1. Bowel Anastomoses For MIS Procedures
2012 MISS Meeting, Salt Lake City
Bowel Anastomoses For MIS Procedures
Richard L. Whelan, MD
St. Luke’s Roosevelt Hospital
New York, N.Y.

2. Whelan Disclosures Ethicon Endosurgery Olympus Corporation
Atrium Corporation
Convatec
Hooters Restaurants
Coca Cola Corporation
Frito Lay
Hospital Vending Machine Corporate Council (who support lengthy operations)

3. What does “MIS” Mean? Laparoscopic (no extraction incision) ?
Laparoscopic-assisted (extraction incision) ?
Hand-assisted ?
Hybrid (part laparoscopic, part open) ?
SILS ?
Robotic ?
NOTES ?

4. Number of Splinter MIS Methods is Growing
Each new method has a group of devoted proponents who have mastered the method
In their hands it works well
Each splinter method handles certain aspects of colorectal resection differently
It is now harder to give a general talk on some topics because what is said will not apply to all MIS methods

5. This Talks Comments Apply to the Following Methods:
Laparoscopic (no extraction incision)
Laparoscopic-assisted (extraction incision)
Hand-assisted

6. What Are You Comfortable Doing?
In the end, the surgeon must be comfortable with the method selected
If you want to learn a new method then:
Read about it, watch videos, talk/visit with surgeons who use the method
Consider doing the first few cases with someone in your area who has experience
What you hear at this conference must be considered in the context of your skill set and your MIS experience

7. Types of Bowel Anastomoses
Stomach to small bowel
Small bowel to small bowel
Small bowel to colon
Colon to colon
Colon to rectum
Colon to anus

8. Types of Anastomoses End to End Side to Side End to Side
Isoperistaltic vs Anti-peristaltic
End to Side
Pouch formation + anastomosis
Ileal
colonic

9. Means of Rejoining the Bowel
Staplers
Circular EEA, linear GIA stapler, TA-staplers
Hand-sewn
Combination
Stapled off bowel end & hand sewn side to side anastomosis
Stapled anastomosis reinforced with sutures
Pressure (seldom used)
Murphy button
Niti method

10. Colorectal Anastomoses After Laparoscopic Bowel Resection
Bariatric / Upper GI and MIS General surgeons:
Staplers
Hand-sewn methods
Colorectal surgeons
Rely on staplers predominately
In general, few intracorporeal hand-sewn ‘moses.
Need to be comfortable sewing intracoporeally

11. Sigmoid & Low Anterior Resection
Almost all distal L anastomoses done in the same manner (double stapled circular EEA):
Specimen exteriorized via lower abdominal extraction incision
Extracorporeal pursestring and anvil placement
Intracorporeal docking of anvil and firing of stapler

12. Laparoscopic-Assisted Sigmoid & Low Anterior Resection

13. Hand-assisted LAR

14. Exteriorization of Specimen

15. Placement of Anvil in Proximal Bowel

16. EEA Anastomosis

17. Stapled EEA Anastomosis

18. Leak Test After EEA Anastomosis
Alerts surgeon as to presence of leak
Choices:
Rigid procto with anastomosis submerged
Flexible sig + mosis submerged (CO2 for insufflation of bowel)
Bulb syringe injected air/betadine in rectum
If leak found suture reinforcement of anastomosis then retest
? Need for proximal stoma if leak found or doughnuts incomplete (must check doughnuts)

19. Circular EEA Anastomosis
Proper stapler size
If too big, anvil won’t fit
If too small, then the “doughnut” may be too bulky
Must clear mesentery
Is anus strictured or narrowed?
Must consider colon & rectal diameters
Largest size possible

20. Factors That Impact Distal Left Anastomotic Healing
Level of the anastomosis (how low?)
Blood supply
Unusual anatomy (vessel origin, marginal art.)
Division IMA at origin or more distal
Tension  flexure takedown
Abnormal tissue
Neoadjuvant RT/chemo
Inflammatory bowel disease
Critical co-morbidities (cardiac, vascular)

21. How to Avoid Leaks For Sigmoid/LAR Anastomoses
Splenic flexure takedown in great majority
Carefully assess & understand the arterial anatomy
Carefully assess vascularity of proximal end when placing dougnut
Use sizers to make sure that stapler can be inserted to proximal end of Hartmann’s pouch

22. Sigmoid Resection for Diverticulitis
Preserve IMA (which improves blood supply)
Devascularize specimen in mid- mesentery
Preserves pelvic autonomic nerves
Danger here is leaving distal rectosigmoid colon and subsequent difficult stapler insertion (to reach proximal end of Hartmann’s)
Can partially mobilize in presacral plane (without detaching or dividing all attachments in order to preserve nerve supply)

23. Fully Laparoscopic Anastomosis
Transanal extraction of specimen
Transanal introduction of EEA Anvil
Placement of anvil in proximal bowel
Anvil into bowel end and then endoloop
Anvil spike exits side of proximal bowel and stapler used to close the bowel end
Close open end of Hartmann’s pouch
Insert stapler transanally
Docking of anvil and firing of stapler

24. Coloanal Anastomosis Mucosectomy (Lone star retractor)
After TME to levators (breakthrough tricky)
TATA (done at start of case)
Need fully mobilized proximal colon
Flexure takedown
IMA at aorta and IMV proximal to L colic
Handsewn colon to anoderm anastomosis
+/- colonic J Pouch
Has clear functional implications

25. Ileocolic and Colo-colic Anastomoses Intracorporeal vs. Extracorporeal
Majority done extracorporeally
Can be safely done intracorporeally
Latter is harder to accomplish, may add time to operation
Is extraction incision size appreciably smaller for intracorporeal method? For most probably not.
Does it matter ? Not been well studied. There is little comparative data.

26. Ileal to Transverse Colon Anastomosis: The Problem
The length of the Middle Colic Artery is highly variable
In some patients it is very short and will not easily reach outside via small extraction incision
In obese patients with a thick abdominal wall this can be a big problem
Intracorporeal anastomosis makes most sense in the very obese population

27. Right Hemicolectomy: Standard Periumbilical Extraction Incision
Takeoff of Middle colic vessels
Extraction Incision

28. Right Hemicolectomy: Extraction Incision in Obese & Short Mesentery Patients
Takeoff of Middle colic vessels

29. Right Hemicolectomy Epigastric Extraction Site
Takeoff of Middle colic vessels

30. Extracorporeal Anastomosis
Two side to side stapling methods
Remove specimen first, then anastomose
Disadvantage: 3 crossing staple lines usually
Make anastomosis with bowel still in continuity (Barcelona Method)
Advantage: avoid 3 staple lines & fewer cartridges
Disadvantage: less sound oncologically ?
GIA 75 (or 80 mm) stapler used for both

31. Extracorporeal Ileocolic Anastomosis

32. Intracorporeal Anastomoses

33. Summary Numerous ways to skin a cat
Before using new method fully investigate & learn about the technique (video/talk/observation). Mentor, if possible.
There are nuances to each method
Must be comfortable with method chosen
Good assistant and considerable colon experience prior to LAR / TME
Divert proximally if concerned about distal L anastomosis

34. Conditions Necessary for Anastomotic Healing
Adequate blood supply
Lack of tension
Technically “sound” anastomosis
Healthy, non-diseased bowel ends

38. Risk Factors for Anastomotic Leaks
Level of the anastomosis (< 6 cm) ** ++
Neoadjuvant RT / chemo **
Perioperative cardiac event *
Other co-morbidities (lung, liver, DM)+
Male gender ?
Smoking, excessive ETOH ?
Double stapled method (vs handsewn) ^ ^^
*Lyall et al. Colorectal Dis 2003;9: **Heald RJ et al. Dis Col Rectum 1981;24: Chessin et al. J Amer Coll Surg 1997;185: Vignali et al. J Amer Coll Surg 1997;185: ^ Mac Rae HM et al, Dis colon Rectum ^^ Lustosa SA et al. , Sao Paulo Med J

39. Cochrane Review of Literature 2005
Main findings regarding laparoscopic method:
Length of stay 1.5 days shorter
Incidence of wound infection lower (4.6% vs. open 8.7%, p=0.002)
No difference in anastomotic leak or abscess rate
Mortality similar
Quality of life better up until POD 30

40. How to Decrease Leak Rate: Blood Supply
Must determine each patient’s anatomy
Check for anatomic variations (common)
Vascular anatomy largely determines resection margins
When possible, palpate pulses, check for bleeding (extracorporeal anastomoses)
Does patient have atherosclerosis, DM ?
Prior Aortic aneurysm (is IMA open) ?

48. Anastomotic Leaks The bane of the GI surgeons existence
They occur regardless of the construction method
Extraperitoneal bowel anastomoses have higher leak rates (no serosa)
Rectum
Esophagus
Types of leaks
Clinical
Radiologic (usually asymptomatic)

49. Anastomotic Morbidity: Not Just Leaks
Abscesses (without documented leak)
Fistulas can develop (abscess or leak related)
Rate of pelvic infection = leak + abscess
Abscess and collection rate not always given
Literature hard to assess for this reason
No uniform complication reporting system in place

50. Incidence of Clinical Leaks After Open LAR
Series N No. Leaks %
Karanjia et al ’
Zaheer et al ’
Enker et al ’
Law et al ’
Marijnen et al ’
Leester et al ’
Wong NY et al ’
Gastinger et al ’
Chessin et al ’
Lyall et al ’

51. Anastomotic Leak After Laparoscopic Colectomy
Trial # pts % leak
Franklin ‘ Gellman et al ‘ Lumley et al ‘ Fielding et al ‘ Kockerling et al ‘ Lacey et al ‘ Regados et al ‘

53. Level of Devascularization for Left Sided Colorectal Resections
In cancer setting:
IMA at origin (+ IMV)  best colon mobility OR
Sigmoidal artery, distal to left colic takeoff
Diverticular disease:
Mid-mesenteric division preserves IMA blood supply to rectum
Also protects pelvic nerves
Downside: rectum not as well mobilized

54. Splenic Flexure Mobilization
For vast majority of left sided resections
Medial mobilization of mesentery
Detach omentum
Can detach base of distal transverse mesocolon
Provides better vascularized colon

55. Prevention of Leak: Splenic Flexure Mobilization
Lower leak rate when descending colon used for anastomosis (vs sigmoid)
15 % with takedown vs 31 % *
Less tension
Well accepted that flexure should be mobilized for vast majority of LAR’s
* Karanja ND et al. Br J Surg 1994;81:

56. Tension: Rectal Mobilization (for LAR)
To level of pelvic floor (levators)
TME (circumferential dissection)
Preserve nerves
Full mobilization increases the “reach” of the remaining rectum

57. Laparoscopic Technique Points for Sigmoidectomy and LAR
Check mobility of proximal bowel intracorporeally prior to exteriorization (will it reach to rectum?)
Select proximal transection point intracoroporeally. Must consider bowel:
Mobility
Blood supply
Use loop suture to mark transection site
Once bowel is exteriorized it is hard to determine what will reach

58. Technique Point: Choosing Site of Incision for Specimen Extraction
Make sure proximal bowel will reach wound and can be exteriorized:
Obese lower abdominal wall is thick
Pfannenstiel’s incision can be placed too low
May be difficult to put in EEA anvil if bowel cannot be well exteriorized

59. LAR: Exteriorization of
Proximal Bowel
Colon will not reach
Incision too low in this patient !!

60. LAR: Exteriorization of
Proximal Bowel
Colon reaches
Incision made higher

61. After Rectal Transection Insert EEA Sizers Into Hartmann’s Pouch
If you cannot fully insert sizer to Hartmann linear staple line:
Rectal mesentery may not be adequately cleared from linear staple line
Carefully clean 1-11/2 cm of posterior & lateral wall
Peritoneum covering the rectum anteriorly & laterally may impair stapler insertion
Score peritoneum in several places
Do further dissection / mobilization and then re-insert

62. Anastomosis: Orientation of Mesentery
Avoid twist of mesentery
Follow free cut edge of the mesentery proximally AND
Follow anti-mesenteric surface of bowel as well
Easier to twist bowel when working laparoscopically

63. Testing Anastomotic Integrity
After rectal transection ?
After circular stapled anastomosis
Method:
Flexible sigmoidoscope with CO2 insufflation
Proctoscope
Bulb syringe (if desperate)
Air pumped into rectum & fluid in pelvis OR
Betadine solution into rectum with dry pelvis

64. Technique Point: After Anastomosis, Prior to Completion:
Medial to lateral methods leave mesenteric windows
Small bowel can get trapped under mesentery or in window
Want free edge of colon mesentery directly overlying retroperitoneum
Small bowel underneath the free mesenteric edge will increase tension & can decrease the blood supply

65. Proximal Diversion of Fecal Stream
Limits consequences of leaks
Choice of diversion:
Colostomy
Less output • Harder to close
Larger stoma, bulky
Ileostomy
Higher output • Smaller, less bulky
Easier to make and close
Loop stomas most commonly made

66. Proximal Diversion: Preop Mark Possible Stoma Locations
Mark sites with patient sitting in chair
Avoid skin creases and deep folds
Keep 4 fingerbreadths away from umbilicus
Mark on right and left
Place port at stoma, if possible
Place other ports at least 4-5 cm away

67. Low Anterior Resection: Site Chosen for Loop Ileostomy
Umbilicus
Planned ileostomy site

68. Low Anterior Resection: Port Site Locations: Option 1

69. Low Anterior Resection: Port Site Locations: Option 2

70. Impact of Diversion at Time of LAR
Prospective study, n= 2,729 patients
881 patients diverted at initial op
Leaks (+ stoma = 14.5%; - stoma = 14.2%)
Lowers chance of requiring laparoscopy / laparotomy (3.6 vs 14.2 % in non-diverted pts)
Lower mortality (0.9 vs 2% in non-diverted, p=0.0310)
Morbidity of closure (ileostomy, 22.4% vs colostomy, 15.4%, p=0.031)
* Gastinger et al Br J Surg 2005;92:

71. Anastomotic Reinforcement
Types of reinforcing materials:
Fibrin glue, fibrinogen, (“paint” anastomosis)
Polyglycolic acid/trimethylene carbonate, random fiber (absorbable)
L-lactic acid-co-epsilon-caprolactomne (absorbable)
Small intestinal submucosa (bioprosthesis)
Bovine pericardium & collagen strips (semi-absorbable)
PTFE (non-absorbable)

72. Anastomotic Reinforcement
Most involve “sleeve” that is slid onto stapler (GIA and for EEA)
Incorporated into the anastomosis
Absorbable materials gone in ~ 6 months
Goal is to decrease leaks and hemorrhage
Limited data available, thus far
Absorbable appears better than non-absorbable

73. Anastomotic Reinforcement: Summary of Studies
Pig study, SB stapled anastomosis: greater bursting pressure in submucosa bioprosthesis reinforced group*
Rabbit study, hand sewn ‘mosis, polyglycolic acid mesh: higher bursting strength**
Human study, 30 pts, no leaks or bleeding noted. Appeared safe +
*Downey DM, et al. Obes Surg Nov-Dec;15(10): **Raboff W, et al. Am Surg Oct;60(10): Franklin ME, et al. Surg Laparosc Endosc Percutan Tech 2005;15(1):9-13.

74. Anastomotic Reinforcement: Summary
Being used commonly in US for gastric bypass to limit bleeding
Being used for colorectal anastomoses
Will be hard to show significantly decreased leak rate without doing large randomized, multicenter study
What are the oncologic implications? (tumor cell implantation??)
Does it impact stenosis rate after EEA?
Studies are ongoing.

75. Low Index of Suspicion: Early Evaluation for Suspected Leak
Physical exam and careful digital
Abdomen / pelvic CT scan (p/o + rectal contrast)
Free air, fluid Extravasation
Collection Inflammatory changes
Contrast enema (gastrograffin)
Careful administration of contrast
Via foley cath for low anastomoses
Transabdominal USG

76. How to Avoid Leaks: Summary
Understand vascular anatomy
Adjust devascularization level to pathology
IMA at takeoff or after left colic takeoff for cancer
Mid mesenteric transection for diverticulitis
Utilize well vascularized bowel
Mobilize flexure
Mobilize rectum well (neoplasms)

77. How to Avoid Leaks: Summary
Determine proximal point of bowel resection intracorporeally
Choose extraction site carefully
Tension free anastomosis
Assess distal left anastomoses (scope, leak test)
Distal 1/3 rectum, divert routinely
If in question, divert

82. Impact of Neoadjuvant Therapy on Leak Rates*
87 patients with rectal cancer
37 had full course preop Chemo/RT with operation 6-8 weeks later
10/87 clinical leaks (11.5%)
All leaks had neoadjuvant therapy
6/10 leak pts had complete clinical response to RT
CR associated with increased leak rate
* Lyall et al. Colorectal Dis 2007;9:801-7.

83. Prevention of Leak: Splenic Flexure Mobilization
Lower leak rate when descending colon used for anastomosis (vs sigmoid)
15 % with takedown vs 31 % *
Less tension
Well accepted that flexure should be mobilized for vast majority of LAR’s
* Karanja ND et al. Br J Surg 1994;81:

84. Colonic J Pouch Some studies found lower leak rates*
Others found no difference
Better blood supply to pouch apex ?
Some attribute better results to higher incidence of splenic flexure takedown in J pouch patients.
Better functional results x 1 year
* Hallbook et al. Ann Surg 1996;224:58-65.

85. Stenting Anastomoses at LAR With Transanal Tube (to decrease leaks)*
50 LAR patients, All EEA
Transanal tube placed in all at initial op
Anastomoses checked at 2, 12 weeks via endoscopy
2 clinical leaks (4.2%)
3 asymptomatic leaks (6.3 %)
Cannot draw meaningful conclusions
* Sterk et al Zentralbl 2001;126:601-4.

86. Clinical LAR Leaks: Presentation
Fever
Tachycardia
Ileus, anorexia (possible nausea & vomiting)
Abdominal pain and tenderness (often absent for extraperitoneal anastomoses)
Most result in localized collections and abscesses in the pelvis
Sepsis may develop

87. Clinical LAR Leaks: Treatment
Antibiotics, NPO, observation (small leak, no collection)
Percutaneous drainage of collection (transabdominal or transgluteal) +/- EUA
EUA, placement of transanal drain via defect (distal pelvic small collection, small defect)
Exploratory laparoscopy / laparotomy, drainage of collection, placement of drain, proximal diversion + EUA

88. In OR, Importance of Exam Under Anesthesia & Direct Transanal Inspection
Endoscopy / rigid procto
Full EUA
Gain better understanding of the problem
May be able to drain collection and place drain tube transanally
In already diverted patients, often all that is needed
If abdomen opened must also do EUA

89. What About Stent at Time of Leak?
Soft or hard stent ?
Would need to fit snugly yet not decrease blood flow
Combined with percutaneous drainage
No data thus far
University of Missouri study in progress: stenting of esophageal leaks

90. Impact of Diversion at Time of LAR
Prospective study, n= 2,729 patients
881 patients diverted at initial op
Leaks (+ stoma = 14.5%; - stoma = 14.2%)
Lowers chance of requiring laparoscopy / laparotomy (3.6 vs 14.2 % in non-diverted pts)
Lower mortality (0.9 vs 2% in non-diverted, p=0.0310)
Morbidity of closure (ileostomy, 22.4% vs colostomy, 15.4%, p=0.031)
* Gastinger et al Br J Surg 2005;92:

91. Rate of SBO in Diverted vs Non-Diverted LAR Patients *
All had RT/Chemo
Diverted at initial op = 119
SBO
Diverted group = 21%
Non-diverted group = 8 % (p=0.04)
* Chessin et al. J Amer Coll Surg 2005;200:

92. Closure of Diverting Stoma after LAR
Series N Retained Stoma %
Nebakken et al ’
Barkley et al ’
Lefebure et al ’

93. LAR Anastomotic Strictures

94. Anastomotic Strictures: Definitions
No uniform criteria exists
Cannot pass 2nd finger ?
Cannot pass adult colonoscope ?
Symptomatic narrowing only ?
Poorly tracked and reported
Often noted at time of pre-stomal closure
Asymptomatic ones dx’ed x 1 year or more
Under reported complication

95. Anastomotic Stricture: Etiology
Ischemia
Fibrosis
Leak related
Tumor recurrence related
Radiation related
IBD related
Diversion related *
*Graffner HP et al. Dis Colon Rectum 1983;26:87-90.

96. Incidence of Anastomotic Stricture After LAR
Series N No. Strictures %
Lyall et al’
Chessin et al ’
Joos et al ’
Bailey et al ’
Balik et al ’
Lazuskas et al ’
Miller et al ’
Shimada et al ’

97. Anastomotic Stricture: Evaluation
Digital exam
Endoscopic (biopsies to rule out recurrent cancer)
Contrast fluoroscopic study
Abdomen / Pelvic CT scan + rectal /p/o contrast
Not ideal to evaluate lumen diameter
In cancer patients needed to rule out recurrent cancer

98. Rate of Stricture After Double Stapled EEA Anastomosis*
282 patients (sigmoid + LAR)
Routine sigmoidoscopy within 5 months
Stricture defined as inability to pass adult colonoscope across ‘mosis (diameter 1.2 cm)
Overall incidence 17.6 % (50 strictures)
EEA #31 = 13.9 %
EEA #28 = 25.8 %
Vast majority asymptomatic
* Balik et al. Presented at 2007 DDW, submitted for publication

99. Why Routinely Check Anastomosis Early After LAR ?
Will detect stenoses
Moderate narrowing can cause symptoms
Stacking of BM’s, increased frequency
Mild pain
Distension (rarely)
Will need to be done if patient to undergo colonoscopy in future
On occasion will find 2-3 mm openings 1-2 years later (may be asymptomatic)

100. Treatment of Stricture
Digital (for distal ones)
Metal dilators
Flexible dilators
Balloons (via endoscope or along side scope)
Division of staple line (extraperitoneal only)
Re-resection and anastomosis
Diversion (last resort)

101. Treatment of Distal Stricture
Digital dilatation (if within reach)
Dilators (metal or flexible)
In office (or OR) by MD at first
At home by patient for difficult cases
Balloon over wire (TTC or esophageal type)
Cutting across staple line (in 1-4 places)
Circular stapler (total 4 cases reported) *
Reoperation (rarely)
* Chia et al. Dis Colon Rectum 1991;34: ** Shimada et al Ann Surg 1996;224:603-8.

102. Recalcitrant Distal Stenoses
Option 1: multiple office dilatations or OR EUA and dilatation
Option 2: teach patient to dilate themselves
Need to be observed in office doing dilation
Daily home dilatations often successful in reducing symptoms and avoiding other Rx
Patients often reluctant (understandably)

103. Stricture Treatment: Through the Channel Balloon Dilatation
Works well for majority of strictures beyond reach of finger
Must be able to see across stenosis
Pass balloon +/- over wire (1 minute inflation/dilatation, 2-3 inflations/session)
Balloon size start at 10 mm  12.5 mm
In Columbia series
8/25 EEA 31 stenoses required 2 or > Rx
13/24 EEA 28 stenoses required 2 or > Rx
Complications = 0 for Columbia series

104. Treatment of Benign Anastomotic Stricture: Circular Stapler
Report 1: 3 patients treated *
Use EEA to resect the stenosis
With 8-14 mos. follow up, no recurrence noted
Report 2: single patient **
Used EEA as well
Must be able to get anvil above the ‘mosis
* Pabst et al. Dig Surg 2007;24: **Arak et al. Kurane Med J 2002;49:

105. Stenting of Benign Anastomotic Strictures
Is an option
No data available for use of stents in patients with benign anastomotic stricture
Retention rate ?
Long term function ?
Erosion
? other complications

106. Resection & Reanastomosis for Stenosis
Last resort
Carries considerable morbidity and some mortality
No guarantee of success
Issues of reach, blood supply, tension remain
Patient must understand that result might be permanent stoma or serious complications
Majority of patients accept stoma
Convert ileostomy  colostomy (an option)

107. Stricture Summary Look for them
Routine flexible sigmoidoscopy within 6 months advised
Dilate to scope diameter (if above finger reach) with balloon
Distal strictures, dilatation with finger or dilator for most
Operative treatment for recalcitrant one

114. Small Intestinal Submucosa (Bioprosthesis) Reinforcement*
Pig study
Small bowel anastomoses (GIA)
½ reinforced
½ stapled alone
Bursting strength significantly greater in reinforced group
*Downey DM, et al. Obes Surg Nov-Dec;15(10):

115. Polyglycolic acid Mesh: Animal Study *
Rabbit study (n=22)
Two hand sewn anastomoses per animal
Two layered anastomoses
1 anastomosis per animal reinforced
Bursting strength determined on POD 4-5
Reinforced anastomoses had significantly higher bursting strength
Histology: Well-developed layer of fibroblasts and collagen between the PGAM and bowel wall serosa.
*Raboff W, et al. Am Surg Oct;60(10):721-7.

116. Polyglycolic acid/trimethylene carbonate: Human Study
30 patients
Variety of anastomoses
Ileocolic, 12; colorectal, 15; other, 3
Median follow up = 7 months
No leaks, strictures, or bleeding postoperatively
Appears safe
2nd study: 159 colorectal ‘moses (no leaks)
* Franklin ME, et al. Surg Laparosc Endosc Percutan Tech 2005;15(1):9-13.

122. Rate of SBO in Diverted vs Non-Diverted LAR Patients *
All had RT/Chemo
Diverted at initial op = 119
SBO
Diverted group = 21%
Non-diverted group = 8 % (p=0.04)
* Chessin et al. J Amer Coll Surg 2005;200:

123. Anastomoses Methods Circular EEA
Single staple (2 purse strings)
Double staple
Side to side stapled (GIA linear stapler)
End to side
Hand-sewn
Colorectal anastomosis
Coloanal anastomosis (post mucosectomy)
Pressure induced anastomosis