Isoperistaltic side-to-side anastomosis for the surgical treatment of Crohn disease

Insufficiency of ileocolic anastomosis in Crohn’s disease patients – prevention and treatment

Resection of the terminal ileum and ileocecal valve remains the most commonly performed procedure in patients with Crohn's disease. However, despite radical treatment, there is a risk of disease recurrence at the site of the intestinal anastomosis in some cases. Therefore, long-term postoperative management is crucial and requires systematic clinical assessment, endoscopic surveillance, and pharmacological support when indicated. A key challenge is identifying the risk factors associated with the recurrence of anastomotic failure and defining the principles of follow-up care to prevent secondary intestinal insufficiency. This paper focuses on both surgical and non-surgical factors that may play a role in preventing complications in patients undergoing ileocecal resection, providing a comprehensive approach to postoperative management.

Operative Management of Small and Large Bowel Crohn's Disease

The majority of patients with Crohn's disease, despite an ever-increasing number of advanced therapies, require abdominal surgery during their lifetime. In this review article, the authors provide a comprehensive overview of abdominal surgery for Crohn's disease, with an evidence-based focus on surgery for upper gastrointestinal Crohn's disease, bowel-preserving surgery with strictureplasties, selection of ileocolic anastomotic technique for terminal ileal Crohn's disease, extended resections and proctectomy for Crohn's proctocolitis, intentional ileoanal pouch for Crohn's disease, and several "hot topics" including early surgery for ileocolic Crohn's disease, and surgical approaches that target the mesentery including the Kono-S anastomosis and extended mesenteric excision.

Isoperistaltic hand-sewn side-to-side bowel primary anastomosis: a safe approach after bowel resection in children with neutropenic enterocolitis

BACKGROUND AND AIM

Whether to perform primary anastomosis (PA) or create a stoma after bowel resection has always been a dilemma in pediatric cancer patients with neutropenic enterocolitis (NEC). The risk of leakage after PA must be weighed against the risk of stoma complications. We evaluated the outcomes of managing NEC patients with either PA or stoma and the utility of the isoperistaltic hand-sewn side-to-side anastomosis (ISSA) technique in PA.

PATIENTS AND METHODS

A retrospective study on all Children's Cancer Hospital Egypt patients with NEC who underwent surgical exploration at our hospital from 2008 to 2022.

RESULTS

Of 153 children, 80 (52.3%) underwent PA and 73 (47.7%) underwent stoma formation. Among the 80 PA patients, 68 (85%) underwent ISSA, 9 (11.2%) end-to-end anastomosis (EEA), and 3 (3.8%) end-to-side anastomosis (ESA). The perioperative complication rate was 38/73 (52.1%) in the stoma patients and 35/80 (43.8%) in the PA patients. Leakage occurred in 6/68 (8.8%) ISSA patients, 5/9 (55.6%) EEA patients, and 1/3 (33.3%) of ESA patients.

CONCLUSIONS

In pediatric cancer patients with NEC, PA using ISSA after bowel resection is considered a better approach than any other anastomotic configuration.

Safety and effectivity of Kono-S anastomosis in Crohn's patients: a systematic review and Meta-analysis

PURPOSE

Kono-S anastomosis, an antimesenteric, functional, end-to-end handsewn anastomosis, was introduced in 2011. The aim of this meta-analysis is to evaluate the safety and effectivity of the Kono-S technique.

METHODS

A comprehensive search of MEDLINE (PubMed), Embase (Elsevier), Scopus (Elsevier), and Cochrane Central (Ovid) from inception to August 24th, 2023, was conducted. Studies reporting outcomes of adults with Crohn's disease undergoing ileocolic resection with subsequent Kono-S anastomosis were included. PRISMA and Cochrane guidelines were used to screen, extract and synthesize data. Primary outcomes assessed were endoscopic, surgical and clinical recurrence rates, as well as complication rates. Data were pooled using random-effects models, and heterogeneity was assessed with I² statistics. ROBINS-I and ROB2 tools were used for quality assessment.

RESULTS

12 studies involving 820 patients met the eligibility criteria. A pooled mean follow-up time of 22.8 months (95% CI: 15.8, 29.9; I2 = 99.8%) was completed in 98.3% of patients. Pooled endoscopic recurrence was reported in 24.1% of patients (95% CI: 9.4, 49.3; I2 = 93.43%), pooled surgical recurrence in 3.9% of patients (95% CI: 2.2, 6.9; I2 = 25.97%), and pooled clinical recurrence in 26.8% of patients (95% CI: 14, 45.1; I2 = 84.87%). The pooled complication rate was 33.7%. The most common complications were infection (11.5%) and ileus (10.9%). Pooled anastomosis leakage rate was 2.9%.

CONCLUSIONS

Despite limited and heterogenous data, patients undergoing Kono-S anastomosis had low rates of surgical recurrence and anastomotic leakage with moderate rates of endoscopic recurrence, clinical recurrence and complications rate.

Mesenteric-based surgery for Crohn's disease: evidence and perspectives

Postoperative anastomotic recurrence of Crohn's disease is challenging and can lead to symptom recurrence and further surgery. The mesenteric pole of the intestine is the initial site of macroscopic anastomotic recurrence, and the mesentery may play an important role in recurrence after surgical resection. Therefore, "mesenteric-based surgery" has gained increasing attention by clinicians. However, the role of mesentery in the postoperative recurrence remains controversial. This review will examine mesenteric changes in Crohn's disease, proposed roles for mesentery in disease progression, and the potential for mesenteric-based surgery in the surgical management of Crohn disease.

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.