Ileocolonic anastomosis: preferred techniques in 999 patients. A multicentric study

Comparative analysis of functional end-to-end and end-to-side anastomosis in laparoscopic right hemicolectomy for colon cancer

BACKGROUND

Despite advancements in laparoscopic right hemicolectomy for right-sided colon cancer, the choice between functional end-to-end anastomosis and end-to-side anastomosis remains a topic of debate. This study aimed to compare these 2 techniques in terms of postoperative complications and disease-free survival.

METHODS

This retrospective analysis included 1,202 patients who underwent laparoscopic right hemicolectomy for nonmetastatic colon cancer at Samsung Medical Center between January 2007 and February 2016. The patients were divided into functional end-to-end anastomosis (n = 968) and end-to-side anastomosis (n = 234) groups based on the anastomosis technique used. Patients' characteristics, oncologic results, operative outcomes, and postoperative complications were analyzed.

RESULTS

The baseline characteristics were similar between the 2 groups, except for a higher incidence of cancer obstruction in the end-to-side anastomosis group (P < .001). After matching, no significant differences were observed in operation time, blood loss, length of hospital stay, time to the first meal, or time to first flatus. Anastomotic leakage rates were comparable (functional end-to-end anastomosis 0.6% vs end-to-side anastomosis 0.4%, P > .999). The functional end-to-end anastomosis group had a higher rate of postoperative ileus (4.9% vs 1.3%, P = .017). Multivariable analysis indicated age, sex, and anastomosis type as significant predictors of postoperative ileus.

CONCLUSION

The study findings demonstrate that both functional end-to-end and end-to-side anastomosis techniques in laparoscopic right hemicolectomy are comparable in terms of operation metrics and disease-free survival. However, functional end-to-end anastomosis is associated with a higher incidence of postoperative ileus. These findings can guide surgical decision-making in the treatment of right-sided colon cancer.

Cost and outcomes of side-to-side versus end-to-end anastomosis in right colectomy: a retrospective cohort study

BACKGROUND

The optimal anastomotic configuration for right-sided colectomies remains controversial, with comparable postoperative outcomes across techniques. Thus, economic considerations may play a larger role in decision-making within cost-constrained healthcare settings.

METHODS

This retrospective cohort study evaluated right-sided colectomies with ileocolic anastomosis at a Swiss tertiary center between 2016 and 2021. We compared costs and outcomes among three anastomotic techniques: end-to-end (EE), side-to-side stapled (SSS), and side-to-side hand-sewn (SSH).

RESULTS

Out of 468 patients (mean age 67.7 ± 16.2 years; 51.7% female), EE was used in 95 cases (20.3%), SSS in 191 (40.8%), and SSH in 182 (38.9%). The majority (72.0%) underwent elective surgery. Insurance coverage included basic (62.2%), semi-private (24.2%), and private (13.7%). Mean operation times were shortest for EE (173.6 ± 72.3 min), followed by SSS (188.0 ± 65.4 min) and SSH (195.1 ± 61.5 min). The median total costs were 26,449 €. The SSS group had the lowest median total costs, 2424 € less than SSH and 2095 € less than EE, with no significant differences (p = 0.1657). Significant differences were observed in operating room (OR) costs, with EE being the lowest and SSH the highest (p < 0.0001). Adjusted OR costs in SSH were 23% more than EE and 21% more than SSS. No significant difference was found between EE and SSS OR costs. For mean OR material costs, EE had the lowest, followed by SSS and SSH. Adjusted costs for EE were 52% lower than SSS (p = 0.0005) and 65% lower than SSH (p = 0.0191). Clavien-Dindo Grade ≥ III complication rates were 2.1% for EE, 1.9% for SSH, and 3.0% for SSS. Anastomotic leakage occurred in 12 cases (2.6%), and in-hospital mortality was 0.9% (no deaths in EE; two in SSS and SSH each).

CONCLUSIONS

EE anastomosis was associated with the lowest OR and material costs in this retrospective analysis while no disadvantages concerning postoperative outcomes could be identified.

Comparison study of two anastomosis techniques in right hemicolectomy: a systematic review and pooling up analysis

PURPOSE

This study aims to compare side-to-side anastomosis (SSA) and end-to-side anastomosis (ESA) in laparoscopic right hemicolectomy from multiple perspectives to guide the selection of the optimal anastomotic technique.

METHODS

This review was pre-registered with PROSPERO (CRD42024614418). A comprehensive literature search was performed using Embase, PubMed, Cochrane Library, and China Biology Medicine (CBM). The primary outcome was anastomotic complications, and secondary outcomes included non-anastomotic complications, short-term prognosis, and surgical parameters.

RESULTS

A total of 18 articles involving 14,555 participants were included in this systematic review and meta-analysis. No significant difference was found between SSA and ESA regarding overall anastomotic complications (OR = 1.14, 95% CI = 0.81 to 1.62, P = 0.45). However, SSA showed advantages in reducing postoperative anastomotic bleeding (OR = 0.64, 95% CI = 0.45 to 0.90, P = 0.01), while ESA appeared more favorable for reducing anastomotic leakage (AL) (OR = 1.29, 95% CI = 0.97 to 1.73, P = 0.08) and intestinal obstruction (OR = 1.20, 95% CI = 0.99 to 1.47, P = 0.07), though these differences were not statistically significant. No significant differences were found in non-anastomotic complications, short-term prognosis, or surgical parameters.

CONCLUSION

Current clinical evidence suggests that SSA is more effective than ESA in reducing postoperative anastomotic bleeding during right hemicolectomy for cancer. However, no significant differences were observed between the two techniques regarding overall anastomotic.

Isoperistaltic vs antiperistaltic anastomosis after right hemicolectomy: A comprehensive review

To optimize the efficiency of ileocolic anastomosis following right hemicolectomy, several variations of the surgical technique have been tested. These include performing the anastomosis intra- or extracorporeally or performing a stapled or hand-sewn anastomosis. Among the least studied is the configuration of the two stumps (i.e., isoperistaltic or antiperistaltic) in the case of a side-to-side anastomosis. The purpose of the present study is to compare the isoperistaltic and antiperistaltic side-to-side anastomotic configuration after right hemicolectomy by reviewing the relevant literature. High-quality literature is scarce, with only three studies directly comparing the two alternatives, and no study has revealed any significant differences in the incidence of anastomosis-related complications such as leakage, stenosis, or bleeding. However, there may be a trend towards an earlier recovery of intestinal function following antiperistaltic anastomosis. Finally, existing data do not identify a certain anastomotic configuration (i.e., isoperistaltic or antiperistaltic) as superior over the other. Thus, the most appropriate approach is to master both anastomotic techniques and select between the two configurations based on each individual case scenario.

Predictive Factors for Anastomotic Leakage Following Colorectal Cancer Surgery: Where Are We and Where Are We Going?

Anastomotic leakage (AL) remains one of the most severe complications following colorectal cancer (CRC) surgery. Indeed, leaks that may occur after any type of intestinal anastomosis are commonly associated with a higher reoperation rate and an increased risk of postoperative morbidity and mortality. At first, our review aims to identify specific preoperative, intraoperative and perioperative factors that eventually lead to the development of anastomotic dehiscence based on the current literature. We will also investigate the role of several biomarkers in predicting the presence of ALs following colorectal surgery. Despite significant improvements in perioperative care, advances in surgical techniques, and a high index of suspicion of this complication, the incidence of AL remained stable during the last decades. Thus, gaining a better knowledge of the risk factors that influence the AL rates may help identify high-risk surgical patients requiring more intensive perioperative surveillance. Furthermore, prompt diagnosis of this severe complication may help improve patient survival. To date, several studies have identified predictive biomarkers of ALs, which are most commonly associated with the inflammatory response to colorectal surgery. Interestingly, early diagnosis and evaluation of the severity of this complication may offer a significant opportunity to guide clinical judgement and decision-making.

Right hemicolectomy anastomotic leak study: a review of right hemicolectomy in the binational clinical outcomes registry (BCOR)

BACKGROUNDS

Surgery remains mainstay management for colon cancer. Post-operative anastomotic leak (AL) carries significant morbidity and mortality. Rates of, and risk factors associated with AL following right hemicolectomy remain poorly documented across Australia and New Zealand. This study examines the Bowel Cancer Outcomes Registry (BCOR) to address this.

METHODS

A retrospective cohort study was undertaken of consecutive BCOR-registered right hemicolectomy patients undergoing resection for colon cancer (2007-2021). The primary outcome measure was AL incidence. Clinicopathological data were extracted from the BCOR. Factors associated with AL and primary anastomosis were identified using logistic regression. AL-rate trends were assessed by linear regression.

RESULTS

Of 13 512 patients who had a right hemicolectomy (45.2% male, mean age 72.5 years, SD 12.1), 258 (2.0%) had an AL. On multivariate analysis, male sex (OR 1.33; 95% CI 1.03-1.71) and emergency surgery (OR 1.41; 95% CI 1.04-1.92) were associated with AL. Private health insurance status (OR 0.66; 95% CI 0.50-0.88) and minimally-invasive surgery (OR 0.61; 95% CI 0.47-0.79) were protective for AL. Anastomotic technique (handsewn versus stapled) was not associated with AL (P = 0.84). Patients with higher ASA status (OR 0.47; 95% CI 0.39-0.58), advanced tumour stage (OR 0.56; 95% CI 0.50-0.63), and emergency surgery (OR 0.16; 95% CI 0.13-0.20) were less likely to have a primary anastomosis. AL-rate and year of surgery showed no association (P = 0.521).

CONCLUSION

The AL rate in Australia and New Zealand following right hemicolectomy is consistent with the published literature and was stable throughout the study period. Sex, emergency surgery, insurance status, and minimally invasive surgery are associated with AL incidence.

Ileocolonic anastomosis-comparison of different surgical techniques: A single-center study

Right hemicolectomy (RH) is a common procedure for both benign and malignant colic disease. Different anastomotic types are performed during this procedure. To assess the association between anastomotic type and postoperative complications (PC) in patients undergoing RH. Retrospective analysis of medical records of 72 patients (39 female and 33 male), aged 24 to 93, undergoing open RH in the Department of Gastrointestinal Surgery. Data regarding anastomotic type [end-to-end anastomosis, side-to-side (SSA), end-to-side anastomosis, and side-to-end anastomosis (SEA)], and different clinical factors were collected. There were 21 (29%) end-to-end anastomosis, 25 (35%) SSA, 15 (21%) end-to-side anastomosis, and 11 (15%) SEA in the analyzed group. Adenocarcinoma G2 was the most frequent indication for RH - 30 (42%). Total duration of hospitalization (in days) was the longest (14, 26) after SEA and the shortest (12, 68) after SSA. PC were noted in 17(24%) patients. Wound infection was the most common complication noted in 15(21%) patients. The overall anastomotic leak rate was 7% (5/72). PC were the most frequent after SEA noted in 64% (7/11) including abdominal bleeding and bowel perforation. The overall reoperations rate was 6% (4/72). The overall mortality rate was 4% (3/72). SEA was associated with the highest incidence of postoperative complication however based on this and other studies there are no satisfying conclusions regarding the best choice of anastomosis.

Comparison of the short-term outcomes between intracorporeal isoperistaltic and antiperistaltic totally stapled side-to-side anastomosis for right colectomy: A retrospective study on 214 consecutive patients

BACKGROUND

Totally laparoscopic right colectomy has been demonstrated to be safe and feasible. Two manners of anastomosis, namely, antiperistaltic and isoperistaltic stapled side-to-side anastomosis, have been described before. However, research concerning the influence of different peristaltic orientations on anastomosis is rare and, if there is, included relatively small cases without long-term outcomes. The aim of this study was to compare the short- and long-term outcomes of intracorporeal isoperistaltic side-to-side anastomosis and antiperistaltic side-to-side anastomosis for right colectomy.

METHODS

We retrospectively reviewed 214 consecutive patients who underwent totally laparoscopic right colectomy from January 2017 to December 2020 at our medical center. Two modalities of anastomosis were used: isoperistaltic totally side-to-side anastomosis and antiperistaltic totally side-to-side anastomosis. Data on demographics, disease features, pathological characteristics, operative details, and short-term outcomes were collected and analyzed.

RESULTS

We found that operative features such as operating time, intraoperative bleeding, length of resected intestine, number of harvested lymph nodes, and length of incision, as well as measures of postoperative recovery such as time to first flatus, time to first defecation, and length of stay, were statistically comparable between the 2 groups. The postoperative complication rate was also similar between the 2 groups. The median follow-up time was 35.6 months, and no differences were observed in the long-term outcomes.

CONCLUSION

Intracorporeal isoperistaltic side-to-side anastomosis can achieve short- and long-term outcomes similar to those of antiperistaltic side-to-side anastomosis. Both techniques are safe and feasible.

A comparison of extracorporeal side to side or end to side anastomosis following a laparoscopic right hemicolectomy for colon cancer

Background

This study aimed to investigate whether an extracorporeal side‐to‐side (SS) or end‐to‐side (ES) stapled anastomosis impacts short‐term and long‐term outcomes after an oncological laparoscopic right hemicolectomy.

Methods

A retrospective cohort study of prospectively collected data from two Victorian tertiary referral hospitals was performed. Patients who underwent oncological resection for colorectal cancer between February 2010 and September 2020 were selected from the colorectal neoplasia database. Patients were divided into two groups depending on the type of stapled anastomosis: Group 1 (functional end‐to‐end/side‐to‐side (SS)); and Group 2 (end‐to‐side (ES)). Primary outcomes were anastomotic leak, postoperative ileus, mortality and morbidity, length of stay post‐surgery, readmission to hospital, and 30‐day mortality.

Results

This large case series of 1040 patients (SS = 625, ES = 415) demonstrated that the type of stapling technique impacted operative duration and postoperative ileus rates. Patients in the SS group had a faster operation of 108 min rather than 130 min in the ES group (p < 0.001). The SS group were more likely to experience a post‐operative ileus (p < 0.001) with no impact on length of stay (SS, 7 days versus ES, 7 days; p = 0.14). There were no differences between the two groups with respect to lymph node yield, lymph node ratio, anastomotic leaks, return to theatre, 30‐day mortality and 5‐year overall survival.

Discussion

The type of extracorporeal stapled anastomosis following an oncological laparoscopic right hemicolectomy has minimal impact on morbidity and survival outcomes; however, a side‐to‐side stapled anastomosis is more likely to be a faster operation with a higher postoperative ileus rate.

Ileocolic anastomosis after right hemicolectomy: stapled end-to-side, stapled side-to-side, or handsewn?

PURPOSE

Anastomotic leak (AL) following ileocolic anastomosis is a cause of significant morbidity and mortality. Stapled end-to-side (ESA), stapled side-to-side (SSA), and handsewn anastomoses (HSA) are commonly performed techniques. There is however conflicting data on the superiority of one technique over the other. The aim of this study was to compare the outcomes of ESA against SSA and HSA.

METHODS

This retrospective cohort study was conducted at a tertiary colorectal unit. All patients who underwent an ileocolic anastomosis from October 2008 to May 2020 were included. Exclusion criteria were missing data on anastomotic technique or clinicopathological variables. Primary outcomes were AL and anastomotic bleeding (AB). Secondary outcomes were length of stay (LoS) and return of gut function.

RESULTS

A total of 1390 patients met the inclusion criteria. A total of 976 (70%) ESA, 308 (22%) SSA, and 108 (8%) HSA were performed. AL occurred in 17/1390 (1.2%) patients, and 54/1390 (3.9%) had AB. On adjusted analysis, ESA experienced a lower AL when compared with SSA (OR 4.93, p = 0.005), with a trend towards a lower AL when compared to HSA (OR 2.6, p = 0.27). There was no difference in AB between all techniques: ESA vs. SSA (OR 1.07 p = 0.84), and ESA vs. HSA (OR 0.24 p = 0.76). Both stapled techniques were associated with a shorter return to gut function compared to HSA; 3.3 vs. 4.2 days (p < 0.001). There was no difference in LoS.

CONCLUSION

ESA has the lowest leak rate when compared to other anastomotic techniques without any increased risk of anastomotic bleeding.

Side-to-side versus end-to-side ileocolic anastomosis in right-sided colectomies: A cohort control study

Aims:

The three main types of anastomotic configurations following colorectal resection are Side-to-Side Anastomosis (S-S), End-to-Side Anastomosis (E-S) and End-to-End Anastomosis (E-E). This study aims to present results from a local cohort supplemented by a systematic review with meta-analysis of existing literature to compare the post-operative outcomes between E-S and S-S.

Methods:

A cohort study of patients who underwent right colectomy with E-S or S-S anastomosis, was conducted at the National University Hospital Singapore. Electronic databases Embase and Medline were systematically searched from inception to 21 August 2020, in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analysis guidelines. Studies were included if they compared post-operative outcomes between E-S and S-S.

Results:

In the cohort study, 40 underwent E-S and 154 underwent S-S. Both post-operative ileus (12.5% vs. 29.2%, P = 0.041) and length of hospital stay (9.35 days vs. 14.04 days, P = 0.024) favoured E-S, but anastomotic bleed favoured S-S (15.0% vs. 3.2%, P = 0.004). Five studies were included in the meta-analysis with 860 E-S and 1126 S-S patients. Similarly, post-operative ileus (odds ratio [OR] =0.302; 95% confidence interval [CI]: 0.122–0.747; P = 0.010) and length of hospital stay (mean differences = ‒1.54 days; CI: ‒3.00 to ‒0.076 days; P = 0.039) favoured E-S. Additional sensitivity analysis including only stapled anastomosis showed a lower rate of anastomotic leak in E-S patients (OR = 0.185; 95% CI: 0.054–0.627; P = 0.007).

Conclusions:

This is the first systematic review to show that the E-S technique produces superior post-operative outcomes after right colectomy compared to S-S. However, the choice of anastomosis was largely surgeon dependent, but surgeon factors were not reported.

Risk Factors and Preventive Measures for Anastomotic Leak in Colorectal Cancer

Anastomotic leak (AL) represents one of the most detrimental complications after colorectal surgery. The patient-related factors and surgery-related factors leading to AL have been identified in previous studies. Through early identification and timely adjustment of risk factors, preventive measures can be taken to reduce potential AL. However, there are still many problems associated with AL. The debate about preventive measures such as preoperative mechanical bowel preparation (MBP), intraoperative drainage, and surgical scope also continues. Recently, the gut microbiota has received more attention due to its important role in various diseases. Although the underlying mechanisms of gut microbiota on AL have not been validated completely, new strategies that manipulate intrinsic mechanisms are expected to prevent and treat AL. Moreover, laboratory examinations for AL prediction and methods for blood perfusion assessment are likely to be promoted in clinical practice. This review outlines possible risk factors for AL and suggests some preventive measures in terms of patient, surgery, and gut microbiota.

Updates of Risk Factors for Anastomotic Leakage after Colorectal Surgery

Anastomotic leakage is a potentially severe complication occurring after colorectal surgery and can lead to increased morbidity and mortality, permanent stoma formation, and cancer recurrence. Multiple risk factors for anastomotic leak have been identified, and these can allow for better prevention and an earlier diagnosis of this significant complication. There are nonmodifiable factors such as male gender, comorbidities and distance of tumor from anal verge, and modifiable risk factors, including smoking and alcohol consumption, obesity, preoperative radiotherapy and preoperative use of steroids or non-steroidal anti-inflammatory drugs. Perioperative blood transfusion was shown to be an important risk factor for anastomotic failure. Recent studies on the laparoscopic approach in colorectal surgery found no statistical difference in anastomotic leakage rate compared with open surgery. A diverting stoma at the time of primary surgery does not appear to reduce the leak rate but may reduce its clinical consequences and the need for additional surgery if anastomotic leakage does occur. It is still debatable if preoperative bowel preparation should be used, especially for left colon and rectal resections, but studies have shown similar incidence of postoperative leak rate.

Objective recovery time with end-to-side versus side-to-side anastomosis after laparoscopic right hemicolectomy for colon cancer: a randomized controlled trial

BACKGROUND

Despite reports of the short-term benefits of end-to-side versus side-to-side anastomosis, we are aware of no prospective studies in which these methods were compared. We hypothesized the superiority of end-to-side over side-to-side anastomosis in terms of recovery after laparoscopic right hemicolectomy for colon cancer under an enhanced recovery program.

METHODS

From September 2016 to August 2019, 130 patients were randomly allocated to receive end-to-side or side-to-side anastomosis at a single tertiary hospital in Korea. The primary outcome was the cumulative recovery rate seven days after surgery, defined as the percentage of patients who met all four recovery criteria: diet tolerance, no analgesia, safe ambulation, and an afebrile status. Student's t test, the Mann-Whitney U test, the χ² test, and Fisher's exact test were used to compare variables, as applicable.

RESULTS

The cumulative recovery rate at seven days did not differ between patients receiving end-to-side (92.3%, 60/65) or side-to-side anastomosis (92.3%, 60/65; P ≥ 0.999). The end-to-side and side-to-side groups had similar cumulative recovery rates at postoperative days 4, 5, and 6 (end-to-side vs. side-to-side: 41.5% vs 35.4%, P = 0.589; 73.8% vs 63.1%, P = 0.257; and 86.2% vs 81.5%, P = 0.634, respectively). None of the secondary endpoints differed for end-to-side vs. side-to-side anastomosis: the median length of postoperative hospitalization (5 [IQR 5-7] vs. 6 [IQR 5-7] days, respectively, P = 0.376), the 30-day complication rate (16.9% vs. 12.3%, respectively, P = 0.620), the enhanced recovery protocol failure rate (10.8% vs. 7.7%, respectively, P = 0.763), and the 30-day readmission rate (4.6% vs. 3.1%, respectively, P ≥ 0.999).

CONCLUSIONS

End-to-side anastomosis was not superior to side-to-side anastomosis in terms of recovery criteria after laparoscopic right hemicolectomy. These findings do not provide evidence for a functional advantage of end-to-side compared to side-to-side anastomosis.

Best evidence topic: Is ileocolic anastomotic leak rate higher in handsewn or stapler's anastomosis?

A best evidence topic has been constructed using a described protocol. The three-part question addressed was: is ileocolic anastomotic leak rate higher in handsewn or stapler's anastomosis? Using the reported search, 150 papers were found. 6 studies were deemed to be suitable to answer the question. The outcomes assessed were anastomotic leaks rate in hands Sewn and stapler's ileocolic anastomosis. The evidence does not provide an agreed consensus for which modalities of anastomosis have higher anastomotic leaks rate. Until a high quality randomized control trial is performed, the authors recommend an individual approach in a term of selection of which anastomotic modalities to be used.

Clinical impact of leakage in patients with handsewn vs stapled anastomosis after right hemicolectomy: a retrospective study

AIM

Anastomotic leakage is a major complication after right hemicolectomy leading to increased morbidity, mortality, length of stay and hospital costs. Previous studies have shown that the type of anastomosis (handsewn or stapled) is a major risk factor for anastomotic leakage. The purpose of this study was to evaluate the clinical impact of anastomotic leakage depending on the type of anastomotic technique (handsewn vs stapled).

METHOD

This was an observational, retrospective, cross-sectional study. Data were collected at two major hospitals in Spain from January 2010 to December 2016. Patients had elective right colectomy for cancer with handsewn or stapled ileocolic anastomosis. The main outcome was the grading of postoperative treatments needed to manage anastomotic leakage according to two major classification systems. The other outcomes were demographics, time of hospitalization and death rate.

RESULTS

Patients (n = 961) underwent elective surgery for neoplasia of the right colon. Anastomotic leakage was diagnosed in 116 patients (12.07%). Patients with handsewn anastomosis had more Type IIIA surgical complications and received milder treatments than patients with stapled anastomosis (SA) who had more Type IIIB complications and more re-laparotomies (P = 0.004). The clinical impact of anastomotic leakage was significantly more severe (Grade C) in patients with SA than in patients with a handsewn anastomosis (P = 0.007). No differences were found for hospital stay of patients with anastomotic leakage depending on the type of anastomosis (P = 0.275). Death due to anastomotic leakage was similar in both groups.

CONCLUSIONS

The clinical impact of anastomotic leakage in patients with handsewn anastomosis is lower than in patients with SA.

Risk factors for leak, complications and mortality after ileocolic anastomosis: comparison of two anastomotic techniques

INTRODUCTION

There are no definitive data concerning the ideal configuration of ileocolic anastomosis. Aim of this study was to identify perioperative risk factors for anastomotic leak and for 60-day morbidity and mortality after ileocolic anastomoses (stapled vs handsewn).

MATERIALS AND METHODS

This is a STROBE-compliant study. Demographic and surgical data were gathered from patients with an ileocolic anastomosis performed between November 2010 and September 2016 at a tertiary hospital. Anastomoses were performed using standardised techniques. Independent risk factors for anastomotic leak, complications and mortality were assessed.

RESULTS

We included 477 patients: 53.7% of the anastomoses were hand sewn and 46.3% stapled. Laterolateral anastomosis was the most common configuration (93.3%). Anastomotic leak was diagnosed in 8.8% of patients and 36 were classified as major anastomotic leak (7.5%). In the multivariate analysis, male sex (P = 0.014, odds ratio, OR, 2.9), arterial hypertension (P = 0.048, OR 2.29) and perioperative transfusions (P < 0.001, OR 2.4 per litre) were independent risk factors for major anastomotic leak. The overall 60-day complication rate was 27.3%. Male sex (31.3% vs female 22.3%, P = 0.02, OR 1.7), diabetes (P = 0.03 OR 2.0), smoking habit (P = 0.04, OR 1.8) and perioperative transfusions (P < 0.001, OR 3.3 per litre) were independent risk factors for postoperative morbidity. The 60-day-mortality rate was 3.1% and no significant risk factors were identified.

CONCLUSION

Anastomotic leak after ileocolic anastomosis is a relevant problem. Male sex, arterial hypertension and perioperative transfusions were associated with major anastomotic leak. Conversion to open surgery was more frequently associated with perioperative death.

Isoperistaltic versus antiperistaltic ileocolic anastomosis. Does it really matter? Results from a randomised clinical trial (ISOVANTI)

BACKGROUND

Right hemicolectomy is a very common surgery. Many studies compare different options for laparoscopic ileocolic anastomoses: intra- or extracorporeal; handsewn or stapled; side-to-side or end-to-side. However, there are no studies about the influence that peristalsis could have on this anastomosis. The aim of this study is to compare safety and feasibility of isoperistaltic and antiperistaltic anastomosis in terms of postoperative morbidity and mortality between both groups. The secondary endpoint is to compare long-term functional outcomes (chronic diarrhoea) and quality of life (GIQLI questionnaire) after a 1-year follow-up period.

METHODS

A double-blind, randomised, prospective trial in patients undergoing scheduled surgery for right colon cancer with laparoscopic right hemicolectomy and isoperistaltic (ISO) or antiperistaltic (ANTI) ileocolic anastomoses.

RESULTS

Hundred and eight patients were included in the study. Patients were randomised either to isoperistaltic or antiperistaltic configuration (54 ISO/ANTI). No significant differences in baseline variables were found. No differences in surgical time (130 [120-150] min ISO vs. 140 [127-160] ANTI, p = 0.481), nor in anastomotic time (19 [17-22] vs. 20 [16-25], p = 0.207) and nor in postoperative complications: 37.0% ISO versus 40.7% ANTI, (p = 0.693) were found. There were no differences in postoperative ileus (p = 0.112) nor in anastomotic leakage (3.7% vs. 5.56%, p = 1.00). Differences in "time to first flatus" and "time to first deposition" were found in favour of the antiperistaltic group (p = 0.004 and p = 0.017). Anastomotic configuration did not influence hospital stay (3 days [2-6] isoperistaltic vs. 3 [2-4] antiperistaltic, p = 0.236). During follow-up, there were no differences between the two groups at 1, 6 and 12 months (p = 0.154, p = 0.498 and p = 0.683), nor in chronic diarrhoea rates in GIQLI scores (24% ISO vs. 31.4% ANTI, p = 0.541).

CONCLUSIONS

The isoperistaltic and antiperistaltic ileocolic anastomosis present similar results in terms of performance, safety and functionality. However, further studies must be carried out in order to assess relationship between postoperative ileus and anastomosis configuration.

TRIAL REGISTRATION

Randomised Clinical trial (Identifier: NCT02309931).

Effects of anastomotic technique on early postoperative outcome in open right-sided hemicolectomy

Background

Despite recent improvements in colonic cancer surgery, the rate of anastomotic leakage after right hemicolectomy is still around 6–7 per cent. This study examined whether anastomotic technique (handsewn or stapled) after open right hemicolectomy for right‐sided colonic cancer influences postoperative complications.

Methods

Patient data from the German Society for General and Visceral Surgery (StuDoQ) registry from 2010 to 2017 were analysed. Univariable and multivariable analyses were performed. The primary endpoint was anastomotic leakage; secondary endpoints were postoperative ileus, complications and length of postoperative hospital stay (LOS).

Results

A total of 4062 patients who had undergone open right hemicolectomy for colonic cancer were analysed. All patients had an ileocolic anastomosis, 2742 handsewn and 1320 stapled. Baseline characteristics were similar. No significant differences were identified in anastomotic leakage, postoperative ileus, reoperation rate, surgical‐site infection, LOS or death. The stapled group had a significantly shorter duration of surgery and fewer Clavien–Dindo grade I–II complications. In multivariable logistic regression analysis, ASA grade and BMI were found to be significantly associated with postoperative complications such as anastomotic leakage, postoperative ileus and reoperation rate.

Conclusion

Handsewn and stapled ileocolic anastomoses for open right‐sided colonic cancer resections are equally safe. Stapler use was associated with reduced duration of surgery and significantly fewer minor complications.

Risk Factors and Oncologic Outcomes of Anastomosis Leakage After Laparoscopic Right Colectomy

PURPOSE

We estimated the incidence of anastomosis leakage and explore possible risk factors and oncologic outcomes following laparoscopic right-side colon resection among colon cancer patients.

MATERIALS AND METHODS

We retrospectively analyzed 423 patients who were diagnosed with appendiceal, cecal, ascending, or hepatic flexure colon cancer who underwent laparoscopic colonic resection and anastomosis between September 2006 and July 2014. We compared short-term and long-term outcomes between no-leakage and leakage groups.

RESULTS

There were 16 cases of right-side anastomosis leakage in a total 423 colon cancer cases (3.78%). The risk of leakage was increased in smokers (odds ratio=6.592, P=0.007) and with a longer operating time (odds ratio=1.024, P<0.001). There were no significant differences between the groups in local recurrence (P=0.106), overall survival (P=0.055), or cancer-specific survival (P=0.235).

CONCLUSIONS

Smoking and long operating time are risk factors for right-side colon anastomosis. There were no significant differences in oncologic outcomes.

Stapled intestinal anastomoses with endoscopic staplers in premature infants

PURPOSE

The safety and effectiveness of a stapled intestinal anastomosis in adults, children, and infants is well documented. However, in neonates it is not well validated. We hypothesized that premature infants who received a stapled bowel anastomosis utilizing endoscopic staplers had similar outcomes compared to patients with a handsewn anastomosis.

METHODS

A retrospective study was performed reviewing premature infants who underwent an intestinal anastomosis over a 4-year period. Patients greater than 36weeks gestational age at birth or a weight greater than 5kg at surgery were excluded. Patient demographics, type of intestinal anastomosis, and anastomotic related complications within 3months were collected and analyzed.

RESULTS

Sixty-five patients underwent 71 operations involving an intestinal anastomosis: 33 cases were handsewn, and 38 cases were stapled. Groups were noted to have differences in age, weight, and diagnosis. Complications including leak and anastomotic stricture did not differ between groups. Reports of blood per rectum after surgery were more common in the stapled group (24% versus 6%, p=0.0522), but this did not reach statistical significance.

CONCLUSION

There were no significant differences in anastomotic complications when comparing the handsewn and stapled intestinal anastomosis techniques in premature infants weighting less than 5kg.

TYPE OF STUDY

Treatment Study.

LEVEL OF EVIDENCE

III.

Risk Factors for Dehiscence of Stapled Functional End-to-End Intestinal Anastomoses in Dogs: 53 Cases (2001-2012)

OBJECTIVE

To identify risk factors for dehiscence in stapled functional end-to-end anastomoses (SFEEA) in dogs.

STUDY DESIGN

Retrospective case series.

ANIMALS

Dogs (n = 53) requiring an enterectomy.

METHODS

Medical records from a single institution for all dogs undergoing an enterectomy (2001-2012) were reviewed. Surgeries were included when gastrointestinal (GIA) and thoracoabdominal (TA) stapling equipment was used to create a functional end-to-end anastomosis between segments of small intestine or small and large intestine in dogs. Information regarding preoperative, surgical, and postoperative factors was recorded.

RESULTS

Anastomotic dehiscence was noted in 6 of 53 cases (11%), with a mortality rate of 83%. The only preoperative factor significantly associated with dehiscence was the presence of inflammatory bowel disease (IBD). Surgical factors significantly associated with dehiscence included the presence, duration, and number of intraoperative hypotensive periods, and location of anastomosis, with greater odds of dehiscence in anastomoses involving the large intestine.

CONCLUSION

IBD, location of anastomosis, and intraoperative hypotension are risk factors for intestinal anastomotic dehiscence after SFEEA in dogs. Previously suggested risk factors (low serum albumin concentration, preoperative septic peritonitis, and intestinal foreign body) were not confirmed in this study.

Comparison of anastomotic configuration after laparoscopic right hemicolectomy under enhanced recovery program: side-to-side versus end-to-side anastomosis

BACKGROUND

Stapled technique for ileocolic anastomosis is largely supported in previous studies. However, standard anastomotic configuration is not conclusive and studies are limited. This study aims to compare postoperative outcomes between side to side (S-S) and end to side (E-S) stapled anastomosis after laparoscopic right hemicolectomy underenhanced recovery program (ERP).

METHODS

Between October 2009 and November 2012, 89 patients (46 in S-S group, 43 in E-S group) who underwent laparoscopic right hemicolectomy for colon cancer and managed with ERP were included in the study. Recovery time and cumulative recovery rates, the length of hospital stays, complication rates were analyzed to compare both configurations.

RESULTS

The recovery time were not different between groups (S-S group, 135 hours [84-183.5] vs E-S group, 117 hours [94-143]; P = 0.349). Difference of cumulative recovery rates were observed in postoperative day 7 (S-S group, 71.7 % vs E-S group, 93.0 %; P = 0.019). The postoperative hospital stay were shorter in E-S group (S-S, 7 days [6-9] vs E-S, 6 days [5-7]; P = 0.003). The overall complication rates were lower in E-S group (26.1 % vs 4.6 %; P = 0.008). Anastomotic leakage was not observed in both groups.

CONCLUSIONS

E-S configuration after laparoscopic right hemicolectomy showed favorable outcomes under enhanced recovery program.

Ileocolonic anastomosis after right hemicolectomy for colon cancer: functional end-to-end or end-to-side?

BACKGROUND

The purpose of this study was to compare short-term clinical outcomes of ileocolonic functional end-to-end anastomosis (FEEA) and end-to-side anastomosis (ESA) following resection of the right colon for cancer.

METHODS

We enrolled 379 patients who underwent ileocolonic anastomosis following resection of the right colon for cancer by a single surgeon, from January 2009 through June 2012. Patient characteristics, operative results, and postoperative complications were analyzed.

RESULTS

A total of 164 patients received ESA and 215 patients received FEEA. The FEEA group had a lower incidence of anastomotic error (0.9% versus 4.3%; P = 0.04) and a shorter operating time (140.4 ± 14.9 min versus 150.5 ± 20.1 min; P = 0.001). The length of hospital stay (10.9 ± 3.5 days versus 11.3 ± 4.0 days; P = 0.36) and anastomotic leakage (1.8% versus 0.5%; P = 0.20) were similar in both groups. No relevant differences between FEEA and ESA were observed for blood loss, retrieved lymph nodes, first flatus and postoperative complications.

CONCLUSION

An FEEA after right hemicolectomy for colon cancer is a safe and reliable anastomotic technique, resulting in a favorable outcome in selected patients with the right colon cancer.

Risk factors and predictive factors for anastomotic leakage after resection for colorectal cancer: reappraisal of the literature

Anastomotic leakage is a serious complication that can occur after colorectal surgery. Several risk factors for anastomotic leakage have been reported based on the findings of prospective and retrospective studies, including patient characteristics, the use of neoadjuvant therapy, the tumor location, intraoperative events, etc. However, as these risk factors affect each other, the statistical results have differed in each study. In addition, differences in surgical methods, including laparoscopy versus laparotomy or stapling anastomosis versus handsewn anastomosis, may influence the incidence of anastomotic leakage. This mini-review summarizes the results of reported papers to clarify the current evidence of risk factors for anastomotic leakage.