Compression anastomoses in colorectal surgery: a review

Abstract

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.

Compression Anastomosis Clips Versus a Hand-Sewn Technique for Intestinal Anastomosis in Pigs

“…The CAC might help avoid persistent foreign material and the resultant excessive inflammatory response by the timely natural expulsion of the device [2]. The previous use of these anastomoses in animals also resulted in appropriate mucosal healing and decreased formation of fibrous tissue [2,26], with very little scar tissue visible at the anastomotic line under microscopic examination [27]. Furthermore, the possible extent of scarring is proportional to the amount of granulation tissue that is formed [25].…”

“…The use of CACs in humans has been reported [2,5,6,[7][8][9][10][11][12][13], including a comparison of CAC anastomoses with stapled anastomoses in the stomach, small intestine, and colon [5][6][7][8]13]. However, to the best of the current authors' knowledge, no comparison of healing between CAC and hand-sewn (HS) anastomoses has previously been reported.…”

“…Kopelman et al [25] suggested that these features of CAC anastomoses are attributable to the lack of any foreign material -either suture material or metal staples -within the anastomotic site, and to the gradual compression applied to the tissue on both sides of the anastomosed bowel. The CAC might help avoid persistent foreign material and the resultant excessive inflammatory response by the timely natural expulsion of the device [2]. The previous use of these anastomoses in animals also resulted in appropriate mucosal healing and decreased formation of fibrous tissue [2,26], with very little scar tissue visible at the anastomotic line under microscopic examination [27].…”

“…The ideal device should ensure good serosal apposition without requiring either transgression of the bowel wall or the presence of foreign material for an extended period of time [2]. Healing occurs when the surgical wound is clean and sharp, Anastomotic dehiscence and leaks are major problems in gastrointestinal surgery and result in increased morbidity and mortality, thus decreasing overall survival.…”

Extended Low Anterior Resection with a Circular Stapler in Patients with Rectal Cancer: a Single Center Experience

“…Neither provides an immediately "sealed" anastomosis and both are prone to uncommon but serious complications such as anastomotic bleeding, infection or leaks. However, controversy remains regarding which of the two methods of creating an anastomosis yields better clinical outcomes (Nir et al, 2012). The theory behind creating a safe, healthy bowel anastomosis remains constant, irrespective of the technique chosen.…”