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Figure depicting side-to-side anastomosis (STSA) ( a ) and end-to-end anastomosis (ETEA) ( b ). Figures drawn by artist Michael Antrim. Endoscopic appearance of a STSA, which forms a pouch-like confi guration ( c ), with proximal (afferent) intestine entering the anastomosis seen on retrofl ex view with colonoscope ( d ). Endoscopic appearance of an ETEA where the lumen continues in a straight, tube-like orientation ( e ). Radiologic appearance ( f ) and intra-operative appearance of the same STSA from c and d , which was created 3 years prior. The dilated, pouch-like confi guration of the STSA is evident both radiographically and at the time of exploratory laparotomy ( g ).
Source publication
Objectives:
Anastomotic reconstruction following intestinal resection in Crohn’s disease (CD) may employ side-to-side anastomosis (STSA; anti-peristaltic orientation) or end-to-end anastomosis (ETEA). Our aim was to determine the impact of these two anastomotic techniques on long-term clinical status in postoperative CD patients.
Methods:
We perfo...
Context in source publication
Similar publications
Perianal fistula is a very debilitating event and a cause of morbidity in patients with Crohn's disease (CD). Its malignant transformation is very rare with an incidence of around 0.004–0.7$. Presence of disease in the colon and rectum is the major risk factor for the development of a perianal fistula. In this report we show a case of adenocarcinom...
Citations
... Nevertheless, when considering HRQL, side-to-side anastomosis may lead to worse quality of life outcomes, probably due to the structural and functional alterations it is associated with, which may predispose to dysmotility and abdominal distension [11]. ...
... In the present study, we have been able to demonstrate that The worse motility profile of the side-to-side anastomosis has already been described in previous experiences. In 2018, Gajendran et al. [11] prospectively collected data on 128 CD patients who had undergone bowel resection with either side-to-side or end-to-end anastomosis, with the aim of assessing the association between anastomosis type and 2-year postoperative QoL: ...
Aim
Crohn's disease has debilitating effects on patients' quality of life. Currently, there are limited data on the effect of anastomotic configuration on health‐related quality of life after ileocaecal resection for Crohn's disease. This study aimed to assess the impact of Kono‐S anastomosis on quality of life after ileocolic resection, compared to the conventional side‐to‐side anastomosis.
Method
Patients with primary or recurrent Crohn's disease participating in the ongoing SuPREMe‐CD trial were interviewed about quality of life using the Inflammatory Bowel Disease Questionnaire (IBDQ). The primary endpoint was disease‐specific quality of life, assessed with IBDQ. Secondary outcomes were quality of life related to bowel symptoms, systemic symptoms, social function and emotional function.
Results
Of the 94 patients included, 51 (54%) received the conventional side‐to‐side anastomosis and 43 (46%) the Kono‐S anastomosis. Demographics were comparable between the two groups. The IBDQ was assessed at a mean follow‐up of 54.0 ± 18.7 months from surgical intervention. The mean total IBDQ score was 155.1 ± 28.07 in the conventional group and 163.8 ± 25.23 in the Kono‐S group ( P = 0.11). When considering bowel symptoms and social function, mean scores were 50.7 and 23.5 in the conventional group, and 56.3 and 26.5 in the Kono‐S group ( P = 0.002 and P = 0.02, respectively). Kono‐S anastomosis was independently associated with improved quality of life regarding bowel symptoms ( P = 0.006) and social function ( P = 0.03) after correcting for other confounding factors on linear regression analysis.
Conclusion
Compared to conventional side‐to‐side anastomosis, patients with Kono‐S anastomosis presented significantly better bowel symptoms and social function scores at 54 months after surgery.
... The third type of anastomosis, the end-to-end handsewn anastomosis appears to be less popular due to its technical complexity [17]. However, a recent study comparing handsewn end-to-end with stapled side-to-side anastomosis, showed reduced healthcare consumption in favour of the end-to-end anastomosis [18]. Additionally, the authors found no difference in endoscopic recurrence rates at 2 years postoperatively (25.4% vs 39.3%, respectively; p = 0.112). ...
... The observations of Gajendran et al. support this hypothesis [18]. In their study, they compared the sideto side stapled with the handsewn end-to-end anastomosis and noted that the former configuration resulted in worse QoL and higher healthcare consumption in the 2 years after surgery due to increased abdominal complaints and consequently diagnostic measures. ...
Background
The most common intestinal operation in Crohn’s disease (CD) is an ileocolic resection. Despite optimal surgical and medical management, recurrent disease after surgery is common. Different types of anastomoses with respect to configuration and construction can be made after resection for example, handsewn (end-to-end and Kono-S) and stapled (side-to-side). The various types of anastomoses might affect endoscopic recurrence and its assessment, the functional outcome, and costs. The objective of the present study is to compare the three types of anastomoses with respect to endoscopic recurrence at 6 months, gastrointestinal function, and health care consumption.
Methods
This is a randomized controlled multicentre superiority trial, allocating patients either to side-to-side stapled anastomosis as advised in current guidelines or a handsewn anastomoses (an end-to-end or Kono-S). It is hypothesized that handsewn anastomoses do better than stapled, and end-to-end perform better than the saccular Kono-S. Two international studies with a similar setup will be conducted mainly in the Netherlands (End2End) and Italy (HAND2END). Patients diagnosed with CD, aged over 16 years in the Netherlands and 18 years in Italy requiring (re)resection of the (neo)terminal ileum are eligible. The first part of the study compares the two handsewn anastomoses with the stapled anastomosis. To detect a clinically relevant difference of 25% in endoscopic recurrence, a total of 165 patients will be needed in the Netherlands and 189 patients in Italy. Primary outcome is postoperative endoscopic recurrence (defined as Rutgeerts score ≥ i2b) at 6 months. Secondary outcomes are postoperative morbidity, gastrointestinal function, quality of life (QoL) and costs.
Discussion
The research question addresses a knowledge gap within the general practice elucidating which type of anastomosis is superior in terms of endoscopic and clinical recurrence, functionality, QoL and health care consumption. The results of the proposed study might change current practice in contrast to what is advised by the guidelines.
Trial registration
NCT05246917 for HAND2END and NCT05578235 for End2End (http://www.clinicaltrials.gov/).
... Traditional surgical anastomosis configurations (e.g. side-to-side, end-to-end, end-to-side) have not demonstrated association with POR, including anastomotic stricturing, across multiple meta-analyses, but may pose unique challenges and considerations [45,54,56,57,[61][62][63]. ...
Purpose of Review
Despite advances in therapeutics, a significant portion of patients with Crohn’s disease still require surgical management. In this article, we present updates to the natural history, prognostication and postoperative monitoring, and novel therapeutics in the prevention and treatment of postoperative Crohn’s disease recurrence.
Recent Findings
Clinical risk factors have been associated with higher rates of postoperative recurrence (POR), and in recent studies demonstrate an increased cumulative risk with presence of additional risk factors. Additional novel clinical, histologic, and “-omic” risk factors for recurrence have recently been elucidated, including the role of the mesentery on recurrence and perioperative intraabdominal septic complications. High-risk patients benefit most from medical prophylaxis, including anti-TNF with or without immunomodulator therapy to prevent recurrence. New biologics such as vedolizumab and ustekinumab have emerging evidence in the use of prophylaxis, especially with recent REPREVIO trial data. Non-invasive disease monitoring, such as cross-sectional enterography, intestinal ultrasound, and fecal calprotectin, have been validated against ileocolonoscopy.
Summary
Recent advances in the prediction, prevention, and monitoring algorithms of postoperative Crohn’s disease may be leading to a reduction in postoperative recurrence. Ongoing trials will help determine optimal monitoring and management strategies for this at-risk population.
... In recent years, several papers have been published related to the different outcomes of patients with i2a vs. i2b lesions [25][26][27] without consistent findings; consequently, it is still unclear whether i2a and i2b findings should be treated and monitored differently. Recent advances in surgical approaches and different anastomotic techniques have highlighted the importance of considering various operative factors and led to the development of different surgical options, each with a different risk of POR [28][29][30]. Evidence indicates stapled intestinal anastomoses, whether side-to-side or end-to-end, demonstrate superior outcomes relative to hand-sewn techniques (anastomotic leak rate of 2% vs. 14%) [31,32]. ...
Crohn’s disease (CD) is a chronic inflammatory bowel disease with different phenotypes of presentation, inflammatory, penetrating, or stricturing disease, that significantly impacts patient well-being and quality of life. Despite advances in medical therapy, surgery sometimes represents the only treatment to address complications, such as strictures, fistulas, or abscesses. Minimizing postoperative recurrence (POR) remains a major challenge for both clinicians and patients; consequently, various therapeutic strategies have been developed to prevent or delay POR. The current review outlines an updated overview of POR management. We focused on diagnostic assessment, which included endoscopic examination, biochemical analyses, and cross-sectional imaging techniques, all crucial tools used to accurately diagnose this condition. Additionally, we delved into the associated risk factors contributing to POR development. Furthermore, we examined recent advances in the prophylaxis and treatment of POR in CD.
... A bibliographic review of these articles identified a further 8 studies, which were additionally considered, resulting in 51 free-text articles being assessed for eligibility. 11,[13][14][15] Of these, 17 studies, 11,[13][14][15]20,22,28,31,35,36,41,44,48,49,55,56,63 with 2087 patients were included in the quantitative analysis (Supplementary Figure 1). Details of these included studies are reported in Table 1 and Supplementary Table 3 Figure 1). ...
... In Kotze's retrospective study, 36 biological therapy with either of the 2 anti-TNF agents (adalimumab or infliximab) was introduced within 4 weeks after surgery with conventional anastomosis, and no differences were observed between the 2 agents regarding early POR. Finally, in Gajendran's study, 44 postoperative prophylaxis with immunomodulators and biologic agents was started 2 to 4 weeks after surgery with conventional anastomosis (E-E-and S-S) based on the decision of gastroenterologists. Of note, the 2-year outcomes were again similar in the 2 groups in complication rates and recurrence of inflammation. ...
... Previous studies have mainly focused on E-E vs S-S. 20,36,41,44,63 Gajendran et al 44 conducted a comparative effectiveness study between S-S with an antiperistaltic orientation and E-E anastomosis. No significant differences were observed in complication rates and recurrence of inflammation between the 2 techniques. ...
Background
Patients with Crohn’s disease (CD) after ileocolic resection may develop an endoscopic postoperative recurrence (ePOR) that reaches 40% to 70% of incidence within 6 months. Recently, there has been growing interest in the potential effect of anastomotic configurations on ePOR. Kono-S anastomosis has been proposed for reducing the risk of clinical and ePOR. Most studies have assessed the association of ileocolonic anastomosis and ePOR individually, while there is currently limited data simultaneously comparing several types of anastomosis. Therefore, we performed a systematic review and meta-analysis to assess the impact of different ileocolonic anastomosis on ePOR in CD.
Methods
We searched PubMed and Embase from inception to January 2023 for eligible studies reporting the types of anastomoses and, based on these, the rate of endoscopic recurrence at ≥6 months. Studies were grouped by conventional anastomosis, including side-to-side, end-to-end, and end-to-side vs Kono-S, and comparisons were made between these groups. Pooled incidence rates of ePOR were computed using random-effect modelling.
Results
Seventeen studies, with 2087 patients who underwent ileocolic resection for CD were included. Among these patients, 369 (17,7%) Kono-S anastomoses were performed, while 1690 (81,0%) were conventional ileocolic anastomosis. Endoscopic postoperative recurrence at ≥6 months showed a pooled incidence of 37.2% (95% CI, 27.7-47.2) with significant heterogeneity among the studies (P < .0001). In detail, patients receiving a Kono-S anastomosis had a pooled incidence of ePOR of 24.7% (95% CI, 6.8%-49.4%), while patients receiving a conventional anastomosis had an ePOR of 42.6% (95% CI, 32.2%-53.4%).
Conclusions
Kono-S ileocolic anastomosis was more likely to decrease the risk of ePOR at ≥6 months compared with conventional anastomosis. Our findings highlight the need to implement the use of Kono-S anastomosis, particularly for difficult to treat patients. However, results from larger randomized controlled trials are needed to confirm these data.
... 19 This might be especially true in the postoperative CD patient, as a recent study showed that the type of anastomosis may drive clinical symptoms without evidence of endoscopic disease recurrence. 20 Thus, in the present study, we used a combined outcome with objective index including treatment intensification and endoscopic or surgical intervention. 9 Our study has certain limitations. ...
Background
The Rutgeerts score (RS) is widely used to predict postoperative recurrence after ileocolonic resection for Crohn’s disease (CD) based on the severity of lesions at the neoterminal ileum and anastomosis (RS i0–i4). However, the value of anastomotic ulcers remains controversial.
Objectives
Our aim was to establish a nomogram model incorporating ileal and anastomotic lesions separately to predict the long-term outcomes of CD after ileal or ileocolonic resection.
Design
A total of 136 patients with CD were included in this retrospective cohort study.
Methods
Consecutive CD patients who underwent ileal or ileocolonic resections with postoperative ileocolonoscopy evaluation within 1 year after the surgery were included. The primary endpoint was postoperative clinical relapse (CR). An endoscopic classification separating ileal and anastomotic lesions was applied (Ix for neoterminal ileum lesions; Ax for anastomotic lesions). A nomogram was constructed to predict CR. The performance of the model was evaluated by the receiver-operating characteristic (ROC) curve and decision curve analysis (DCA).
Results
CR was observed in 47.1% (n = 64) of patients within a median follow-up of 26.9 (interquartile range, 11.4–55.2) months. The risk of CR was significantly higher in patients with an RS ⩾ i2 assessed by the first postoperative endoscopy compared with patients with an RS ⩽ i1 (p < 0.001). Moreover, the cumulative rate of CR was significantly higher in patients with ileal lesions (I1–4) compared with patients without (I0) (p < 0.001). Besides, patients with anastomotic lesions (A1–3) had significantly higher rates of CR than patients without (A0) (p = 0.002). A nomogram, incorporating scores of postoperative ileal or anastomotic lesions, sex, L2-subtype and perianal disease, was established. The DCA analysis indicated that the nomogram had a higher benefit for CR, especially at the timeframe of 24–60 months after index endoscopy, compared to the traditional RS score.
Conclusion
A nomogram incorporating postoperative ileal and anastomotic lesions separately was developed to predict CR in CD patients, which may serve as a practical tool to identify high-risk patients who need timely postoperative intervention.
... Over the years, the association between the surgical technique used for the ileocolonic anastomosis and POR has been investigated extensively. Sixteen studies have focused on this topic including four RCT [45][46][47][48][49][50][51][52][53][54][55][56][57][58][59] . The majority of studies investigated the effect of the anastomotic configuration, typically end-to-end (E-E) versus side-to-side (S-S). ...
... A retrospective study of prospectively collected data on patients undergoing first or second ICR, assessed the association between anastomosis type and 2-year postoperative quality of life (QoL), healthcare utilization, clinical, endoscopic and surgical POR, and use of medications 45 . One hundred and twenty-eight CD patients (60 S-S and 68 E-E) were evaluated. ...
Postoperative recurrence (POR) after an ileocolonic resection with ileocolonic anastomosis is frequently encountered in patients with Crohn's disease. The 8 th Scientific Workshop of ECCO reviewed the available evidence on pathophysiology and risk factors for POR. In this manuscript, we will discuss published data on the role of the microbiome, the mesentery, the immune system, and the genetic background. In addition to the investigation of causative mechanisms of POR, identification of risk factors is essential to tailor preventive strategies. Potential clinical, surgical and histological risk factors are presented along with their limitations. Emphasis is placed on unanswered research questions, guiding prevention of POR based on individual patient profiles.
... Further, CD may also penetrate to other systemic organs outside the GI tract through fistulation [3,4,45]. The clinical features for diagnosing CD includes an imprecise mixture of categorization system mentioned in section three above of IBD clinical diagnosis, and histopathological interpretation showing important, transmural, or granulomatous, asymmetric features [46,47]. Computed tomography (CT) enterography of the abdomen is the leading recommended and preferred first-line radiologic test used in the evaluation and/or assessment of CD. ...
... Endoscopic score metrics are the benchmark tool used to estimate the CD activity and often are used in the clinical setting trials to compute proof of the efficacy and safety of various drugs on causing and continuing remission and epithelial convalescence. There are many recommended scoring systems in the guideline but the most commonly used to measure clinical disease severity (CDS) include short inflammatory bowel disease questionnaire (SIBDQ, HBI-Harvey-Bradshaw index (HBI), and Lehmann score and Crohn's Disease Activity Index (CDAI) [46,47]. ...
Inflammatory bowel disease have an enormous impact on public health, medical systems, economies, and social conditions. Biologic therapy has ameliorated the treatment and clinical course of patients with inflammatory bowel disease. The efficacy and safety profiles of currently available therapies are still less that optimal in numerous ways, highlighting the requirement for new therapeutic targets. A bunch of new drug studies are underway in inflammatory bowel disease with promising results. This is an outlined guideline of clinical diagnosis and pharmaceutical therapy of inflammatory bowel disease. Outline delineates the overall recommendations on the modern principles of desirable practice to bolster the adoption of best implementations and exploration as well as inflammatory bowel disease patient, gastroenterologist, and other healthcare provider education. Inflammatory bowel disease encompasses Crohn’s disease and ulcerative colitis, the two unsolved medical inflammatory bowel disease-subtypes condition with no drug for cure. The signs and symptoms on first presentation relate to the anatomical localization and severity of the disease and less with the resulting diagnosis that can clinically and histologically be non-definitive to interpret and establish criteria, specifically in colonic inflammatory bowel disease when the establishment is inconclusive is classified as indeterminate colitis. Conservative pharmaceuticals and accessible avenues do not depend on the disease phenotype. The first line management is to manage symptoms and stabilize active disease; at the same time maintenance therapy is indicated. Nutrition and diet do not play a primary therapeutic role but is warranted as supportive care. There is need of special guideline that explore solution of groundwork gap in terms of access limitations to inflammatory bowel disease care, particularly in developing countries and the irregular representation of socioeconomic stratification with a strategic plan, for the unanswered questions and perspective for the future, especially during the surfaced global COVID-19 pandemic caused by coronavirus SARS-CoV2 impacting on both the patient’s psychological functioning and endoscopy services. Establishment of a global registry system and accumulated experiences have led to consensus for inflammatory bowel disease management under the COVID-19 pandemic. Painstakingly, the pandemic has influenced medical care systems for these patients. I briefly herein viewpoint summarize among other updates the telemedicine roles during the pandemic and how operationally inflammatory bowel disease centers managed patients and ensured quality of care. In conclusion: inflammatory bowel disease has become a global emergent disease. Serious medical errors are public health problem observed in developing nations i.e., to distinguish inflammatory bowel disease and infectious and parasitic diseases. Refractory inflammatory bowel disease is a still significant challenge in the management of patients with Crohn’s disease and ulcerative colitis. There are gaps in knowledge and future research directions on the recent newly registered pharmaceuticals. The main clinical outcomes for inflammatory bowel disease were maintained during the COVID-19 pandemic period.
... Surgery on the gastrointestinal (GI) tract generally involves 2 removal (resection) of a diseased segment (cancer, inflamma-3 tion) and its reconnection (i.e, an anastomosis) to reestablish 4 continuity. The Achilles heel of this procedure involves unan- 5 ticipated complications with healing such as tissues separation 6 leading to leakage of toxic intestinal contents to over-healing 7 with resultant strictures and occlusions of the new formed con- 8 nection. In intestinal surgery, multiple anastomotic geometries 9 are routinely performed including end-to-end, end-to-side and 10 side-to-side, with side-to-side being the most common ( Figure 11 1). ...
... Different techniques 15 for bowel anastomosis have been developed and debated (1) 16 since the days of Halsted (2). The surgical canon is filed with 17 discussions invoking geometry and mechanics, though largely 18 from a phenomenological standpoint (1,2,8). 19 Surgeons can in large part manipulate the geometry of their 20 anastomosis. ...
Following resection of a diseased segment of intestine, a reconnection (anastomotic) geometry is chosen to reduce postoperative stress and optimize outcomes. As proper healing of an intestinal anastomosis is strongly affected by its mechanobiology, much attention has been devoted to the conical structures formed along the suture lines, where stress-focusing is expected. However, geometric considerations reveal that in addition to the obvious loci of stress-focusing, additional remote locations of stress-focusing may form. We identify conical structures that inevitably form within regions of otherwise uninterrupted tissue. In this work we use geometric analysis, finite element modeling (FEM), and in-vivo experiments to investigate these emergent stress-focusing structures, their mechanical stresses, and the resulting submucosal collagen fiber re-orientation, as these naturally arise in the side-to-side small bowel anastomosis (SBA), the most common configuration performed in patients. FEM predicts the appearance of remote high-stress regions. Allowing for tissue remodeling, our simulations also predict an increased dispersion of submucosal collagen fibers in these regions. In-vivo experiments performed on ten-week-old male C57BL/6 mice assigned the creation of side-to-side SBA or sham-laparotomy corroborate this result. Anastomoses were analyzed at sacrifice on post-operative day (POD) 14 and 88 with histologic-sectioning, staining, high magnification imaging, and submucosal collagen fiber orientation ( κ ) mapping. The mean and variance of κ , a measure of collagen fiber dispersion, at POD-14 far from the anastomosis show similar values to those obtained for sham-operated mice, while the FEM-predicted loci of stress-focusing display statistically significant higher values. The values at POD-88 at all loci show no statistically-significant difference, and agree with those of the sham-operated mice at POD-14.
... It has been suggested that an end-to-end (ETE) anastomosis might be superior to a side-to-side (STS) as it could reduce stasis thereby reducing recurrence and improving gastrointestinal function. Gajendran et al. 2 demonstrated that patients with a surgical reconstruction of the bowel as an intact tube (ETE) had improved quality of life and less healthcare utilization when compared with STS reconstruction. In addition to the configuration, there might be a difference in wound healing between these two techniques. ...
