled bowel stumps heal with a mucosa-mucosa adaptation without complications. This difference can lead to overscoring of disease recurrence early in
follow-up (i.e., 6 months) at the level of inverted stapled lines where ulcerations
develop as part of healing process [52, 53].
Currently, the evidence is not clear about disease recurrence at the anastomotic
site. There are contradictory studies showing either reduced recurrence for wide
lumen side-to-side stapled anastomosis [38, 54] or no difference [39, 55].
It should be remembered that most of the evidence is retrospective and that
many studies were underpowered. More homogeneous clinical trials are needed
to define whether a specific anastomotic configuration has a benefit in decreasing
recurrence for CD patients.
10.3.2 End-to-End Handsewn Ileocolonic Anastomosis
End-to-end ileocolonic anastomosis (EEA) is generally handsewn, and most often
extracorporeal. Folllowing bowel resection the two ends are placed facing each
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Fig.10.3 End-to-end ileocaecal anastomosis
other, and the anastomosis is fashioned either with interrupted seromuscular
sutures, or with continuous one- or two-layered sutures (Fig. 10.3). In practical
terms, this anastomotic type has a clear disadvantage when there is a size mismatch
between the two anastomotic ends.
From the point of view of endoscopic surveillance, this procedure allows for
easier navigation through the anastomosis. In general, if there is no active disease,
the anastomotic visualisation is straightforward [50].
Many studies have focused on the possible differences in terms of recurrence
and morbidity between SSA and EEA in CD patients undergoing resectional
surgery. Overall, no major difference in terms of recurrence and postoperative morbidity has been found [39, 55–57]. A recent study describes an improved quality
of life after EEA in CD patients [58].
10.3.3 End-to-Side and Side-to-End Ileocolonic Anastomosis
A less commonly used anastomosis is the end-to-side. It can be performed handsewn or stapled. The ileal terminal end is aligned in a 90-degree orientation with
respect to the colonic end.
Additionally, a side-to-end configuration can be used. In this anastomosis, the
colon is oriented at 90 degrees with respect to the ileal end. The anastomosis can
be performed with staples or circular firing mainly extracorporeally or manually.
A limited number of studies have evaluated these types of anastomoses. Overall,
no major differences have been defined with respect to the more commonly used
anastomotic configurations [59–61].
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10.3.4 Antimesenteric Hand-Sewn Functional End-to-End
Anastomosis: Kono-S Anastomosis
A major innovation in restorative CD surgery after ileocaecal resection was introduced in the early 2000s, the Kono-S anastomosis, first reported in 2011, with
the aim of minimizing anastomotic restenosis due to recurrent disease at the
peri-anastomotic level [9]. Kono and colleagues described the antimesenteric functional end-to-end handsewn anastomosis. A minimal resection is performed: the
mesentery is divided at the bowel wall edge in a mesenteric sparing approach to
preserve innervation and vasculature, and the bowel loops are transected using staples proximally and distally to the affected bowel segment. The anastomosis has
been designed for application at any level of the bowel (ileocolonic, ileal/jejunal,
colonic). Loop stumps are oversewn with absorbable sutures and then sutured
together with single stitches (4 or 5) to create the supporting column (Figs. 10.4A
and B, 10.5A). On the antimesenteric side of the bowel loops longitudinal incisions
are performed starting from a safety distance of 1 cm from the stapled end lines
and extended to 7–8 cm (Figs. 10.4C and 10.5B). This allows for optimization
and securing of the column support, ideally limiting anastomotic distortion and
stenosis. It is seen as unnecessary to close the mesentery. The mesenteric resection is minimal, and the bowel ends are sutured, so the mesenteric margins come
close to each other. Then an anastomosis is performed by suturing in a transverse
fashion the opened bowel loops in a single layer running suture in a Gambee manner (Figs. 10.4D–F, 10.5C, D). As already discussed, creating a wide lumen is a
major factor in reducing anastomotic recurrence. This three-dimensional configuration allows for the preservation of a wide anastomotic luminal diameter in the
long term. Faecal stasis and bacterial overgrowth are likely to be minimal with this
anastomosis. Ease in endoscopic access is guaranteed. Moreover, the mesenteric
luminal side is confined to the centre of the anastomosis and is not integrated in
the anastomotic suture. Anastomotic leakage is known to occur more often on the
mesenteric side in conventional EEA. Mesenteric exclusion from the anastomosis
seems to be one of the factors allowing for reduced recurrence of the disease
[40]. At the same time the column maintains sufficient vascularization to the
superimposed anastomosis. The importance of maintaining adequate mesenteric
vascularization and innervation lies in the presumptive role of the mesentery as a
column that stabilizes and supports the overlying anastomotic structure. Blood supply is fundamental for mucosal healing and this can be a problem in CD patients
as bowel blood supply has been shown to be reduced.
The initial results were very promising compared to the conventional end-to-end
and side-to-side anastomoses with reduced reoperation rates, similar endoscopic
recurrence, lower endoscopic grading scores at the 5-year follow-up, lower surgical
recurrence and no difference for the Kono-S group in recurrence with anti-TNF
therapy. The Kono-S group of patients had no anastomotic leakage verifying the
safety of the procedure. This finding has been confirmed by recent studies. It
appears that Kono-S anastomosis is associated with reduced surgical recurrence at
1 year compared to end-to-end anastomosis [62].
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Fig.10.4 Antimesenteric hand-sewn functional end-to-end anastomosis: Kono-S anastomosis. A) Bowel loops are stapled and minimal mesenteric excision is performed. B) The supporting
column (S) is fashioned by aligning the two bowel stumps and suturing them together with single stitches (4–5), at the upper part a view of the supporting column from above, at the lower
part a lateral view. C) A longitudinal incision of 7 cm is performed on the antimesenteric side of
both bowel loops (highlighted in blue) to open the loops starting 1 cm away from the supporting
column (D), in the lower part a scheme of the incisions. Finally, the Kono-S anastomosis is built
through continuous sutures (E, F). Above and l ateral view showing the supporting column below
the anastomosis
The promising results of this anastomotic configuration prompted a rapid adoption of the technique by centres worldwide. Single-centre and multicentric studies
were developed, confirming the initial results [63, 64]. A recent systematic review
has further strengthened this opinion [65].
Two prospective randomized clinical trials have been undertaken to better define
the possible advantages of this anastomosis over conventional anastomoses, in the
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Fig.10.5 Kono-S anastomosis – operative pictures after a single-port ileocecal resection.A)
View from above of the supporting column (S). B) The sites of longitudinal incisions are marked
to measure 7 cm, at a 1 cm distance from the stapled lines. C) The bowel loops are opened. D) The
anastomosis is fashioned and this is the view of the Kono-S anastomosis
USA (NCT03256240) and in Italy (NCT02631967). The latter showed a reduction
in endoscopic and surgical recurrence rates [40].
The favourable results prompted the development of variations and adaptations
of the anastomosis. One example is the totally stapled Kono-S anastomosis first
described in 2021 [66], which reported acceptable results [67]. The main aim
of this adaptation is to increase technical reproducibility. In this technique, after
the construction of the supporting column and the longitudinal incisions on the
antimesenteric sides, a linear stapler is used to complete the anastomosis.
As expected, minimally invasive surgeons started to implement the Kono-S
anastomosis. Robotic intracorporeal Kono-S anastomosis has also been described
[68].
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10.3.5 Additional Anastomotic Techniques
Ileocolonic nipple valve anastomosis
A peculiar anastomotic construction was first described in 1990, the ileocolonic
nipple valve anastomosis [69]. Practically, after ileocolonic resection, the distal
ileal end is everted for 3–4 cm and secured with interrupted sutures. Then, an
end-to-end anastomosis is created by inserting the everted ileal portion—the nipple—inside the colonic lumen. Two layers of interrupted or continuous sutures
complete the anastomosis at the base of the nipple. The concept underlying this
technique is that the colo-ileal reflux, which inevitably occurs in a conventional
wide lumen ileocolic anastomosis, may damage the ileal mucosa, and favour anastomotic recurrence. Three studies have reported results regarding this anastomosis
[69–71]. The most recent study [71], reported a surgical recurrence of 16% at 5
years of follow-up, which seems very promising. A randomized clinical trial was
never performed, as patients refused to be randomized.
H-anastomosis: single-stapled circular side-to-side anastomosis
H-anastomosis has been recently described [72]. This type of anastomosis aims at
maximizing the possibility of restoring continuity between loops of different sizes.
This occurs when severe proximal dilation develops. This single-stapled circular
side-to-side anastomosis (CSTS) is performed after resection of a diseased bowel
segment with intervening strictures. The antimesenteric sides of the bowel loops
are paired in an anisoperistaltic fashion. The distal ends are resected and opened so
that the circular stapler is easily inserted in the blind end of the proximal dilated
loop. A single-stapled circular anastomosis is created. The two blind ends are
closed independently by linear stapling at least 1 cm away from the circular anastomotic line. The authors recommend oversewing both the circular line and the
distal stapled lines with absorbable single stitches. As of standard, a patency pinch
test is recommended to ascertain the wide lumen of the anastomosis. Currently, no
results on recurrence and postoperative morbidity are available.
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10.4 Extracorporeal and Intracorporeal Anastomoses
The technological revolution of minimal access surgery and the progressive expertise of surgeons lead to an increase in the number of reports and studies on
intracorporeal anastomoses after ileocaecal resection in CD patients. In the majority of centres ileocaecal anastomosis, during laparoscopic and single-incision
ileocaecal resection for CD is performed extracorporeally through a larger incision
usually in the midline of approximately 4–5 cm after wound protector placement.
The use of a larger incision presents two main advantages. Firstly, it provides the
opportunity for manual examination of the entire bowel and secondly, simplifies
performing additional procedures when needed, such as stricturoplasties, in other
bowel segments.
Increasingly, intracorporeal anastomosis has been utilized. Initially, it was
described in right hemicolectomy for colorectal cancer. It has been shown to
be feasible and safe [73, 74], may have a faster postoperative recovery [75],
and a reduced anastomotic leak rate [76]. It has also been shown that patients
undergoing intracorporeal anastomosis in laparoscopic right hemicolectomy have
a reduced surgical stress response. Lower levels of inflammatory mediators (IL-6
and PCR) were found in the bloodstream when compared to patients who underwent extracorporeal anastomosis [77]. No differences between intracorporeal and
extracorporeal anastomosis were found in a randomized clinical trial in terms of
perioperative care and patient-reported outcomes [74].
The introduction of intracorporeal anastomosis resulted in its application in
CD surgery, both with the laparoscopic and robotic approaches. Most commonly,
intracorporeal anastomoses are stapled side-to-side, mainly with an isoperistaltic
orientation. The ileal terminal end and the colonic stump are aligned in an isoperistaltic orientation in a tension-free configuration. A small opening is performed in
both loops to allow the laparoscopic or robotic linear stapler into the bowel lumen.
A wide lumen stapled anastomosis is created. The common luminal channel is
then closed with a continuous suture. A possible advantage of intracorporeal anastomosis is the reduced traction on the mesentery compared to when extracorporeal
extraction is performed.
Robotic intracorporeal and robotic extracorporeal anastomoses in CD patients
during ileocaecal resection have been compared [78]. The two procedures showed
similar results, and a reduced time to return to bowel function was apparent for
robotic intracorporeal anastomosis.
In a recent retrospective study stapled robotic intracorporeal anastomoses were
compared with laparoscopic handsewn/stapled extracorporeal anastomoses after
ileocolic resection [79]. In both groups the alignment of the loops was variable:
side-to-side, iso- and anti-peristaltic and end-to-end. Robotic intracorporeal anastomosis showed reduced postoperative complications, length of stay and return
of bowel function. Generally, intracorporeal anastomosis requires a longer operative time compared to the extracorporeal one, but this does not seem to impact
postoperative outcomes.
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