Anastomosis in IBD

Barry Salky, MD FACSProfessor of Surgery

Chief (Emeritus), Division of Laparoscopic Surgery

The Mount Sinai HospitalNew York

Anastomosis in IBD

Ulcerative Colitis

Mucosectomy versus Double-staple

Anastomosis in IBD

Mucosectomy Vs. Double-Stapled M DSTechnical ease N YPreserves ATZ N YImproved function N YDecrease septic event ? ?Decrease dysplasia Y NDecrease cancer risk N N Larson, Pemberton; Gastroenter, 2004

Anastomosis in IBD

ATZ• Portion of the anal canal between squamous epithelium below and the columnar epithelium above.• Nocturnal fecal incontinence less with DS as the ATZ is preserved. (multiple RCTs, a few RCTs don’t agree)

Anastomosis in IBD

Leaks and sepsis• Several series demonstrated a better prognosis from leaks and sepsis in DS compared to mucosectomy. ( non RCT)

MacRae et al Ziv et all

DCR 1997 Am J Surg 1996

Anastomosis in IBD

Cancer risk• Dysplasia in ATZ at 10 years 5%. *• Multiple reports of development of cancer in both DS and mucosectomy patients ( that means residual rectal mucosa can be left behind)• Most experts agree that if dysplasia is present in the rectum-mucosectomy is procedure of choice. Remzi et al DCR 2003 (*) O’Connell et al DCR 1987

Anastomosis in IBD

Crohn’s Disease

Does type of anastomosis make a difference in recurrence, leak or function?

Anastomosis in IBDCrohn’s Disease

Whether the actual anastomotic technique impacts rate of recurrence or the need for a second surgery is completely unknown.

Larson, Pemberton Gastroenterology 2004

Anastomosis in IBDCrohn’s Disease

Several non-randomized papers have suggested that the recurrence free time is lengthened by using a stapled anastomosis at the original surgery.

Hashemi et al Yamamoto et al Munoz-Juarez et al DCR 1998 World J Surg 1999 DCR 2001

Anastomosis in IBDCrohn’s Disease

“Stapled vs handsewn methods for ileocolic anastomoses”Cochrane analysis5 large RCT including 1125 ileocolic pts441 stapled, 684 hand sewn• Stapled anastomosis (functional end to end) had significantly fewer anastomotic leaks p=0.03(CONT)

Anastomosis in IBDCrohn’s Disease

“Stapled vs handsewn methods for ileocolic anastomoses”All other outcomes: stricture, hemorrhage, time, re-operation, mortality, abscess, wound infection, LOS showed not significant difference. Choy et al Cochrane Library 2011

Patient Demographics Intracorporeal ( n=54)

Extracorporeal (n=51)

P value

45 50 0.181 19(35) 28(23) 0.042

BMI (kg/m2) 23.8 23.4 0.705ASA class* 2.1 2.2 0.242Prior operation 21 23 0.519IBD 33 30 0.167Neoplasm 19 16Other 2 5*Mean

Operative DataIntracorporeal n = 54

Extracorporeal n = 51

p value

Operation performed

Ileocolic 33 33 0.583 R hemi 14 15 L hemi 6 3Subtotal 1 0Fistula take down 14 16 0.537OR time (minutes) 190 156 0.001EBL (ml) 85.4 164 0.014Intraop narcotics (mg)*Morphine equivalents

49 48 0.826Intraop complications 0 0

Post-op DataIntracorporeal Extracorporeal P value

Narcotic use (mg)* 16 49 0.001

Time to flatus(days)* 2.0 2.4 0.017

Time to BM (days)* 2.2 2.5 0.167

Length of stay (days)* 3.2 3.8 0.019

Periop morbidity (n) 6 15 0.019

Anastomotic leak 0 1

Enterotomy 1 0

GI bleed 0 2

Obstruction 1 4

Intra-abd abscess 0 2

Wound infection 0 2

Cardiac 2 0

Blood transfusion 1 3

Urinary retention 0 1

Hematuria 0 2

Other 0 2

Mortality 0 0

QuickTime™ and aDV/DVCPRO - NTSC decompressor

are needed to see this picture.

Anastomosis in IBD

Conclusions (UC)1. DS is comparable to mucosectomy, and it is technically easier to perform.2. Use mucosectomy for rectal dysplasia3. No difference between laparoscopic

and open cases (so far)

Anastomosis in IBD

Conclusions (Crohn’s Disease)

1. Stapled techniques are appropriate in the surgery for CD.

2. Intracorporeal anastomosis appears to decrease morbidity and LOS.