Ch.9 - Anastomosis

Question 1

What 3 things can you do when making a colorectal anastomosis to relieve tension?

Answer 1

1) high ligation of the IMA
2) ligation of the IMV at the inferior border of the pancreas
3) complete mobilization of the splenic flexure

Question 2

Which artery is responsible for proximal colon perfusion for a left sided anastomosis?

Answer 2

Marginal artery

Question 3

What is the PILLAR II trial?

Answer 3

Prospective multicenter clinical trial that studied the utility of fluorescence angiography on colorectal anastomoses.

Question 4

Loop ileostomies vs. Loop colostomies

• which one is more prone to prolapse?
• peristomal dermatitis?
• acute renal failure?

Answer 4

• prolapse: colostomies
• peristomal dermatitis: ileostomies
• acute renal failure: ileostomies

Question 5

For a side to side ileocolic anastomosis, is there a difference in leak rate between Stapled vs hand sewn anastomosis?

What about for cancer pts?

Answer 5

Based on a Cochrane review of 7 RCTs comprising 1125 patients, the leak rate for stapled (2.5%) was lower than hand sewn (6%)

For a subgroup of 825 cancer pts, stapled (1.3%) had a significantly lower leak rate compared to hand sewn (6.7%)

Question 6

What is a Barcelona anastomosis?

Answer 6

For ileocolic anastomosis, make a common channel first between proximal ileum and distal colon by using a GIA

Then use another GIA to fire proximal to the hole to complete the anastomosis

Question 7

Explain how to do an ileocolic anastomosis with an EEA

Answer 7

Cut the ileum. Insert the EEA anvil

Make a cut in the distal colon to insert EEA

Mate the anvil and the stapler in an end to side fashion and do the anastomosis.

Fire a GIA across the colon, completing the resection of the specimen.

Question 8

When doing a colorectal anastomosis, which is preferred for the proximal end, sigmoid or descending colon? Why?

Answer 8

If doing the resection for cancer, high ligation of the IMA often results in not enough blood flow to the anastomosis combined with loss of collaterals from the loss of middle rectal

Also sigmoid colon has thicker muscular wall and diverticuli

Question 9

For colorectal anastomosis, what’s the difference between a single stapled vs double stapled technique?

Answer 9

Double stapled- AMC way. Staple the rectum. Anvil goes into colon. Colorectal end to end anastomosis.

Single stapled- rectum is divided sharply. purse string to the open rectal stump and put the stapler in. Purse string is tied around the spike. Anvil goes into colon.

Question 10

Hand sewn vs stapled anastomosis for colorectal anastomosis.

Leak rate?

Stricture rate?

Answer 10

Leak rate equivalent.

Hand sewn may have a slightly lower stricture rate

Question 11

For colonic J pouches, which one is better? Large 10-12cm pouch or smaller 5-6cm pouch?

Answer 11

Smaller 5-6cm pouch has significantly lower constipation/evacuatory difficulties.

Question 12

What’s the deal with colonic J pouch vs straight end to end anastomosis?

Answer 12

Colonic reservoirs have benefits for low rectal anastomosis, <5-6cm from anal verge.

For mid or higher colorectal anastomosis, straight is preferred because colonic J pouch may create emptying problems for these

Question 13

What pt factors may steer you away from colonic J-pouch?

Answer 13

Narrow pelvis
Extensive diverticuli
Fatty mesentery
Insufficient length

Question 14

What’s another option to create a colonic reservoir besides J-pouch?

Answer 14

Transverse coloplasty. Basically Heineke mikulicz of the colon.

Identical outcome as j pouch albeit small numbers

Question 15

Physiologically, how is colonic J pouch better than other reservoir techniques?

Answer 15

Holds liquid stool better

Question 16

When would you have to do a hand sewn coloanal anastomosis?

Answer 16

1) mucosectomies
2) failure of the transverse rectal staple line
3) tumors that require a combined transabdominal and transanal approach

Question 17

You do a colorectal anastomosis and the leak test is positive. What can you do?

Answer 17

1) diverting ostomy
2) suture repair
3) redo the anastomosis

Question 18

What is a baker anastomosis?

Answer 18

Just an end to side colorectal anastomosis.

Question 19

Complete splenic flexure mobilization requires not just freeing the peritoneal attachments but also what things?

Answer 19

1) separation of the omentocolic attachments to the distal transverse colon
2) division of the renocolic attachments of the mesentery to Gerota’s fascia of the left kidney
3) lysis of gastrocolic attachments between the posterior gastric wall and the transverse colon mesentery

Question 20

When you’re doing an extended left colectomy and you’re trying to gain length, what is the transverse colon tethered by?

So what do you do?

Answer 20

Middle colic

Serial ligation of the middle colic vessels from left to right

Question 21

What is Deloyers’ procedure

What supplies the colon after this?

Answer 21

Mobilize the hepatic flexure and right colon (including all retroperitoneal attachments) and mobilization of SB mesentery. Rotate it counterclockwise to bring it down to pelvis

Ileocolic

Question 22

After an extended left, you can’t reach to do colorectal anastomosis. You start ligating middle colic and you still can’t. What can you do?

Answer 22

Make a hole in the mesentery between ileocolic and SMA and bring the colon through the mesentery