Harmonising anastomotic technique

Objective 3. Review the evidence for a harmonised technique for stapled anastomosis

Harmonising techniques for right sided anastomoses may have long term benefits to patients, and improve training.

As a community of colorectal surgeons, we have a vast array of experience and expertise that can be shared globally to improve patient outcomes. This section of the module aims to review the evidence base for technical elements of the stapled ileocolic anastomosis, and identify where areas of best practice can be promoted.

 

Importantly, no single technique is recommended here. The objective is simply to promote discussion and reflection about technical elements of the anastomosis.

 

There is little evidence from randomised, or high-quality non-randomised studies to support specific technical decision making in stapled right sided anastomosis. However, the ESCP 2015 Cohort Studies audit has shown that excessive practice variation may contribute to risk of anastomotic leak.

 

• Specifically, the following were noted in 2015 ESCP audit data:
  1. There were over 25 different configurations and variations of technique for stapled ileocolic anastomosis, however over 90% of patients underwent one of 4 more common techniques.
  2. There was a disproportionately high rate of leak in the patient subgroup that underwent uncommon anastomotic configurations.
  3. Being a general rather than colorectal surgeon was associated with a higher risk of anastomotic leak, suggesting that training may have a part to play in improving patient outcomes.

Related paper: The impact of stapling technique and surgeon specialism on anastomotic failure after right-sided colorectal resection: an international multicentre, prospective audit

In order to learn from one another and share best practice, a Delphi Consensus process involving 400 surgeons from around the world was undertaken to determine consensus around anastomotic technique.

Key learning points from the ESCP Delphi Consensus for stapled ileocolic anastomosis are shared in this section.

 

1. Technical preferences for anastomotic configuration were for:

  • A side-to-side configuration.
  • An anti-peristaltic configuration.

 

2. Surgeons agreed that enterotomies to permit passage of the stapler arms:

  • Should be made in the antimesenteric border of the bowel to reduce bleeding risk.
  • Should be 1 cm or less in diameter to minimise contamination.
  • Stay sutures should be placed either side.

 

3. Regarding the use of the stapler, surgeons agreed that:

  • Tissue compression should last for 15 seconds before the staple gun is fired.
  • The staple line should be inspected for bleeding.
  • The diameter of the anastomosis should be at least the transverse diameter of the patient’s small bowel.

4. Regarding closure of the common enterotomy

There is a lack of evidence for benefit of a non-cutting versus cutting stapler for apical closure. Surgeons agreed that either techniques were acceptable.

Related paper: The impact of stapling technique and surgeon specialism on anastomotic failure after right-sided colorectal resection: an international multicentre, prospective audit

Related paper: Common side closure type, but not stapler brand or oversewing, influences side-to-side anastomotic leak rates

 

5. Regarding reinforcement of the anastomosis by securing the two limbs with a ‘crotch stitch’

Surgeons agreed that this suture reinforcement may be of benefit, and is unlikely to convey any additional harm.

6. Regarding oversewing of staple lines

Surgeons did not recommend routine oversewing of the staple lines. They agreed that the apical staple line should be oversewn only if there are specific concerns, for example the staple line being incomplete or bleeding.

7. Regarding returning the laparoscopically assisted anastomosis

Surgeons agreed that the anastomosis should be returned into the abdomen by lifting the abdominal wall and using passive force or gentle pressure, through an appropriate size wound, to prevent stress across the anastomosis

 

Summary points

The video below provides some closing summary points about optimisation of the stapled ileocolic anastomosis:

Personal Module Notes