Bowel resection and anastomosis

BOWEL RESECTION AND ANASTOMOSIS ITS PRINCIPLES AND TECHNIQUE

1. BOWEL RESECTION AND ANASTOMOSIS DR. AJAY KUMAR 2 ND YEAR PG MKCG MCH

2. AIMS OF DISCUSSION Introduction and History Indications of Resection and Anastomosis Types of Anastomosis General Principles of anastomosis Complications Management of complications.

3. INTRODUCTION WHAT IS RESECTION? Surgical removal of all or part of an organ , tissue or structure. WHAT IS ANASTOMOSIS? The word anastomosis is come from Greek word ‘ ana ‘ means without, stoma means a mouth, i.e. when a tubular viscus is joined after resection without exteriorisation with a stoma.

4. Intestinal anastomosis is a surgical procedure to establish communication between two formerly distant portion of the intestine. This procedure restores the intestinal continuity after removal of pathological condition affecting the bowel.

5. HISTORY Galen – coined the term anastomosis 1826 – Lembert – Sero-muscular technique 1893 – Nicholas Sen - Two layer closure using silk. Halsted – Single layer closure, extramucosal. 1926 – Carrel – End to end vascular anastomosis. 1963 – Connell – Single layer interrupted, full thickness Kocher – Two layered technique with silk and catgut

6. IDEAL ANASTOMOSIS Zero leak rate Should promote early recovery of function. Should not narrow the lumen of viscus. No vascular compromise at the incised and /or divided margin of a viscus. Easy to learn, teach and perform. Technique should preferably be quick to perform

7. INDICATIONS Broadly divided into two categories :- Restoration of bowel continuity following resection of diseased bowel. Bypass of unresectable diseased bowel.

8. RESECTION OF DISEASED BOWEL Bowel gangrene due to vascular compromise. Malignancy . Benign conditions (e.g. intestinal polyps). Infections (eg. tuberculosis complicated with stricture or perforation). Traumatic perforations.

9. Inflammatory bowel disease, that is refractory to medical therapy/ associated with complications (eg. bleeding, perforation, toxic megacolon, dysplasia/carcinoma. Intussusception. Hirschprung disease

10. BYPASS OF UNRESECTABLE DISEASED BOWEL Locally advanced tumor causing luminal obstruction. Metastatic disease causing intestinal obstruction. Poor general condition or condition that prevents major resection.

11. TYPES OF ANASTOMOSIS ON THE BASIS OF ORIENTATION:- End to end End to side Side to side

12. ON THE BASIS OF TECHNIQUES :- Hand sewn Stapled - - Linear - Circular

13. ON THE BASIS OF LAYER :- 1. Single layered - Interrupted - Seromucosal - Absorbable suture used 2. Double layered - Outer seromuscular, interrupted, non absorbable - Inner full thickness , continuous

14. ON THE BASIS OF ANATOMICAL POSITION Oesophago - jejunostomy Gastro - jejunostomy Entero-enterostomy Entero-colic anastomosis Colo-colic anastomosis Colo-rectal anastomosis Colo-anal anastomosis Ileo-anal anastomosis

15. FACTORS ESSENTIALS FOR SAFE BOWEL ANASTOMOSIS LOCAL FACTORS :- Good blood supply. No tension on suture line Inverting anastomosis with appropriate suture Accurate apposition and suture technique Avoidance of tissue damage by clamps.

16. SYSTEMIC FACTOTS :- Bowel preparation (and avoidance of spillage) Antibiotic prophylaxis Maintenance of good perfusion and tissue oxygenation during anaesthesia (correction of shock) Adequate nutritional attention Adequate resectional margins (cancer or inflammatory bowel disease) Avoidance of chemotherapy/radiotherapy

17. PHYSIOLOGY OF INTESTINAL ANASTOMOTIC HEALING Most of the strength of the bowel wall resides in the sub mucosa. However , Serosa holds sutures better than either the longitudinal or the circular muscle layer . Collagen is the single most important molecule =>Content highest in sub mucosa.

18. A critical stage in collagen formation :- Hydroxylation of proline => Hydroxyproline fibril cross-linking maturity of the collagen Overall strength of the scar tissue

19. PHASES OF HEALING Acute inflammatory phase ( 0 – 4 days ). Proliferative phase (3 – 14 days ):- - Fibroblast proliferation occurs with collagen formation. Maturation phase ( > 10 days ) :- - This is the period of collagen remodeling and stability and strength of anastomosis increases.

20. TECHNIQUES OF ANASTOMOSIS Intestinal anastomosis can be performed by :- Hand sewn technique using absorbable/ non absorbable sutures. Stapling devices

21. Hand sewn techniques ( sutured anastomosis) :- - Commonly used techniques - Availability - Affordability of suture materials - Familiarity with the procedure. Stapling devices :- - Reduces the operation time - Ease of doing the procedure

22. END TO END TWO LAYER TECHNIQUE A point of transection is selected sufficiently distant from the diseased portion. The peritoneum of the mesentery is opened without transecting the blood vessel.

23. Mesentery is opened in V shaped fashion. The small vessel crossing the line of transection are clamped and tied.

24. The line of transection in the bowel is oblique rather than perpendicular. The blood supply to the small bowel is such that the anti mesenteric border of the bowel can become ischemic if the vascular arcade supplying the edge of the resected bowel is transected perpendicularly. Secondly an oblique transection will give a larger anastomosis and reduce the incidence of stricture formation

25. The bowel ends must be brought together without tension. The all-layers continuous inner suture is undertaken with an absorbable suture. Started from one angle . Reached to same angle covering whole circumference .

26. Finally the anastomosis is inverted using a sero muscular , anterior , continuous Lembert suture.

27. Suture bites should be 3-5mm deep and 3- 5mm apart depending on thickness of bowel. Suture material size 2/0-3/0, absorbable, mounted on round bodied needle . Bowel of similar diameter is essential for end to end anastomosis In major size discrepancy, side- to-side or end-to-side anastomosis is preferable. At last, mesentery should always be closed to avoid internal hernia.

28. ADVANTAGES OF SIDE TO SIDE ANASTOMOSIS:- Segment of bowel to be united have no interruption of blood supply. Size discrepancy can be tackled. DISADVANTAGES :- More suture line involved More degree of stasis and bacterial growth.

29. STAPLING DEVICES It is a technical equipment used to mechanically connect hollow organ Stapling devices were first used successfully by Humer Hulti, in Hungary. Give strong predictable suture lines, with minimal tissue necrosis. Allow access to difficult areas.

30. TYPES OF INTESTINAL STAPLER Three different types of stapler are commonly used :- Transverse Anastomosis (TA) Stapler Gastrointestinal Anastomosis (GIA) Stapler Circular or End to End Anastomosis (EEA) Stapler

31. TRANSVERSE ANASTOMOSIS STAPLER Simply provides two row of staples for a single transverse anastomosis. Useful for closing bowel ends.

32. GASTROINTESTINAL ANASTOMOSIS STAPLER Two detachable limbs. Each limb can be introduced into bowel loops, then limb reassembled and fired. Two row of staples along with division of the septum between the rows .

33. TYPES OF CARTRIDGE

34. TYPES OF CARTRIDGE

35. CIRCULAR OR EEA STAPLER Commonly used in esophagus and low rectum . Stapling head/anvil is introduced into one end of bowel, secured with purse string suture. Body/shaft of device is introduced via rectum in low rectal anastomosis or via an enterotomy elsewhere and secured with purse-string suture. Head is reattached to the shaft and two ends of bowel approximated till a green signal window appear. S tapler is fired.

36. It is important to assess the integrity of anastomosis by examining the doughnuts of tissue for completeness.

37. STAPLES Titanium staples are ideal for tissue apposition because :- they provoke only a minimal inflammatory response. provide immediate strength to the cut surfaces during the weakest phase of healing.

38. DRAWBACKS OF STAPLING DEVICES U s e o f Stapli n g d evice s needs familiarity with the instrument. Technical failure during operation. Grossly much expensive than sutures Size of the device is a concern too. More compromise of blood supply to anastomotic site due to two rows of staples in an interlocking manner.

39. COMPLICATIONS Anastomotic leak F istula formation Bleeding Wound infection Anastomotic stricture

40. ANASTOMOTIC LEAK Anastomotic leak is the most feared early complication of intestinal anastomosis. Any systemic or local factor that causes delay in the transition from the inflammatory phase to the fibroplasia phase can result in poor healing and anastomotic leak.

41. CRITERIA FOR ANASTOMOTIC LEAK Fa ecal fistulas to the skin or vagina or bladder. Fever > 38 °C with septicaemia. Radiological signs of anastomotic leakage. Also an intraperitoneal abscess or peritonitis in the presence of an anastomotic leak. IF ANY ONE OF THE ABOVE CRITERIA PRESENT- DIAGNOSIS

42. RISK FACTORS FOR ANASTOMOTIC LEAK :- Mechanical bowel preparation Drains Advanced malignancy Emergency surgery Malnutrition Steroid therapy Neoadjuvant therapy Vitamin c, iron, zinc, cysteine deficiency

43. WARNING SIGNS OF LEAK :- Malaise Fever Abdominal pain Ileus Localised erythema around incision Leucocytosis Surgical wound dehiscence

44. DIAGNOSIS OF ANASTOMOTIC LEAK :- Clinical signs Leucocytosis Positive blood cultures Abdominal/chest X-ray CECT scan- GOLD STANDARD Fistulogram

45. PREVENTION OF ANASTOMOTIC LEAK :- Adequate exposure. Gentle handling of tissue. Aseptic precautions. Meticulous and careful dissection Adequate mobilisation for a tension-free anastomosis . Correct placement of suture and staplers.

46. MANAGEMENT :- SUSPICION OF ANY LEAK EVEN BEFORE DIAGNOSIS SHOULD BE MANAGED PROMPTLY. Immediate resuscitation. Correction for third space loss and Intestinal content losses. NPO again ,if orally started. Infected surgical wound should be drained. BLOOD TRANSFUSION if required. Broad spectrum antibiotics.

47. RE-OPERATION IS PERFORMED WHEN :- Diffuse peritonitis Intra-abdominal haemorrhage Suspected intestinal ischemia Major wound disruption or evisceration Reoperation is always associated with significant mortality and morbidity. Poor prognosis must be explained to the patient.

48. INTESTINAL FISTULAS Presents with triad of sepsis , fluid and electrolyte imbalance, malnutrition. Fistula in general classified- 1. Anatomically:- INTERNAL FISTULA- Enteroenteric, enterovescical, enterovaginal . EXTERNAL FISTULA- Enterocutaneous fistula

49. CONT.. 2. Physiologically- LOW OUTPUT- <200ml/24hr MODERATE OUTPUT- 200-500ml/24hr HIGH OUTPUT- >500ml/24hr

50. In proximal small bowel fistula- output is high, fluid loss ,electrolyte imbalance & malabsorption is profound . Distal and colonic fistula, output is low and dehydration , acid-base imbalance & malnutrition is are uncommon. Effluent dermatitis due to corrosive effects of intest inal content causing irritation, maceration and excoriation.

51. DIAGNOSIS :- FISTULOGRAM-

52. CT FISTULOGRAM –

53. TREATMENT OF FISTULAS :- Combined effort from surgeon, nutritionist , radiologist . Resuscitation TPN Electrolyte correction. Antibiotics therapy Drainage of abscess and wound infections

54. Trace elements and vitamin supplements. Somatostatin- reduces secretions , reduces output. FISTULOCLYSIS- infusion of nutrition directly through the fistula into the bowel distal to it. Provided -more than 75cm of healthy bowel present distally. Safer and less expensive than TPN Prevents atrophy of bowel distal to fistula.

55. Protection of peri-fistula skin is by : Barriers – Zinc oxide cream Sealants

56. Negative pressure wound therapy :-

57. BLEEDING :- Bleeding may manifest in the immediate postoperative period. It may be either hemorrhagic aspirate from the nasogastric tube, hematemesis, melena, or bleeding from an intra-abdominal drain. Patients with bleeding should be aggressively managed with correction of coagulopathy (if present) and blood transfusion.

58. WOUND INFECTION :- Wound infection occurs when there is uncontrolled spillage of intestinal contents during anastomosis. It is managed by removing a few skin sutures and ensuring proper drainage of pus.

59. ANATOMOTIC STRICTURE :- Anastomotic stricture is a late complication of intestinal anastomosis. The risk of anastomotic stricture is marginally increased after end-to-end anastomosis, especially when performed using a stapled technique. Managed conservatively, If this fails surgical revision might be required.