Circular 'superelastic' compression anastomosis: from the animal lab to clinical practice

A systematic analysis of controlled clinical trials using the NiTi CAR™ compression ring in colorectal anastomoses

Anastomotic leak following colorectal surgery can be a devastating adverse event. The ideal stapling device should be capable of rapid creation of an anastomosis with serosal apposition without the persistence of a foreign body or a foreign body reaction which potentially contribute to early anastomotic dehiscence or late anastomotic stricture. A systematic review was performed examining available data on controlled randomized and non-randomized trials assessing the NiTi compression anastomosis ring-(NiTi CAR™) (NiTi Solutions, Netanyah Israel) in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) standards. A protocol for this meta-analysis has been registered on PROSPERO (CRD42016050934). The initial search yielded 45 potentially relevant articles. After screening titles and abstracts for relevance and assessment for eligibility, 39 of these articles were eventually excluded leaving 6 studies for analysis in the review. Regarding the primary outcome measure, the overall anastomotic leak rate was 2.2% (5/230) in the compression anastomosis group compared with 3% (10/335) in the conventional anastomosis group; this difference was not statistically significant (RR 0.75, 95% CI 0.25-2.24; participants = 565; studies = 6; I ² = 0%). There were no statistically significant differences between compression and conventional anastomoses in any of the secondary outcomes. This review was unable to demonstrate any statistically significant differences in favor of the compression anastomosis technique over conventional manual or stapled mechanical anastomoses.

Can a nickel-titanium memory-shape device serve as a substitute for the stapler in gastrointestinal anastomosis? A systematic review and meta-analysis

BACKGROUND

Recently, a nickel-titanium (NiTi) memory-shape device has been successfully used in gastrointestinal anastomosis. The aim of this study was to investigate the feasibility and safety of the device.

METHODS

Four databases, reference lists, and the World Health Organization International Clinical Trials Registry Platform were systematically searched for randomized controlled trials assessing the clinical efficacy of a NiTi memory-shape device compared with that of a stapler in gastrointestinal or colorectal anastomosis.

RESULTS

Seven randomized controlled trials regarding the use of compression anastomosis clips (CACs) were enrolled for meta-analysis. The use of CACs was associated with a significant reduction in hospital duration (mean = -0.88 d; 95% confidence interval [CI], -1.38 to -0.38), the time to flatus (mean = -0.36 d; 95% CI, -0.08 to -0.04), and the start of oral intake (mean = -0.45 d; 95% CI, -0.83 to -0.06), as well as a nonsignificant change in postoperative complications and mortality. These clinical outcomes did not significantly change with the use of compression anastomosis rings.

CONCLUSIONS

Colonic anastomosis with a CAC is likely to reduce hospital duration, time to flatus, and the start of oral intake without influencing mortality or postoperative complications and may be a safe and preferable choice in colonic anastomosis. Further well-designed trials should be performed to determine the safety and efficacy of the newly developed compression anastomosis ring in both ileocolic and colorectal anastomosis.

COMPRES: a prospective postmarketing evaluation of the compression anastomosis ring CAR 27(™) /ColonRing(™)

AIM

Preclinical studies have suggested that nitinol-based compression anastomosis might be a viable solution to anastomotic leak following low anterior resection. A prospective multicentre open label study was therefore designed to evaluate the performance of the ColonRing(™) in (low) colorectal anastomosis.

METHOD

The primary outcome measure was anastomotic leakage. Patients were recruited at 13 different colorectal surgical units in Europe, the United States and Israel. Institutional review board approval was obtained.

RESULTS

Between 21 March 2010 and 3 August 2011, 266 patients completed the study protocol. The overall anastomotic leakage rate was 5.3% for all anastomoses, including a rate of 3.1% for low anastomoses. Septic anastomotic complications occurred in 8.3% of all anastomoses and 8.2% of low anastomoses.

CONCLUSION

Nitinol compression anastomosis is safe, effective and easy to use and may offer an advantage for low colorectal anastomosis. A prospective randomized trial comparing ColonRing(™) with conventional stapling is needed.

Diagnosis, management and outcome of early anastomotic leakage following colorectal anastomosis using a compression device: is it different?

AIM

Compression anastomosis has proved to be safe for rectal reconstruction with leak rates comparable to those observed using circular stapling devices. However, there are no data on whether the metallic compression ring alters the ease of diagnosis or the treatment in cases of leakage. In this study, we present our experience with early leakage following compression anastomosis.

METHOD

A prospective registry was used for data review. Patients with anastomotic leakage following compression anastomosis between November 2008 and September 2013 were included.

RESULTS

In all, 197 (92 female) patients were operated using a novel compression device. Early leakage was found in 10 (5.1%) patients after a median of 5 (3-14) days. The radiologist was able to detect leakage using CT in nine out of 10 cases unequivocally. Removal of the ring was necessary in eight of the 10 cases, and salvage of the anastomosis was feasible on six occasions. In all diverted cases with a low anastomosis, a transanal repair of the defect was feasible in three cases, including a single patient with complete separation of the anastomosis.

CONCLUSION

Artefacts on the CT scan caused by the compression ring did not hamper the diagnosis of anastomotic leakage. Removal of the ring in the early postoperative period is not associated with complete separation of the bowel ends. Salvage of anastomosis is feasible in most cases.

Histopathologic advantages of compression ring anastomosis healing as compared with stapled anastomosis in a porcine model: a blinded comparative study

BACKGROUND

The performances of compression and stapled devices were compared previously in porcine colorectal anastomosis. The compression anastomosis was associated with elevated bursting strength and anastomotic patency in this model as compared with the stapled anastomosis.

OBJECTIVE

The purpose of this work was to compare the histopathologic features between compression and stapled methods in the healing of colorectal anastomoses using a porcine model.

DESIGN

This was a blinded comparison study.

SETTINGS

The study was conducted at a single university surgery department.

PATIENTS

Fifty crossbred pigs were used in this study.

MAIN OUTCOME MEASURES

Fifty crossbred pigs underwent rectal transection 20 cm from the anal verge and end-to-end compression or stapled anastomosis. The anastomotic tissues were harvested 3, 7, 30, and 90 days postoperatively (n = 5-6). Tissue repair parameters associated with the wound healing were analyzed using image analysis morphometry and histological architecture assessments.

RESULTS

A different microscopic pattern of the anastomotic area was shown between groups. Foreign body response was rated (p < 0.001) as minimal in the compression and moderate in the stapled group. The scarring area in the compression anastomosis group, on postoperative day 90 (4 ± 3 × 10(5) μm) was lower (p = 0.016) than in the stapled group (2 ± 1 × 10(6) μm). In addition, the anastomotic line was narrower (p = 0.003) 90 days after surgery in the compression samples (0.77 ± 0.20 mm) compared with that in the stapled group (1.86 ± 0.19 mm). Lastly, in terms of inflammatory cells, the compression biopsies showed lower (p < 0.001) numbers of mononuclear cells, polymorphonuclear cells, and lymphocytes in the anastomotic tissues 30 and 90 days from surgery.

LIMITATIONS

The long-term effect of the compression technique on the anastomotic patency in colorectal anastomoses should be further investigated in human studies.

CONCLUSIONS

Compression anastomotic healing was associated with less foreign body reactions, scarring, and inflammation as compared with stapled anastomoses in a large animal model.

Anastomotic leakage after low anterior resection for rectal cancer: comparison of stapled versus compression anastomosis

PURPOSE

Surgical technique and perioperative management in rectal cancer surgery have been substantially improved and standardized during the last decades. However, anastomotic leakage following low anterior resection still is a significant problem. Based on animal experimental data of improved healing of compression anastomosis, we hypothesized that a compression anastomotic device might improve healing rates of the highest-risk anastomoses.

METHODS

All low anterior resections for rectal cancer performed or directly supervised by the senior author between January 2004 and June 2012 were analyzed. Only patients with a stapled or compression anastomosis located within 6 cm from the anal verge were included. Until December 2008, circular staplers were employed, while since January 2009, a novel compression anastomotic device was used for rectal reconstruction exclusively.

RESULTS

Out of 197 patients operated for rectal cancer, a total of 96 (34 females, 35.4 %) fulfilled inclusion criteria. Fifty-eight (60.4 %) were reconstructed with circular staplers and 38 (39.6 %) using a compression anastomotic device. Significantly, more laparoscopic procedures were recorded in the compression anastomosis group, but distribution of gender, age, body mass index, American Society of Anaesthesiologists score, rate of preoperative radiotherapy, tumor staging, or stoma diversion rate were similar. Anastomotic leakage was observed in seven cases (7/58, 12.1 %) in the stapled and twice (2/38, 5.3 %) in the compression anastomosis group (p = 0.26).

CONCLUSIONS

In this series, rectal reconstruction following low anterior resection using a novel compression anastomotic device was safe and (at least) equally effective compared to traditional circular staplers concerning leak rate.

Healing of ileocolic nitinol compression anastomosis: a novel porcine model of subtotal colectomy

BACKGROUND

There are limited large animal models for the research of novel anastomotic technologies. Subtotal colectomy requires the anastomosis of relatively remote segments of the alimentary tract that are different anatomically, histologically, and pose significant physiological challenge. The quest for a foreign material-free anastomotic line reintroduced nitinol compression anastomosis into clinical use in the last decade.

OBJECTIVE

To evaluate the safety, histological, and physiological parameters of side-to-side ileocolic nitinol compression anastomosis in a newly developed large animal model, mimicking the human subtotal colectomy.

INTERVENTION

Resection of the entire spiral colon with an ileocolic side-to-side compression anastomosis in 12 animals, compared to resection of a short ileal segment in 6 animals. All anastomoses were constructed by using a novel nitinol-based compression device. The animals were followed up to 30 days postoperatively and were reoperated and sacrificed.

RESULTS

All 12 animals underwent successful subtotal colectomy with side-to-side nitinol compression anastomosis. No signs of abdominal infection were found. The increase in the colectomized animals' bodyweight over the postoperative course was significantly lower and the animals presented with longer periods of diarrhea. The histopathology revealed minimal inflammation and foreign body reaction with good alignment of the bowel wall layers in both groups. The anastomotic line width was shown to be reduced during the healing course of the compression anastomoses.

CONCLUSIONS

Side-to-side nitinol compression anastomosis is safe and demonstrates favorable functional and histopathological features. The porcine model of subtotal colectomy can be used for further research of novel anastomotic technologies.

Compression anastomosis ring device in colorectal anastomosis: a review of 1,180 patients

BACKGROUND

The nickel-titanium compression anastomosis ring device (ColonRing, NiTi Surgical Solutions, Netanya, Israel) has been cleared by the Food and Drug Administration in 2006 to construct gastrointestinal anastomoses. We evaluated the anastomotic leak rate after end-to-end anastomosis using the ColonRing device.

METHODS

Using a multinational (16 countries), multicenter (178 centers) data registry provided by NiTi Surgical Solutions, Netanya, Israel, we retrospectively examined clinical data of patients who underwent elective laparoscopic or open left-sided colectomy and anterior resection from January 2008 to June 2010.

RESULTS

A total of 1,180 patients underwent end-to-end anastomosis using the ColonRing device during the study period. The overall anastomotic leak rate was 3.22% (38 patients). The median length of hospital stay was 6 days (range 2 to 21 days). The median ring expulsion time was 8 days. The earliest ring expulsion time was 6 days; however, in 1 patient, the ring did not expel. In 4 patients, the anastomosis had to be immediately recreated because of 1 misfiring and 3 incomplete anastomoses.

CONCLUSIONS

The use of the ColonRing device is feasible and safe and could be considered an alternative technology for end-to-end colorectal anastomosis.

Safety and efficacy of the NiTi Shape Memory Compression Anastomosis Ring (CAR/ColonRing) for end-to-end compression anastomosis in anterior resection or low anterior resection

PURPOSE

Compression anastomoses may represent an improvement over traditional hand-sewn or stapled techniques. This prospective exploratory study aimed to assess the efficacy and complication rates in patients undergoing anterior resection (AR) or low anterior resection (LAR) anastomosed with a novel end-to-end compression anastomosis ring, the ColonRing.

METHODS

In all, 20 patients (13 male) undergoing AR or LAR were enrolled to be anastomosed using the NiTi Shape Memory End-to-End Compression Anastomosis Ring (NiTi Medical Technologies Ltd, Netanya, Israel). Demographic, intraoperative, and postoperative data were collected.

RESULTS

Patients underwent AR (11/20) or LAR using laparoscopy (75%), robotic (10%) surgery, or an open laparotomy (15%) approach, with a median anastomotic level of 14.5 cm (range, 4-25 cm). Defunctioning loop ileostomies were formed in 6 patients for low anastomoses. Surgeons rated the ColonRing device as either easy or very easy to use. One patient developed an anastomotic leakage in the early postoperative period; there were no late postoperative complications. Mean time to passage of first flatus and commencement of oral fluids was 2.5 days and 3.2 days, respectively. Average hospital stay was 12.6 days (range, 8-23 days). Finally, the device was expelled on average 15.3 days postoperatively without difficulty.

CONCLUSIONS

This is the first study reporting results in a significant number of LAR patients and the first reported experience from South Korea; it shows that the compression technique is surgically feasible, easy to use, and without significant complication rates. A large randomized controlled trial is warranted to investigate the benefits of the ColonRing over traditional stapling techniques.

Compression anastomoses in colorectal surgery: a review

The main serious risks of anastomotic construction in the colon and rectum include dehiscence and stricture formation. There is a resurgence of interest in sutureless anastomoses formed by compression elements since the introduction of shape memory alloy (SMA) systems, which evoke minimal early inflammatory response whilst maintaining anastomotic integrity. Currently, the most commonly used SMA is the nickel-titanium (NiTi) alloy that is highly biocompatible, returning to its pre-deformed stable (austenite) shape under different mechanical and thermal loads for use in humans. Pre-clinical data for shape memory alloy systems in colorectal anastomoses are limited, but it appears to be safe in porcine and canine models with limited leakage and reduced stricture formation. There does not appear to be any difference in tissue biochemistry of inflammatory markers when compared with conventional stapled techniques, although the few studies available show a markedly reduced early inflammatory response at the anastomotic site with the NiTi device. The majority of the clinical data concerning compression anastomoses are derived from the biofragmentable anastomotic ring device. This device has fallen out of use because of reported leaks, instrumental failure and problems with device expulsion. A novel SMA device, the NiTi anastomotic ring, permits construction of a low rectal anastomosis construction during open or laparoscopic procedures. The preliminary data demonstrate a safety comparable to conventional staple technology. This device also provides the potential of benefit of reduced anastomotic inflammation, because the compression ring results in direct serosa-to-serosa (or alternatively serosa-to-muscularis propria) apposition without the persistence of residual foreign material. This type of construction could lead to a reduced incidence of early anastomotic leakage and/or the development of anastomotic stenosis. Randomized clinical trials employing a NiTi arm for elective, emergency and high-risk colorectal anastomoses are required to determine its indications and clinical profile as well as to assess whether such technology may selectively obviate the need for proximal diversion in low colorectal anastomoses.

Anastomosis by use of compression anastomosis ring (CAR™ 27) in laparoscopic surgery for left-sided colonic tumor

PURPOSE

The safety and efficacy of the compression anastomosis ring (CAR™ 27) had been demonstrated by animal studies. This study was designed to evaluate clinical validity of the CAR™ 27 anastomosis in laparoscopic surgery for patients with left-sided colonic neoplasm.

METHODS

Intracorporeal anastomosis using the CAR™ 27 (CAR group) was performed in 66 patients (male 35; median age, 64.5 years), and short-term results were compared with consecutive 116 patients (male 70; median age, 64 years) where the anastomosis was constructed by double stapling technique using a circular stapler for the same indications (stapled group).

RESULTS

There were no statistically significant differences between the two groups in terms of gender, age, and distribution of pathologic lesion. The laparoscopic procedures, pathologic diagnosis/stage, and length of operation time and postoperative hospital stay were comparable between the two groups. Conversion rate in the CAR and stapled group was 3% and 6%, respectively. There was no surgical mortality in either group. No intraoperative complications associated with the CAR™ 27 anastomosis were encountered. One patient in the CAR group was complicated by anastomotic leakage and none in the stapled group (p = 0.36). There was intestinal obstruction in two patients, in whom one required re-operation for entrapped small bowel adhesions within pelvis. No patient in either group showed symptomatic anastomotic stricture.

CONCLUSIONS

The anastomosis using the CAR™ 27 is an innovative technique. The CAR™ 27 anastomosis in patients undergoing laparoscopic colectomy for left-sided colonic tumor proved to be a safe and efficacious alternative to the standard double stapling technique.

Compression anastomoses in colon and rectal surgery with the NiTi ColonRing™

BACKGROUND

The aim of this prospective study was to evaluate safety and efficacy of the NiTi ColonRing™ for anastomoses on the colon or rectum.

METHODS

During the period September 2008-June 2011, anastomosis using the NiTi ColonRing™ was scheduled to be performed on 60 patients (36 females, 24 males/mean aged 67 years), 53 of whom underwent colectomy for cancer and 7 reconstruction after Hartmann's procedure. Application of the device failed in one case due to anatomical reasons. Colorectal resections performed were as follows: Right hemicolectomy (5 patients), left colectomy (2), sigmoidectomy (15) and low anterior resection (31). A follow-up clinic visit after 1 month was planned for all patients. Ten patients among the first 14 had rectosigmoidoscopy at 2-3 months. All cancer patients were scheduled for colonoscopy at 12 months.

RESULTS

No intraoperative or postoperative bleeding related to the anastomotic technique was recorded. Median hospital stay after surgery was 10.2 days (9-22 days). One patient died on day 13 due to myocardial infarction. Clinically apparent leak was detected in one patient who had undergone reconstruction after Hartmann; the only treatment required was total parenteral nutrition for 12 days. Anastomotic stenosis occurred in another one patient who had undergone reconstruction after Hartmann; it was easily resolved by balloon dilatation. Mild complications were encountered in 23 other patients (39%). Oral feeding started after day 4. Anastomotic rings were expelled naturally within 7-17 days (mean, 9.2 days). A satisfactory anastomosis was revealed in patients examined colonoscopically at 2-3 and 12 months. Mean follow-up was 15.2 months (2-33 months).

CONCLUSIONS

NiTi ColonRing™ is reliable, safe and efficacious for large bowel anastomoses.

Early experience of the compression anastomosis ring (CARTM 27) in left-sided colon resection

AIM: To evaluate clinical validity of the compression anastomosis ring (CAR™ 27) anastomosis in left-sided colonic resection.

METHODS: A non-randomized prospective data collection was performed for patients undergoing an elective left-sided colon resection, followed by an anastomosis using the CAR™ 27 between November 2009 and January 2011. Eligibility criteria of the use of the CAR™ 27 were anastomoses between the colon and at or above the intraperitoneal rectum. The primary short-term clinical endpoint, rate of anastomotic leakage, and other clinical outcomes, including intra- and postoperative complications, length of operation time and hospital stay, and the ring elimination time were evaluated.

RESULTS: A total of 79 patients (male, 43; median age, 64 years) underwent an elective left-sided colon resection, followed by an anastomosis using the CAR™ 27. Colectomy was performed laparoscopically in 70 patients, in whom two patients converted to open procedure (2.9%). There was no surgical mortality. As an intraoperative complication, total disruption of the anastomosis occurred by premature enforced tension on the proximal segment of the anastomosis in one patient. The ring was removed and another new CAR™ 27 anastomosis was constructed. One patient with sigmoid colon cancer showed postoperative anastomotic leakage after 6 d postoperatively and temporary diverting ileostomy was performed. Exact date of expulsion of the ring could not be recorded because most patients were not aware that the ring had been expelled. No patients manifested clinical symptoms of anastomotic stricture.

CONCLUSION: Short-term evaluation of the CAR™ 27 anastomosis in elective left colectomy suggested it to be a safe and efficacious alternative to the standard hand-sewn or stapling technique.

[Intestinal anastomoses and techniques in the lower gastrointestinal tract]

Surgery of the lower gastrointestinal tract includes segmental resections for benign colorectal diseases and radical resections for treating colorectal cancer performed under elective and emergency conditions. The most important part of the surgical procedure is the reconstruction of the physiological intestinal continuity by anastomosis. At present laparoscopic surgery has widened the array of different suturing and stapling techniques. The effectiveness of manual and stapled anastomoses depends on the expertise of the surgeon. However, skillful preparation of the hand-sutured technique is essential.

The use of a compression device as an alternative to hand-sewn and stapled colorectal anastomoses: is three a crowd?

BACKGROUND

The NiTi CAR™ 27 is a newer device that uses compression to create an anastomosis. An analysis of this device in the creation of colorectal anastomoses in humans has yet to be reported in the USA.

METHODS

A non-randomized, prospective pilot study of the NiTi CAR™ 27 device in patients undergoing a left-sided colectomy between March 2008 and August 2009 was performed.

RESULTS

Twenty-three patients (9 men and 14 women) underwent a left-sided colectomy and compression anastomosis with the CAR™ 27 device. Minor morbidities, 3 of 23 (13%) patients, included one small postoperative abscess requiring antibiotics alone and two postoperative anastomotic strictures requiring balloon dilation. Major morbidities, 1 of 23 (4%) patients, included a partial anastomotic dehiscence/leak requiring surgical dismantling of the anastomosis and diversion.

CONCLUSION

The CAR™ 27 device shows promise as a safe and effective alternative for the creation of colorectal anastomoses. However, studies in a larger patient population are warranted to demonstrate equivalence of this device.

Evaluation of the NiTi Shape Memory BioDynamix ColonRing™ in colorectal anastomosis: first in human multi-center study

BACKGROUND

Shape-memory compression bowel anastomosis using a nickel and titanium alloy may reduce leak rates and eliminate foreign anastomotic material. Its safety and efficacy had been demonstrated by animal studies. We conducted the first prospective multi-center clinical evaluation of the safety and effectiveness of BioDynamix anastomosis with ColonRing™ for large-bowel end-to-end or side-to-end anastomosis.

MATERIALS AND METHODS

The ColonRing™ was compared to the standard double-stapled colorectal/colocolonic anastomosis. Intraoperative and immediate postoperative and 1- and 3-month postoperative follow-up data were recorded.

RESULTS

Ten study patients (four males, median age 62 years, range 35-75) were compared to 13 demographically matched controls (six males, median age 62 years, range 47-82). Colorectal neoplasia was the most frequent indication for surgery (21/23 patients, 91%). The median anastomotic distance from the anal verge for both groups was 10 cm (6-20 cm). The first postoperative bowel movement was on day 5 ±2.2 (study group) and on day 4 ±1.8 (controls), and the median hospital stay was 8 days (6-14 days) and 7 days (6-13 days), respectively. There were no anastomotic leaks. There were three minor complications in each group, unrelated to the device in the study group. Two patients required transanal digital extraction of the ring which was detached but not expelled (one had a soft anastomotic stricture).

CONCLUSIONS

Our preliminary results in this first study on humans indicate that the safety and efficacy of BioDynamix anastomosis with ColonRing™ in colorectal anastomosis in human is comparable to standard staples technology and warrant larger studies for further validation.

Techniques for colorectal anastomosis

Colorectal anastomotic leak remains one of the most feared post-operative complications, particularly after anterior resection of the rectum with, the shift from abdomino-peritoneal resections to total mesorectal excision and primary anastomosis. The literature fails to demonstrate superiority of stapled over hand-sewn techniques in colorectal anastomosis, regardless of the level of anastomosis, although a high stricture rate was noted in the former technique. Thus, improvements in safety aspects of anastomosis and alternatives to hand-sewn and stapled techniques are being sought. Here, we review alternative anastomotic techniques used to fashion bowel anastomosis. Compression anastomosis using compression anastomotic clips, endoluminal compression anastomotic rings, AKA-2, biofragmental anastomotic rings, or Magnamosis all involve the concept of creating a sutureless end-to-end anastomosis by compressing two bowel ends together, leading to a simultaneous necrosis and healing process that joins the two lumens. Staple line reinforcement is a new approach that reduce the drawbacks of staplers used in colorectal practice, i.e. leakage, bleeding, misfiring, and inadequate tissue approximation. Various non-absorbable, semi or fully absorbable materials are now available. Two other techniques can provide alternative anastomotic support to the suture line: a colorectal drain and a polyester stent, which can be utilized in ultra-low rectal excision and can negate the formation of a defunctioning stoma. Doxycycline coated sutures have been used to overcome the post-operative weakness in anastomosis secondary to rapid matrix degradation mediated by matrix metalloproteinase. Another novel technique, the electric welding system, showed promising results in construction of a safe, neat, smooth sutureless bowel anastomosis. Various anastomotic techniques have been shown to be comparable to the standard techniques of suturing and stapling. However, most of these alternatives need to be accepted and optimized for future use.

Anastomoses of the lower gastrointestinal tract

Patients with gastrointestinal anastomoses are treated by physicians of multiple specialties, including gastroenterologists, radiologists and surgeons. This Review provides an overview of the surgical principles and techniques involved in the creation of lower intestinal anastomoses, including some of the mechanisms of healing. Anatomical configurations of small and large bowel anastomoses are illustrated. Stapled, hand-sewn, and sutureless anstomotic techniques are also discussed. Laparoscopy has revolutionized our approach to surgery of the gastrointestinal tract and we describe some of the current and future minimally invasive techniques for creating anastomoses. The article also highlights principles important in minimizing potential short-term and long-term complications such as anastomotic leaks and strictures. Common risk factors for dehiscence include poor nutrition, immunosuppression, microvascular disease, obesity and technical errors. An evidence-based review of perioperative and postoperative management of intestinal anastomoses is provided to help optimize patient care. The routine use of nasogastric tubes and mechanical bowel preparation has no documented benefits and could contribute to postoperative complications. Upcoming strategies that might prove useful to reinforce anastomoses are also reviewed.