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9 Anastomotic Construction
127
handsewn and stapled colorectal anastomoses
are equivalent in leak rate.
• If a handsewn anastomosis is selected, there is
no proven advantage of double-layer over single-layer anastomosis. We will describe a twolayer colorectal anastomosis, but the
techniques to create a single-layer anastomosis are similar.
• The fatty mesentery of the colon and rectum
makes a handsewn end-to-end anastomosis
difcult to perform. Baker described a sideto-end colon to rectal anastomosis that is
created several centimeters proximal to this
closed end of the colon. A posterior layer of
interrupted Lembert sutures is placed, and
then a longitudinal antimesenteric colotomy
is created. A running layer absorbable
monolament suture is started at the midpoint of the posterior wall and advanced
posterior inner layer. As the sutures proceed
onto the anterior aspect of the anastomosis,
a Connell suture is used to create the anterior inner layer closure. The anterior suture
line is then oversewn with interrupted
Lembert sutures.
Ileorectal Anastomosis
• The ileorectal anastomosis after an abdominal
colectomy is performed in the same fashion
and following the same precautions as the
colorectal anastomosis. Often, the small caliber of the ileum will not accommodate the use
of the larger EEA stapler, and a smaller 25mm
stapler diameter is required.
Ultralow Colorectal andColoanal
Anastomoses
• The techniques involved in creating the low
anastomoses in the pelvis remain the same as
the upper rectal anastomoses. However, in
addition to the technical challenges inherent
in creating a low anastomosis, the surgeon
must be mindful of the functional consequences of resecting the majority of the rectal
reservoir.
Neorectal Reservoirs
• Using techniques developed for restorative
proctocolectomy, Lazorthes and Parc both
proposed the creation of a colonic reservoir in
order to decrease the functional consequences
of a low anastomosis.
• Over the ensuing years, multiple studies demonstrate that the colonic J-pouch is superior to
the straight coloanal anastomosis in terms of
frequency, incontinence, and quality of life
and long-term results show that these functional advantages are durable out to 5 years.
• Several trials evaluating smaller (5–6 cm)
colonic pouches found them to be superior to
larger pouches.
• Creation of the colonic J-pouch rst requires
conrmation that the colon is adequately
mobilized and that the intended apex of the
pouch will reach the cuff without tension
(Fig. 9.7a–d). An antimesenteric colotomy is
then created 5–6cm from the divided end of
the colon. A linear cutting stapler is inserted
through this colotomy, with one limb of the
stapler inserted into the blind end and the other
limb delivered up the proximal limb (avoid
including the mesentery in the staple line) of
the colon the pouch is created by ring the stapler. If a stapled anastomosis is to be created, a
purse-string suture is then placed around the
apical colotomy, and the anvil is secured in the
pouch. The anastomosis is then created similarly to other colorectal anastomoses.
• Some studies showed a signicant decrease in
the anastomotic leak rate for the colonic
J-pouch when compared to a straight coloanal
anastomosis.
• Reservoirs anastomosed more than 5–6 cm
above the anal verge may actually create problems emptying.
• Patients with a small pelvis, fatty mesentery,
extensive diverticulosis, mucosectomy, or
insufcient colonic length are not good candidates for J-pouch creation.
• Z’graggen was the rst to describe the transverse coloplasty as an alternative to the colonic
J-pouch.
• An 8cm longitudinal incision is made on the
antimesenteric colon with the distal end of the
128
5-6 cm
abc
S. R. Hunt and M. L. Silviera
Anti-mesenteric
colotomy
Fig. 9.7 (a–c) Colonic J-pouch. (a) A 5–6 cm colonic
J-pouch is formed, and a colotomy is made on the antimesenteric portion of the bowel wall. (b) The pouch is formed
incision approximately 4cm proximal to the
stapler anvil, and the colotomy is closed transversely (Fig.9.8a–d).
• A large, multicenter randomized controlled
trial compared the colonic J-pouch to the
transverse coloplasty (and comparing coloplasty to straight coloanal anastomosis for
patients in whom a J-pouch was not technically possible). At 2 years, the colonic J-pouch
proved superior to the transverse coloplasty in
frequency, clustering, soilage, and continence.
Although the sample sizes were smaller, the
transverse coloplasty showed no improvement
in any functional assessment compared to the
straight coloanal anastomosis.
using a linear stapler with 1–2 loads ensuring the colon
mesentery is pulled out of the staple line. (c) The colorectal anastomosis is constructed using an EEA stapler
• Huber etal. proposed the side-to-end anastomosis (Fig.9.9a, b). A randomized controlled
trial compared side-to-end anastomosis with
colonic J-pouch and showed that the techniques had similar frequency, continence,
and functional scores. At 2years neorectal
volumes were 40% higher in the colonic
J-pouch group.
• A systematic review comparing the side-toend anastomosis to the colonic J-pouch did
not show any difference in function between
these two techniques.
• The physiologic basis for the improved function of neorectal reservoirs is not completely
understood, but the increased volume reservoir
cd
ab
9 Anastomotic Construction
ab
8 cm
4 cm
129
4
1
Fig. 9.8 (a–d) Transverse coloplasty. (a) An 8cm linear
colostomy is made 4cm from the distal end of the colon
(panel 1). (b) The anvil is placed in the end and stay
sutures are placed at the midpoint on each side of the
Fig. 9.9 (a–b)
Side-to-end coloanal
anastomosis. (a) A
colotomy is made
proximal to the open end
of the colon (left), and
the EEA anvil is passed
through this opening
(right). (b) The colonic
opening is closed using
a linear stapler (left),
and the anastomosis is
performed using an EEA
stapler (right)
23
colotomy (panel 2). (c) The longitudinal colotomy is
closed in a transverse fashion (panel 3). (d) An end-to-end
anastomosis is performed (panel 4)
cd
130
S. R. Hunt and M. L. Silviera
is one explanation. Ho etal. showed the function of the J-pouch was superior (J-pouch vs
straight) but the neorectal capacity was similar
for both groups. Furst etal. reached the same
conclusion and suggested that the pouch works
by decreasing forward propulsive motility in
the J segment.
• Ho etal., using radioactive isotopes, found that
solid stool transport through the colon was the
same for both techniques and that the J-pouch
had signicantly better retention of liquid
stools in the distal colon above the pouch.
• In summary, for low colorectal or coloanal anastomoses, the colonic J-pouch may give the best
functional results, but the long-term durability
of this benet is unclear. When the J-pouch is
not feasible, the transverse coloplasty or the
straight coloanal anastomosis appear to offer
similar functional results. The role of the sideto-end coloanal anastomosis is still undened.
Handsewn Coloanal Anastomosis
• There are circumstances in which a handsewn
coloanal anastomosis is the only option to
avoid an ostomy.
• In order to perform a handsewn anastomosis,
the surgeon must have good visualization of
the cut edge of the anal canal. This is accomplished through a combination of sutures or
self-retaining retractors (for exposure) and
lighting.
• The transanal dissection, either intersphincteric dissection or mucosectomy, should be
performed as appropriate for the pathology.
• The orientation of the colon mesentery should
be conrmed after it is passed through the anal
canal. A simple full-thickness suture is then
placed in each quadrant of the anal canal. The
anastomosis is then completed by placing
intervening sutures in the remaining gaps.
• Baik etal. reported on a case series of patients
that had straight handsewn coloanal anastomoses, 31% of patients had anal incontinence
at 6 months. The percentage of patients with
incontinence decreased to 14% at 1 year.
Twenty percent of patients reported more than
6 bowel movements a day at 1year.
• In the only randomized controlled trial comparing handsewn to stapled coloanal J-pouch
anastomoses (total 37 pts), Laurent et al.
reported that functionally the two groups
appeared equivalent.
Assessment ofPelvic Anastomosis
• Some form of intraoperative anastomotic
assessment should be performed at the time of
creation. Mechanical tests of anastomoses
demonstrate intraoperative leaks in 5–25% of
anastomoses.
• The air insufation test is the simplest to perform, and multiple studies show it reduces
postoperative anastomotic leak rates. In addition to allowing for an air-leak test, intraoperative exible endoscopic assessment of the
anastomosis allows for visualization of the
anastomosis.
• There is no denitive conrmation that intraoperative endoscopy is more effective than a
simple air-leak test.
• The bowel several centimeters proximal to
the anastomosis should be occluded manually or with a bowel clamp. Saline is added
to the pelvis to cover the anastomosis, and
air is insufated into the rectum. The anastomosis should be manipulated in all directions to conrm that a small leak is not
being hidden or occluded by extraneous tissue. If there is bubbling, the saline should
be slowly removed with suction down to the
level of the anastomosis in order to localize
the leak.
• When an intraoperative leak is discovered,
options include suture repair, proximal diversion, or takedown and refashioning of the
anastomosis. For small leaks, suture repair is
often adequate.
• Larger leaks, circumferential leaks, and leaks
that cannot be visualized or adequately
repaired require takedown and refashioning of
the anastomosis.
9 Anastomotic Construction
131
Troubleshooting Problems
withPelvic Anastomoses
Unanticipated Pelvic Anastomosis
• Situations arise in which the surgeon must
create an unplanned pelvic anastomosis and
the patient is positioned so that access to the
perineum is not possible. One option is repositioning that allows for the standard doublestapled anastomosis.
• It is not always necessary or possible to reposition the patient. A handsewn anastomosis
remains an option, but becomes more difcult
lower in the pelvis.
Fig. 9.10 (a–d)
Unexpected colorectal
anastomosis. (a) A purse
string is sewn into the
open end of the rectum.
(b) The EEA anvil is
placed through the rectal
stump, and the EEA
stapler is passed
retrograde through the
open end of the colon.
(c) The anastomosis is
completed with ring of
the EEA stapler. (d) A
liner stapler is used to
close the open end of the
colon
a
• It is also possible to create a stapled side-toend anastomosis similar to the Baker anastomosis with the patient in supine or even lateral
position. In this technique the anvil for the
circular stapler is secured in the rectum and
the stapler introduced into the colon via a
colotomy. (Fig.9.10a–d)
Inadequate Colonic Length
• For a left colectomy, adequate reach is usually
achieved by performing basic maneuvers
including splenic exure mobilization, division
of the inferior mesenteric artery at its origin,
b
cd
132
ab
S. R. Hunt and M. L. Silviera
and division of the inferior mesenteric vein at
the inferior border of the pancreas cephalad to
the vein branch to the splenic exure.
• Complete mobilization is accomplished by
division of the peritoneal attachments in the
left upper quadrant, separation of the omentocolic attachments to the distal transverse
colon, deliberate division of the renocolic
attachments of the mesentery to Gerota’s fascia of the left kidney, and lysis of the gastrocolic attachments between the posterior gastric
wall and the transverse colon mesentery.
• Resection of the splenic exure as part of an
extended left hemicolectomy often presents a
challenge in obtaining adequate colonic length.
• Serial ligation of the middle colic vessels proceeding from left to right provides more
length. Unfortunately, adequate blood supply
and adequate reach sometimes nd themselves at odds.
• If, after division of the middle colic pedicles, there is compromise of the blood ow
to the pre-anastomotic colon, it should be
resected back to the point where there is
good arterial inow and satisfactory venous
drainage.
• If the colon will not reach the pelvis in the
typical course to the left of the ligament of
Treitz, one opion is to create a window in the
terminal ileal mesentery that allows passage of the colon through this retroileal
opening (Fig. 9.11a, b). The window is
created in the space between the ileocolic
artery and the distal superior mesenteric
artery.
• Another option is mobilization of the
hepatic flexure and counter-clockwise
rotation of the colon (Deloyers’ procedure)
(Fig.9.12a–d).
Fig. 9.11 (a and b) Retroileal pull-through. (a) A win-
dow is made on the superior aspect of the ileocolic pedicle
after the terminal ileum is mobilized from the retroperito-
neum. (b) The colon is passed through this window and
into the pelvis to perform the end-to-end anastomosis
bc
9 Anastomotic Construction
a
133
Fig. 9.12 (a–c) Deloyer’s technique. (a) The hepatic
exure and right colon are mobilized laterally along with
the terminal ileum from the retroperitoneum. (b) The
• If all salvage maneuvers fail to allow a tension-free colorectal anastomosis with adequate blood supply, remaining options include
a completion colectomy with an ileorectal
anastomosis or an end colostomy.
Intraoperative Anastomotic Failure
• Failed anastomoses are inevitable in pelvic
surgery.
• When a pelvic anastomosis fails, an attempt
should be made to resect below the anastomosis and recreate it in standard fashion.
colon is rotated in a counter-clockwise direction and
delivered to the pelvis. (c) The anastomosis is
constructed
• If it is impossible to place the transverse
stapler below a failed anastomosis, the
anastomosis should be excised and a purse
string placed around the open rectum. The
circular stapler is then passed through the
anal canal and delivered to the point just
below the open end of the rectum and purse
string. The stapler spike is advanced through
the open rectal cuff, and the purse string is
tied around the spike and inspected to conrm that the purse string is complete. A
standard stapled anastomosis to the preanastomotic colon is then performed and
assessed.
Anastomotic Complications
KonstantinUmanskiy andNeilHyman
10
Key Concepts
• Patients who develop diffuse peritonitis after
intestinal resection with anastomosis should
undergo prompt exploratory laparotomy.
• Colorectal anastomoses should be routinely
tested prior to abdominal closure.
• Hemodynamically unstable patients who
develop a leak after sigmoid resection should
undergo a Hartmann procedure.
• Late anastomotic leaks commonly present
with subtle and insidious symptoms such as
failure to thrive.
• Endoscopic balloon dilation is the procedure
of choice for short anastomotic strictures.
• Most cases of anastomotic bleeding resolve
with conservative measures.
• Persistent anastomotic bleeding should be
treated by colonoscopy with epinephrine
injection and/or endoscopic clips.
Anastomotic Leak
Overview
• Anastomotic leak is perhaps the most feared
and dreaded complication after bowel resection and typically necessitates a lengthy
hospitalization with considerable morbidity
and cost.
• The cause of leak in any particular patient is
frequently unknown although many risk factor
have been identied.
• The pathophysiology of this potentially devastating problem is poorly understood.
• Avoiding tension on the anastomosis and
assuring adequate perfusion to the two ends of
the intestine to be joined remain valid and fundamental surgical principles.
• Optimization of comorbid conditions and suspected risk factors is also of value.
• Leaks often occur when no technical error,
defect in surgical judgment, or patient- specic factor can be readily identied.
• In short, it seems clear that our present concepts regarding the causes and prevention of
anastomotic leak are lacking.
K. Umanskiy
Department of Surgery, University of Chicago,
Chicago, IL, USA
N. Hyman (*)
Section of Colon and Rectal Surgery, University of
Chicago Medicine, Chicago, IL, USA
e-mail: nhyman@surgery.bsd.uchicago.edu
© ASCRS (American Society of Colon and Rectal Surgeons) 2019
S. R. Steele et al. (eds.), The ASCRS Manual of Colon and Rectal Surgery,
https://doi.org/10.1007/978-3-030-01165-9_10
Scope oftheProblem
• The reported incidence of anastomotic leakage after bowel resection varies from 1 to
more than 20% (5–8% most commonly),
135
136
K. Umanskiy and N. Hyman
based on the denitions used, location of the
anastomosis, and length of follow-up.
• Small bowel anastomoses have the lowest leak
rate, and low colorectal or coloanal anastomoses carry the highest risk.
• The denition of a leak varies. In a systematic
review, Bruce noted that there were 56 different
denitions of “leak” used in the 97 constituent
studies of gastrointestinal anastomoses.
• “Anastomotic leak” can signify anything from
an apparently trivial, clinically meaningless
radiologic nding to a profound septic insult
causing a rapid decline, multiorgan failure,
and death.
• The spectrum of clinical entities with distinct
clinical consequences that can complicate low
pelvic anastomoses include “free” leaks, anastomotic sinuses, peri-anastomotic abscesses,
and stulas.
• Patients with “simple” uid alone in the pelvis
on a CT scan without any other evidence of a
leak appeared to have impaired long-term
function.
• Anastomotic infectious complications may be
divided into leak, surgical site infection (SSI)
organ space, and SSI deep.
Consequences
• An anastomotic leak is a life-threatening
complication, with a mortality of 10–15%
range from sepsis to progressive multiorgan
failure.
• Timely diagnosis and treatment prior to the
onset of advanced organ dysfunction has been
emphasized as a key factor in reducing the
mortality rate.
• Patients with a more indolent course may also
succumb to venous thromboembolic or other
indirect complications owing to the prolonged
hospital stay, limited mobility, and persistent
inammatory state.
• Patients with an anastomotic leak often require
difcult and complicated reoperations in a
hostile local environment, with considerable
additional postoperative morbidity.
• Functional, physical, emotional, and psychological recovery is often measured in months
or even years.
• Prolonged wound care, ventral hernias, bowel
obstructions, and management challenges
associated with gastrointestinal adaptation to
the altered anatomy may continue to be active
considerations for long periods of time.
• Local sepsis may lead to an impaired functional result, especially after low pelvic
anastomosis.
• There is an adverse relationship between anastomotic leak and local recurrence after rectal
resection for cancer.
Prevention
• Because we still do not know why most anastomotic leaks occur, we remain limited in our
ability to prevent many of them.
• Even among high-volume surgeons, signicant differences may be found in leak rates,
suggesting that technical and/or judgment
errors play a causative role in at least some
leaks.
• Many patient- and surgeon-specic factors
have been associated with an increased risk of
an anastomotic leak (Table10.1).
• Many patient factors are simply markers for a
sicker patient, and it is unclear which of the
factors on this list are simply associated with a
leak versus actually contributory.
• Attention to controlling certain risk factors
(smoking, nutritional status, weight) does
seem worthwhile.
– A systematic review documented an
impressive reduction in anastomotic complications when the anastomosis was tested
during surgery.
• When a leak is identied intraoperatively, the
options are to (1) repair a well-dened defect,
(2) redo the anastomosis, (3) proximally
divert, or (4) a combination of the above.
• Intriguing work regarding the relationship of
the microbiome and anastomotic leak has
been reported by Alverdy and coworkers.
10 Anastomotic Complications
137
Table 10.1 Reported risk factors for anastomotic leak
Patient
factors
Surgeon
factors
Overall physiological status
Steroids
Need for low rectal/anal anastomosis
Immunomodulators
Malnutrition/weight loss
Emergency surgery
Obesity
Male gender
Advanced age
Alcohol use
COPD
Cigarette smoking
Previous radiation
Prior abdominal surgery
Right vs. left colon (left increased)
Primary disease (e.g., Crohn’s disease,
diverticulitis)
Length of surgery
Blood loss
Use of pelvic drain
Bowel preparation
Use of vasopressors
Proximal diversion
Blood supply
• Specic bacteria that produce locally destructive collagenolytic proteins (e.g., certain
Enterococcus, Pseudomonas, or Serratia species) may be an important cause of anastomotic
leaks, and perioperative suppression/eradication of these microbes may reduce leak rates.
with anastomosis. The predictive value for
abnormal vital signs or leukocytosis ranged
from only 4 to 11%.
• Radiologic ndings are often ambiguous and
equivocal requiring careful and considered
correlation with the clinical picture.
• The sensitivity for contrast radiography and CT
scan in the setting of a leak has been reported to
be in the range of 50%; therefore, a high index
of suspicion must be maintained even when the
imaging study appears to be negative.
• There is broad overlap of radiologic ndings
in postoperative patients with or without a
leak. For example, free air was seen on CT
scan up to 9days after surgery and localized
extraluminal air up to 26days postoperatively
in patients without a leak.
• Of the radiologic ndings that are often considered to be indicative of a leak, only loculated
uid with air (Fig. 10.1) was observed more
commonly in patients with an anastomotic leak.
• In a review of patients undergoing an intestinal anastomosis, the leak rate was 2.7%. 14/33
leaks were only diagnosed upon readmission
to the hospital, and 12% were identied more
than 30days after surgery.
• The positive predictive value of CT scan was
89.5% versus 40% for contrast enema, but these
studies were used in different clinical settings.
Diagnosis
• The diagnosis is simple in patients who present in the rst few days after surgery with
excruciating abdominal pain, hemodynamic
instability, diffuse peritonitis, and/or a rapid
and dramatic change in their clinical course.
• The diagnosis of anastomotic leak is not
always straightforward or clinically obvious
as many leaks present in a subtle and insidious
manner.
• One study reviewed the clinical course of 452
consecutive patients who had a bowel resection
Fig. 10.1 CT scan in a patient with anastomotic leak
after low anterior resection