1. Anastomosis in IBD Barry Salky, MD FACS Professor of Surgery Chief (Emeritus), Division of Laparoscopic Surgery The Mount Sinai Hospital New York

3. Anastomosis in IBD Ulcerative Colitis Mucosectomy versus Double-staple

4. Anastomosis in IBD Mucosectomy Vs. Double-Stapled M DS Technical ease N Y Preserves ATZ N Y Improved function N Y Decrease septic event ? ? Decrease dysplasia Y N Decrease cancer risk N N Larson, Pemberton; Gastroenter, 2004

5. Anastomosis in IBD ATZ Portion of the anal canal between squamous epithelium below and the columnar epithelium above. Nocturnal fecal incontinence less with DS as the ATZ is preserved. (multiple RCTs, a few RCTs don’t agree)

6. Anastomosis in IBD Leaks and sepsis Several series demonstrated a better prognosis from leaks and sepsis in DS compared to mucosectomy. ( non RCT) MacRae et al Ziv et all DCR 1997 Am J Surg 1996

7. Anastomosis in IBD Cancer risk Dysplasia in ATZ at 10 years 5%. * Multiple reports of development of cancer in both DS and mucosectomy patients ( that means residual rectal mucosa can be left behind) Most experts agree that if dysplasia is present in the rectum-mucosectomy is procedure of choice. Remzi et al DCR 2003 (*) O’Connell et al DCR 1987

8. Anastomosis in IBD Crohn’s Disease Does type of anastomosis make a difference in recurrence, leak or function?

9. Anastomosis in IBD Crohn’s Disease Whether the actual anastomotic technique impacts rate of recurrence or the need for a second surgery is completely unknown. Larson, Pemberton Gastroenterology 2004

10. Anastomosis in IBD Crohn’s Disease Several non-randomized papers have suggested that the recurrence free time is lengthened by using a stapled anastomosis at the original surgery. Hashemi et al Yamamoto et al Munoz-Juarez et al DCR 1998 World J Surg 1999 DCR 2001

11. Anastomosis in IBD Crohn’s Disease “Stapled vs handsewn methods for ileocolic anastomoses” Cochrane analysis 5 large RCT including 1125 ileocolic pts 441 stapled, 684 hand sewn Stapled anastomosis (functional end to end) had significantly fewer anastomotic leaks p=0.03 (CONT)

12. Anastomosis in IBD Crohn’s Disease “Stapled vs handsewn methods for ileocolic anastomoses” All other outcomes: stricture, hemorrhage, time, re-operation, mortality, abscess, wound infection, LOS showed not significant difference. Choy et al Cochrane Library 2011

13. Patient Demographics Intracorporeal ( n=54) Extracorporeal (n=51) P value 45 50 0.181 19(35) 28(23) 0.042 BMI (kg/m 2 ) 23.8 23.4 0.705 ASA class* 2.1 2.2 0.242 Prior operation 21 23 0.519 IBD 33 30 0.167 Neoplasm 19 16 Other 2 5 *Mean

14. Operative Data Intracorporeal n = 54 Extracorporeal n = 51 p value Operation performed Ileocolic 33 0.583 R hemi 14 15 L hemi 6 3 Subtotal 1 0 Fistula take down 14 160.537 OR time (minutes) 190 1560.001 EBL (ml) 85.4 1640.014 Intraop narcotics (mg)* Morphine equivalents 49 480.826 Intraop complications 0 0

15. Post-op Data IntracorporealExtracorporealP value Narcotic use (mg)*16490.001 Time to flatus(days)*2.0 2.40.017 Time to BM (days)*2.22.50.167 Length of stay (days)*3.23.80.019 Periop morbidity (n)6150.019 Anastomotic leak01 Enterotomy1 0 GI bleed 0 2 Obstruction 1 4 Intra-abd abscess 0 2 Wound infection 0 2 Cardiac 20 Blood transfusion 13 Urinary retention 0 1 Hematuria 0 2 Other 0 2 Mortality 0 0

17. Anastomosis in IBD Conclusions (UC) 1.DS is comparable to mucosectomy, and it is technically easier to perform. 2.Use mucosectomy for rectal dysplasia 3.No difference between laparoscopic and open cases (so far)

18. Anastomosis in IBD Conclusions (Crohn’s Disease) 1.Stapled techniques are appropriate in the surgery for CD. 2.Intracorporeal anastomosis appears to decrease morbidity and LOS.