Overall 5 module summary
Module 1: Decision making
- Anastomotic leak occurs in around 1 in 12 patients and is associated with increased risk of death.
- Risk-stratification helps surgeons and patients make shared decisions, including whether the patient should have a primary anastomosis or an end stoma.
- By objectively estimating risk of leak, pre-, intra-, and post-operative care can be tailored to individual patients.
- The anastomoticleak.com calculator is a freely accessible, online, internationally validated risk stratifier.
Module 2: ESCP Safe-anastomosis Checklist
- Checklists have been demonstrated to improve surgical safety by improving communication, reducing avoidable harm and increasing vigilance around key care processes.
- The ESCP Safe-anastomosis checklist is a three-step process which can be implemented within your theatre team to support multidisciplinary operative decision making in right-sided, ileocolic resection.
- We recommend that the checklist is performed immediately before performing the anastomosis (or formation of stoma). It should be completed by an unscrubbed member of the theatre team and involve all team members.
Module 3: Preparing for the anastomosis
- Anastomotic healing requires good blood flow, but the colonic vascular supply can be compromised by resection.
- Collagen matrix in the submucosa is essential for structure and healing.
- Intestinal microbiota probably influence leaks, but more research is required for us to understand this process.
- The order in which resection and anastomosis is performed and its anatomical arrangement matter less than the need to ensure a good blood supply and the formation of a tension free anastomosis.
- The decision between creating a hand sewn or stapled anastomosis should be individualised to each case.
- There are specific scenarios where stapled anastomosis is likely to be inappropriate.
Module 4: Stapled anastomosis
- Optimal anastomosis requires adequate blood supply, free tension and reliable technique.
- Choose the right staple size for the tissue thickness.
- Compression must be exerted for at least 15 seconds to displace tissue fluids
- The correct use of the device is more important than the manufacturer of the device
- Consider harmonisation of anastomotic techniques between your surgical teams to reduce unnecessary variation
- Remember to test your right sided anastomosis (using the SAFE anastomosis principle)
Module 5: Handsewn anastomosis
- Absorbable sutures are preferential, although these can be monofilament or multifilament dependant on surgeons preference
- Suture bites are recommended between 3-5 mm depth and spaced 3-5mm apart in healthy tissue. 10mm bites may be necessary in diseased bowel
- Single layer closure is sufficient, but must include the submucosa. Full-thickness bites may be preferential in diseased bowel to ensure all layers are taken.
- Interrupted sutures may be preferential in diseased bowel.
- Side-to-side configurations are most common, although no consensus around the optimal configuration exists.
- Remember to always check for a SAFE handsewn anastomosis.