INTESTINAL ANASTOMOSIS is an important surgical procedure that connects two sections of the intestines once a diseased portion has been removed. A key concern is to prevent leakage at the anastomosis site and subsequent peritonitis, but this complication can be avoided if the procedure is done correctly and preventive measures are taken.
Indications for intestinal resection and anastomosis include devitalization, irresolvable obstruction or segmental dysfunction, or irreparable perforation of the intestines.1-4 These conditions can result from a variety of causes, including foreign bodies, intussusception, neoplasia, abscess, trauma, volvulus or torsion, herniation, neurologic disorders, chronic constipation (e.g. feline idiopathic megacolon), or ulceration secondary to corticosteroid administration.4 Intestinal resection and anastomosis are most frequently performed in dogs and cats because of foreign bodies, neoplasia, and trauma.4,5
Intestinal anastomosis can be performed with sutures, staples, or anastomotic devices.1-3,6,7 Intestinal anastomoses can be strengthened by omentalization or serosal patch graft techniques, which reduce the risk of postoperative leakage and improve vascularity.1
A sutured anastomosis is the most common option because of the availability and cost of materials and familiarity with the procedure. Perform sutured anastomoses with appositional suture patterns since inversion reduces the lumen diameter and eversion can increase adhesion formation.2,3,8 Avoid double-layer closure because of luminal compromise, poor submucosal apposition, avascular necrosis, and prolonged healing time.2
Monofilament sutures are recommended for sutured anastomosis because multifilament material has more drag and is more likely to promote inflammation.2 Although nonabsorbable suture can be used for anastomosis, avoid it when using continuous suture patterns because of potential luminal extrusion and subsequent foreign body entrapment.2,9 Swaged, tapercut needles penetrate easily through the submucosa, which is the holding layer of the intestines, and limit tissue trauma.5 Tapercut needles have a round shaft and a cutting point that can penetrate both delicate and dense tissue. Taper needles, which are more commonly found in practice than tapercut needles, are also acceptable for intestinal surgery.2
Simple continuous suture patterns are quick to perform and provide better approximation than interrupted patterns.2,5,10 Histologically, mucosal eversion is reported in 66% of simple interrupted closures while inversion, eversion, or malalignment is seen in only 38% of simple continuous closures.2,6 With both techniques, mucosal eversion can be reduced by trimming excess mucosa or by using a modified Gambee suture pattern.5
Using surgical staplers to anastomose intestines reduces surgery time and provides bursting strength, lumen diameter, and healing similar to anastomosis with simple interrupted sutures.6 Complications are reported in 13% to 14% of animals undergoing stapled anastomoses and include severe hemorrhage (13%), postoperative leakage at the anastomosis site (8%), and localized abscess formation at the staple line (4%).11,12
Anastomosis ring and laparoscopy
Other options for anastomosis include biofragmentable intestinal anastomosis ring placement and laparoscopic-assisted anastomosis.7,13 Little information is available in the veterinary literature on the clinical use of these techniques.
TECHNIQUE FOR SINGLE-LAYER CONTINUOUS END-TO-END INTESTINAL ANASTOMOSIS
For general perioperative considerations when performing this procedure, including diagnostic testing, patient monitoring, and postoperative support, please see the symposium introduction.