Modified side-to-side ileocolic anastomosis with wide mesenteric excision for Crohn’s disease: surgical technique and early outcomes

Introduction

Ileocolic involvement represents the most prevalent intestinal manifestation of Crohn’s disease. Historically, medical treatment has been the mainstay for this subgroup of patients, with surgical management being reserved for complicated cases including bowel obstruction due to stenosis or perforation secondary to penetrating disease (1). This dogma was further accentuated following the efficacy of biologics in the treatment of inflammatory bowel diseases (IBDs). Nonetheless, about 50% of patients with Crohn’s disease would need surgery within five years of diagnosis, with over 90% requiring surgical intervention after 10 years (2-4). Besides the primarily palliative nature of surgery for Crohn’s, anastomotic recurrence with rates of up to 80% at endoscopy have been reported within 12 months in patients undergoing ileocolic resection for Crohn’s disease (5).

In recent years, high quality evidence about the role of surgery for non-complicated ileocolic Crohn’s became available. In fact, minimally invasive ileocolic resection was shown in the LIRIC trial to be an effective treatment option in biologic-naïve patients with uncomplicated ileocolic involvement (3). Thus, laparoscopic ileocolic resection may be a primary option for patients with isolated ileocolic Crohn, independent of disease behavior. This change of dogma is supported by very encouraging data demonstrating acceptably low recurrence rates when specific surgical techniques are used in this subgroup of patients. A 5-year recurrence free survival of over 98% was reported for the Kono-S anastomosis for example (6,7). The technical aspects of the Kono-S anastomosis include shielding off the anastomosis from the mesentery, creating a wide anastomosis (7–8 cm) and maintaining optimal bowel perfusion and innervation. Another technique published by Coffey et al. demonstrated a significant reduction in the risk of anastomotic recurrence following a wide excision of the mesentery during ileocolic resection (8). Rutgeerts et al. indicated in 1991 that the risk of recurrence at the neo-terminal ileum following ileocolic resection for ileocolic Crohn’s may be associated with fecal stream after studying a group of patients before and after ileostomy closure following ileocolic resection (9). These data suggest that the risk of anastomotic recurrence following ileocolic resection for Crohn’s may be reduced by paying attention to specific technical aspects. Herein, a personal experience with a modified side-to-side anastomotic configuration using a combination of the above-mentioned surgical techniques with the aim of reducing the risk of anastomotic recurrence following ileocolic resection for Crohn’s is presented. This article was presented in accordance with the SUPER reporting checklist (available at https://asj.amegroups.com/article/view/10.21037/asj-25-7/rc) (10).

Preoperative preparations and requirements

The study was conducted in accordance with the local legislation and institutional requirements. All procedures performed in this study were in accordance with the institutional standards, and with the Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from the participants for the participation and publication of this study and accompanying images (11). All patients underwent a laparoscopic assisted ileocolic resection with extracorporal anastomosis.

Step-by-step description

The laparoscopic part of the procedure was performed using three ports. A 10 mm camera port was placed 3 cm above the umbilicus in the midline using the open technique. A second 10 mm port was placed 6 cm above the camera port in the midline while a 5 mm port was place in the suprapubic position. Dissection and mobilization of the caecum, ascending colon and the hepatic flexure was done via the lateral to medial. The hepatic flexure was completely mobilized up to the falciform ligament, so that the right colon could be easily pulled to the left to display the duodenum. Then the terminal ileum was mobilized down to the mesenteric roots to identify the superior mesenteric pedicle. At this point, the vermiform appendix was clamped. A midline extraction site of 6 cm was made by connecting the two 10 mm ports. The rest of the procedure was performed extracorporal and includes the following steps:

First, the involved terminal ileum and caecum as well as accompanying mesenterium were marked (Figure 1A). A wide mesenteric excision was performed as described by Coffey et al. (8). In short, the terminal ileal branches were identified and the last branch 1 cm oral to the planed resection line at the terminal ileum was marked. Then this vessel was dissected using an energy device, carrying the dissection down to the central vessel. At this point, the ileocolic vessels were exposed and divided off the superior mesenteric artery and vein. The resection line of the ascending colon was determined after real—time bowel perfusion studies using indocyanine green (ICG). Hereafter, bowel transection was performed using linear cutters (Figure 1B). The staple lines of the small bowel and colon were inverted using 4-0 PDS sutures.

Figure 1 Wide mesenteric excision for Crohn’s. (A) The extent of mesenteric excision marked considering the extent of disease involvement. (B) The extent of mesenteric excision (over 10 cm) can be appreciated using a ruler.

Second, the antimesenteric side of the neoterminal ileum and ascending colon were marked to enable a strict antimesenteric configuration of the side-to-side isoperistaltic ileocolic anastomosis (Figure 2).

Figure 2 Construction of the anastomosis. (A) The future anastomosis is prepared by marking 10 cm of the antimesenteric side of the small bowel. Note, the mesentery is located opposite to the marking. (B) A wide side-to-side anastomosis is created using a 10 cm linear cutter. Note the staple line lays on the marked antimesenteric surface of the small bowel and the free colonic taenia. (C) Construction of the anastomosis. Completed isoperistaltic side-to-side ileocolic anastomosis with a strict antimesenteric configuration.

Third, a stapled anastomosis was performed using a 10 cm linear cutter. For this step, the small and large bowel were placed in an isoperistaltic orientation. Incisions were made on the antimesenteric side of the small and large bowel (free tenia) as previously marked and an isoperistaltic side-to-side ileocolic anastomosis was fashioned at the antimesenteric bowel wall (Figure 2). The common enterostomy was closed in a transverse manner in two layers.

Postoperative consideration

Endoscopic follow-up at a median of 9 months (range, 8–23 months) demonstrated a wide anastomosis without no relevant sign recurrence (Rutgeerts scores 0–1) (Figure 3). The results of 15 patients (seven males and eight females), median age of 32 years (range, 17–67 years) undergoing ileocolic resection for Crohn’s are reported in this manuscript. Disease behavior included penetration in four cases, stenosis in eight case and inflammatory with stenosis or penetration in three cases. Eight patients were had underwent treatment with biologics, seven with a combination of steroids and immunomodulation. The median duration of surgery was 147 min (range, 117–184 min). Median blood loss was 170 mL (range, 95–250 mL). No postoperative complication occurred, and the median length of stay was 5 days (range, 4–7 days).

Figure 3 Endoscopic follow-up. Endoscopic control at 6 months following surgery demonstration the size of the anastomosis.

Tips & pearls

The personal technique includes adapting the mucosa using a 5-0 PDS running suture. To prevent pouching of the blind loop, the mucosa of the ileum stump was included in this suture. This was done by pushing (intussuscepting) the closed end of the terminal ileum towards the common enterotomy and catching the mucosa of the stump in the 5-0 running mucosa suture. This was followed by a 4-0 PDS running Cushing suture in the resulting in a wide anastomosis of about 10–12 cm (Figure 2). Perfusion studies of the anastomosis was performed using ICG (Figure 4). A personal approach is to hind the staple lines with 4-0 PDS on both sides. The reconstruction is completed with the closure of the mesenteric window.

Figure 4 Perfusion study of the anastomosis. Real time ICG fluorescence studying demonstrating perfect bowel perfusion. ICG, indocyanine green.

Discussion

Anastomotic recurrence following ileocolic resection for Crohn’s disease may be prevented or reduced using specific surgical techniques. This has been shown in the Kono-S anastomosis (6,7) and following wide mesenteric resection by Coffey et al. (8). This manuscript reports on a modifies ileocolic anastomosis created by incorporating technical aspects from the Kono-S and Coffey techniques. The goal is to achieve a wide anastomosis (at least 10 cm) away from the mesenterium (antimesenteric orientation) without compromising bowel perfusion.

Optimal perfusion and innervation of the bowel have been reported as important factors for anastomotic healing in the Kono-S technique. Equally, resistance to fecal flow was shown by Rutgeerts et al. as a risk factor for recurrence after ileocolic resection (9). Therefore, the significant reduction in the rate of anastomotic recurrence seen in the Kono-S anastomosis may reflect these physiologic facts. The involvement of the mesenterium as a trigger for recurrence was demonstrated by Coffey et al. (8). Addressing all these important surgical aspects may therefore result in an optimal anastomosis with reduced risk of recurrence following ileocolic resection for Crohn’s disease.

The technique reported in this manuscript addresses resistance to flow by creating a wide anastomosis of at least 10 cm. This is 2–3 cm wider than the Kono-S anastomosis. The mesenterium as a potential origin for recurrence is addressed in two ways; first via a wide excision as reported by Coffey et al. (8), and secondly via an antimesenteric orientation of the anastomosis. This antimesenteric orientation puts the mesenterium as far away from the anastomosis, while maintaining an optimal perfusion as seen in the ICG studies. An important shortcoming of the side-to-side anastomosis is the risk of dilation of the blind ileum end. This must be prevented in this specific group of patients to reduce the risk of future disease activity in the blind loop. This can be achieved by creating the common enterostomy as close to the end of the resected ileum as possible, and by intussuscepting the blind end of the ileum and including the mucosa of the intussuscepted ileum stump into the 5-0 running mucosa sutures. A personal preference is to hide all staple lines using 4-0 PDS.

Endoscopy after a median follow-up of 9 months (range, 8–23 months) confirmed a wide anastomosis without signs of recurrence in all patients managed with this technique so far.

Although the initial results regarding clinical and endoscopic data in this small population are encouraging, more data is needed to judge the efficacy of this technique on the long run. Besides, the role of confounders e.g., medical treatment before and after surgery (not examined in this manuscript) needs to be considered.

Conclusions

Anastomotic recurrence following surgery for ileocolic Crohn’s may be reduced using a combination of available techniques. Three important aspects used in the technique discussed in this manuscript include a wide anastomosis, excision of the involved mesenterium while maintaining optimal bowel perfusion and an antimesenteric orientation of the anastomosis. These simple surgical aspects may have a huge impact on the risk of anastomotic recurrence.

Acknowledgments

None.

Footnote

Reporting Checklist: The author has completed the SUPER reporting checklist. Available at https://asj.amegroups.com/article/view/10.21037/asj-25-7/rc

Peer Review File: Available at https://asj.amegroups.com/article/view/10.21037/asj-25-7/prf

Funding: None.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://asj.amegroups.com/article/view/10.21037/asj-25-7/coif). P.C.A. serves as an unpaid Section Editor of AME Surgical Journal from November 2024 to December 2026. The author has no other conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. The study was conducted in accordance with the local legislation and institutional requirements. All procedures performed in this study were in accordance with the institutional standards, and with the Declaration of Helsinki and its subsequent amendments. Informed consent was obtained from the participants for the participation and publication of this study and accompanying images.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

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