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  • Review Article
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Anastomoses of the lower gastrointestinal tract

Abstract

Patients with gastrointestinal anastomoses are treated by physicians of multiple specialties, including gastroenterologists, radiologists and surgeons. This Review provides an overview of the surgical principles and techniques involved in the creation of lower intestinal anastomoses, including some of the mechanisms of healing. Anatomical configurations of small and large bowel anastomoses are illustrated. Stapled, hand-sewn, and sutureless anstomotic techniques are also discussed. Laparoscopy has revolutionized our approach to surgery of the gastrointestinal tract and we describe some of the current and future minimally invasive techniques for creating anastomoses. The article also highlights principles important in minimizing potential short-term and long-term complications such as anastomotic leaks and strictures. Common risk factors for dehiscence include poor nutrition, immunosuppression, microvascular disease, obesity and technical errors. An evidence-based review of perioperative and postoperative management of intestinal anastomoses is provided to help optimize patient care. The routine use of nasogastric tubes and mechanical bowel preparation has no documented benefits and could contribute to postoperative complications. Upcoming strategies that might prove useful to reinforce anastomoses are also reviewed.

Key Points

  • Complications of anastomoses are rare, but may have serious adverse consequences

  • Careful selection of patients and the proper surgical technique are vital in minimizing anastomotic complications

  • Patients with radiation enteritis, microvascular disease, malnutrition, diabetes mellitus and obesity are at increased risk of anastomotic leaks

  • Tension-free anastomosis and a good blood supply are imperative to anastomotic healing

  • The choice of type of anastomosis varies by anatomical location, diagnosis, and surgeon preference

  • Laparoscopic anastomoses have good outcomes and might offer certain additional benefits, such as decreased incidence of postoperative complications and length of hospital stay

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Figure 1: Anastomotic configurations.
Figure 2: Intestinal staplers.
Figure 3: Different methods of strictureplasty.
Figure 4: J-pouch.
Figure 5: Hand-sewn coloanal anastomosis.

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Acknowledgements

We thank Yuko Tonohira for preparing the original artwork for our figures.

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Correspondence to Govind Nandakumar.

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Nandakumar, G., Stein, S. & Michelassi, F. Anastomoses of the lower gastrointestinal tract. Nat Rev Gastroenterol Hepatol 6, 709–716 (2009). https://doi.org/10.1038/nrgastro.2009.185

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