Colonic Anastomosis--A New Approach:

Preliminary Report*

I. L. HOROVITZ, M.D.

From the Department of Surgery A, Rothschild University Hospital, Aba Khoushy School of Medicine, P.O.B. 4940, Haila, Israel

T H E INCIDENCE Of anastomotic breakdown and leakage in colonic anastomoses is con- siderably higher than incidences in other parts of the gastrointestinal tract. The inci- dence reported varies with the diligence with which it is sought. Most investigators agree on a rate of leakage between 5 and 30 per cent. 1, 10, 13 Goligher e t al . 4 have re- ported an average incidence of 51 per cent, comprised of 40 per cent for high anterior resections and 69 per cent for low anterior resections.

The reported incidence of leakage is gen- erally based on clinical observation only, the criteria for leakage being fistulization with or without need for reoperation, z These criteria are inadequate because leakage will frequently remain obscure, with very little or no clinical manifestation. Goligher has shown that careful examination of colonic anastomoses, both by direct inspection and by radiologic studies, reveals dehiscence in otherwise unsuspected cases. Thus, the re- ported incidence of 5-25 per cent, on the basis of clinical manifestations, must actu- ally be assumed to be higher. Dissatisfaction with the high incidence of anastomotic breakdown has led me to abandon the con- ventional two-layer anastomosis in favor of a modification.

* Received for publication January 26, 1976. Address reprint requests to Dr. Horovitz.

Dis. Cot. & Rect. Nov.-Dec. 1976

Material and Method

Lindenmuth and MayS have described an anastomosis using a seromuscular tubular cuff. I have used an adaptation of the prin- ciples of their technique for anterior resections since 1973.

The lower midline incision is considered to be most convenient. The "no-touch" tech- nique was adopted for the preparation of the segment to be resected. At both ends a marginal strip, 1 to 2 cm wide, is denuded of its epiploic appendices. The colon is then transected at one end, whereas on the other end, only the seromuscular layer is incised (Fig. 1). Tile mucosa is ablated and resected

about 9 cm from the serosal edge (Fig. 2).

This end of the colon, which is to serve as cuff, presents two edges; one the seromuscu-

far cut end, and the other the mucosal edge,

retracted about 9 cm within the cuff. The

unaltered end of the colon is sutured to the

mucosal edge of the other end (Fig. 3) by con-

tinuous chromic atraumatic catgut. Thus,

one end of the colon is anchored at the base

of the seromuscular cuff of its counterpart

(Fig. 4). The second layer of sutures fixes

the seromuscnlar cuff to the wall of invagi-

nated colon using atraumatic interrupted

silk sutures (Fig. 5). Thus, the outer suture line is diverted from the inner suture line,

which is covered by the cuff.

667 Volume 19 Number 8

668 H O R O V I T Z Dis. CoL & Reef. Nov.-Dec. 1976

for acute diverticulitis, two for volvulus of the sigmoid, and one for traumatic rupture of the colon.

During the postoperative period two pa- tients died of causes unrelated to the opera- tion. The postoperative courses of all other patients except patients who had fistuliza- tion were uneventful. Spontaneous bowel movements occurred between the third and eighth days after operation. During the follow-up periods, barium-enema examina- tions were repeated every six months. In a few cases the immediate postoperative barium-enema studies showed some narrow- ing at the anastomotic site, but in no case was any evidence of stricture or narrowing evident on later occasions.

Fie. I. Colonic serosa is incised.

At the beginning I considered it impor- tant to form the cuff in the distal end. Re- cently the proximal end was found to serve as well. In some instances, when the anasto- mosis is very low, there is some technical advantage in forming the cuff in the proxi- nxal end of the transected colon.

At the end of the operation the abdomen is closed without drainage.

Since 1973 1 have performed 24 such anastomoses and have carefully followed the immediate postoperative courses of the pa- tients. Most patients had control barium- enema studies between the fourth and tenth postoperative days. In two patients leakage was demonstrated, without any clinical man- ifestation. Another patient had clinically evident leakage, necessitating a temporary transverse colostomy for four weeks. There is little doubt in my mind that two of the three leaks were due to faulty performance, as a result of overconfidence gained by previous successes.

The average age of the patients was 63 years, ranging from 29 to 78 years. Nineteen patients were operated upon for cancer, two

Discussion

The remarkable tendency of colonic anastomoses to break clown is an undisputed fact. Controversy exists in regard to the rate

Fro. 2. Dissection of seromuscular cuff from 1TIUCOSa.

Volume 19 C O L O N I C A N A S T O M O S I S 669 Number 8

Fro. 3, M u c o s a l edge is now su- t u r e d to o t h e r e n d of colon.

FIG, 4. S e r o m u s c u l a r cuff serves to cover first su tu r e s u n d e r n e a t h .

FIG. 5. F i n a l l y , cuff is s u t u r e d to colon.

670 HOROVITZ Dis. Col. & Rect. Nov.-Dee, 1976

of i n c i d e n c e a n d its u n d e r l y i n g causes, e, 3, 5,

6, 9, 11, 12 T h e r e is sufficient e v i d e n c e tha t

a n a s t o m o t i c l eakage can occur w i t h o u t cl in-

ical m a n i f e s t a t i o n . T h e r e f o r e , the ra te of

i n c i d e n c e based o n c l in ica l obse rva t i ons

a l o n e does no t r e p r e s e n t the t rue rate. O n l y

ca r e fu l p o s t o p e r a t i v e r ad io log i c s tudies m a y

r e n d e r the t rue ra te of inc idence , w h i c h , as

d e m o n s t r a t e d by Go l ighe r , is far h i g h e r t h a n

is a p p a r e n t .

O u r p r e sen t a p p r o a c h to co lon ic anasto-

moses is based on o u r surgical e x p e r i e n c e in

the ga s t ro in t e s t i na l tract . T h e a s s u m p t i o n

tha t e q u a l t e c h n i q u e shou ld r e n d e r e q u a l

resul ts is p r o b a b l y mi s l ead ing , and re-

assessment of o u r t e c h n i q u e m a y be indi -

cated. I have, there fore , t r i ed to a d o p t a

n e w a p p r o a c h in an a t t e m p t to i m p r o v e

co lon ic anas tomoses . T h e first resul ts are

e n c o u r a g i n g bu t do n o t a l low any stat ist i-

cal conc lus ions so far. I e x p e c t f u r t h e r t r ia l

of this t e c h n i q u e to p r o v e its mer i ts .

Sul l l lna ry

T h e exac t i n c i d e n c e of co lon ic anasto-

m o t i c b r e a k d o w n is difficult to assess. T h e

low i n c i d e n c e r e p o r t e d on the basis of cl ini-

cal o b s e r v a t i o n o n l y is mi s l ead ing , s ince i t

has b e e n d e m o n s t r a t e d tha t leakages occur

w i t h o u t c l in ica l m a n i f e s t a t i o n . B e t t e r evalu-

a t i on of the ra te of i nc idence wi l l r e q u i r e

m e t i c u l o u s p o s t o p e r a t i v e inves t iga t ion , as

shown by Go l ighe r . A n e w co lon ic anas to-

mosis was p e r f o r m e d in 24 cases of h i g h a n d

low a n t e r i o r resect ions. T h e p r i n c i p l e of

f o r m i n g a s e r o m u s c u l a r cuff has been em-

p loyed . T h e e n c o u r a g i n g results m e r i t

f u r t h e r t r ia l ,

A c k n o w l e d g m e n t s

The author thanks Mr. Ilan Hadar, department of Biochemical Communication, Technion, School of Medicine, Haifa~ for his help, and Mrs. Ruth Tilo, Medical Illustration, Technion, School of Medicine, for the medical illustrations.

R e f e r e n c e s

1. Adam YG, Volk H, State D: Low colorectal anastomosis after resection for cancer. Surg Gynecol Obstet 125: 1259, 1967

2. Berliner SD, Burson LC, Lear PE: Use and abuse of intraperitoneaI drains in colon sur- gery. Arch Surg 89: 686, 1964

3. Corer TW Jr, Ray EJ, Gathright JB Jr: Does neostigmine cause disruption of large-intes- tinal anastomoses? A negative answer. Dis Colon Rectum 17: 235, 1974

4. Goligher JC, Graham NG, de Dombal FT: Anastomotic dehiscence after anterior resec- tion of rectum and sigmoid. Br J Surg 57: 109, I970

5. Hawley PR: Causes and prevention of colonic anastomotic breakdown. Dis Colon Rectum 16: 272, 1973

6. Herter FP, Slanetz CA Jr: Influence of anti- biotic preparation o[ the bowel on compli- cations after colon resection. Am J Surg 113: 165, 1967

7. Kronborg O, Kramh6ft J, Backer O, et al: Early complications following operations for cancer of the rectum and anus. Dis Colon Rectum 17: 741, 1974

8. Lindenmuth WW, May CJ: Anastomoses in alimentary tract using a sero-muscular tubu- lar cuff technic. Ann Surg 165: 590, 1967

9. Manz CW, La Tendresse C, Sako Y: The detri- mental effects of drains on colonic anasto- moses: An experimental study. Dis Colon Rectum 13: 17, 1970

10. Morgenstern L, Yamakawa T, Ben-Shoshan M, et al: Anastomotic leakage after low colonic anastomosis: Clinical and experimental as- pects. Am J Surg 123: 104, 1972

11. Ryan P: The effect 6f surrounding infection upon the healing of colonic wounds: Experi- mental studies and clinical experiences. Dis Colon Rectum 13: 124, 1970

12. Schrock TR, Deveney CW, Dunphy JE: Factors contributing to leakage of colonic anasto- moses. Ann Surg 177: 513, 1973

13. Vandertoll DJ, Beahrs OH: Carcinoma of rec- tum and low siomnoid: Evaluation of anterior resection of 1,766 favorable lesions. Arch Surg 90: 793, 1965