First International Consensus Conference on Kono-S anastomosis, Kyoto 2011A new antimesenteric functional end to end hand-sewn anastomosisSurgical prevention of anastomotic recurrence in Crohn’s disease. Diseases of the Colon & Rectum 2010 Asahikawa (1 hour 40 min flight from Tokyo) Toru Kono Division of Gastroenterologic and General Surgery Department of Surgery, Asahikawa Medical College Tokyo Kyoto Mt. Taisetu National Park, Asahikawa, (Scenery from the window of my office)
Anastomotic recurrence and surgical recurrence of CD (1993 to 2003) Autumn in Kyoto, Kinkakuji temple
5-year postoperative cumulative recurrence-free survival (ulcerative changes) below 10% in historical CD cases > 90% recurrence within 5 years Cumulative recurrence-free survival (Kaplan-Meier analysis) 1 Mean time to recurrence (mo.) 0.8 25% 6.4 50% 12.3 0.6 75% 38.6 0.4 5 years 0.2 0 0 20 40 60 80 100 120 140 (mo) N=84
Postoperative (POP) stenosis at anastomotic sitesPOP 11 months POP 40 months POP 52 months
5-year postoperative cumulative surgical recurrence increased to 26% in historical CD casesCumulative surgical recurrence(Kaplan-Meier analysis) Mean time to reoperation (mo.) 1 25% 56.8 0.8 50% 104.0 0.6 0.4 0.2 0 0 20 40 60 80 100 120 140 (mo) N=84
The S anastomosis technique was developed in 2003 at the Asahikawa Medical University Hospital Dept. Surgery Asahikawa Medical University hospital
Concept• Anastomotic recurrence site, which usually start at mesenteric side of the anastomosing the ends of the remnant intestine. However, conventional anastomoses do not pay attention to this, besides the size of the anastomosis site. We designed an anastomotic technique to avoid the stenosis at the anastomosing the ends of the remnant bowel by creating a supporting column, like a stent.• It is also important that the blood flow and nervous system should be preserved when a resected intestine and its mesentery is divided, because both are important factors for ulcer healing and are etiologically abnormal in CD intestine.
Submucosal nervous system is damaged due torepeated inflammation and can not fully recover in Crohn’s disease Normal ileum Crohn’s disease ileum Red : nervous fiber and cell, Blue: DAPI indicate cell nucleus
Selective loss of neuropeptide CGRP, but not ADM, in Crohn’s disease model and human Ann N Y Acad Sci. 1992;657:319-27. Dig Dis. 2008;26:149-55. CGRP ADM 100 1.5 CGRP ( ng / g tissue weight ) ADM ( ng / g tissue weight ) 80 1.2 60 0.9 40 0.6 ** 20 0.3 0 0.0 Control CD Model Control CD Model Kono T. et al J Gastroenterology 2011 (in press)It has been reported that blood flow is decreased by more than50% in the terminal ileum and colon of Crohn’s disease patients Gastroenterology. 1977;72:388-96. Gut. 1986;27:542-9.
Blood flow is decreased in Crohn’s disease because ofdepletion of neuronal peptide (CGRP),a potent vasodilatator, in human and animal models. Blood 0.14 normal colon Flow 0.12 TNBS treated colon 0.10 0.08 CV 0.06 0.04 0.02 0.00 0 15 30 45 60 75 90 min Kono T. et al J Gastroenterology 2011 (in press)
Crohn’s disease and intestinal blood flowSlovenia
Blood flow is a very important factor in pathogenesis of Crohn’s diseaseIleal ulcers tend to occur along the mesenteric margin of the bowel wall in CD and experimental models of CD J Clin Pathol. 1997;50:1013-7. Aliment Pharmacol Ther. 1999;13:531-5. Aliment Pharmacol Ther. 2000;14:241-5. Florida Everglade
Crohn’s disease ileum Mesenteric side Mesenteric sideMesenteric side stenosis stenosis
Who can answer the prepotency of theCrohn’s disease?Hypothesis:Primary pathological abnormality inCrohn’s disease is in the mesentericblood supply Lancet. 1989;2:1057-62.
Schematic diagram of human small intestine in Crohn’s disease Normal Remission Mucosal barrier Active flora vessel bacteria inflammation * granuloma ulcer Mesenteric Mesenteric margin marginlong artery short artery CGRP glanulomatous Blood flow vasculitis Lancet. 1989;2:1057-62. No connection between the submucosal plexuses derived from short artery and long artery* The association might well be explained in terms of granulomatous vasculitis affecting small end-arteries that specifically supply the mesenteric margin
Intraoperative endoscopy Intraoperative endoscopy Transection of intestine ulcer stenosis mesenteryThe whole bowel was inspected carefully for diseased segments using an endoscopic fiber viaenterotomy at a nearby obvious stenosis site in all cases.Before resection of the diseased intestine, the surgeon and the gastroenterologist ensure byintraoperative endoscopy or direct observation there are no apparent mucosal lesions at the site ofthe intestine designated for anastomosis.
How to divide “mesentery”The nearby mesentery of the intestinal loop which is to be excised is dividedusing the LigaSure system (Valleylab) in order to avoid an unnecessaryneurectomy as well as blood vessel dissection diseased intestine blood vessel nerve fiber
How to make a “Supporting Column” the intestine designated Kono-S resection with LS Conventional resection with LS for anastomosis Diseased intestine Mesenteric side Linear stapler (LS) the intestine designatedMultiple stenosis at ileum for anastomosis Diseased ileum specimen Diseased ileum
The reason : Both ends of the stump are reinforced with 3/0 Vicryl (Ethicon) , when alinear staple cutter is used. End of the stump has a risk (leakage) for sealing with single stapling, therefore reinforcement is needed at the both ends. 3/0 Vicryl control-release
The reason : Both threads of the ends of stumps are firstly tied for adjusting somedifferences of the size of the stump, when a supporting column is made. Mesenteric side relapse starting point at mesenteric side Both stumps are united with 3 or 4 threads.
“Supporting Column” avoids stenosis Supporting columnBefore anastomosis, both stumps are securely sutured in order to create aSupporting Column that can maintain the shape of the anastomosisThe creation of a supporting column that maintains the shape of theanastomosis in order to prevent distortion due to relapse at the anastomotic site.
Longitudinal enterotomy is performed in the antimesenteric side 1cm from thesupporting column so as to obtain the optimal effect of the supporting column onthe anastomosis, and the incision is opened across the intestinal longitudinalaxis, resulting in a large anastomosis resembling the Heineke-Mikulicz type. Thelength of the opened incision across the longitudinal axis should be 7-8 cm, andit is closed to the length of the intestinal circumference.
Antimesenteric functional end to end hand-sewn anastomosisA side-to-side enteroenteric transverse anastomosis is performed by ahandsewn, single-layer Gambee manner, using 3/0 Vicryl running sutures. Supporting column Resembles anastomosing the bottom ends of two flasks
Videotape on Kono-S anastomosis technique 34 years old. maleReoperation for anastomotic stenosis within 6 years of initial surgery Ileocolic anastomosis + ileoileal anastomosis
Results of Kono-S anastomosis 84 consecutive cases of intestinal resection for CD from 2003 to 2010 Asahikawa Medical University Hospital S anastomosis at 107 sites Ileal/jejunal: 44 Ileocolic: 57 Colonic: 6Comparative analysis with 73 historical CD patients who underwent conventional anastomoses from 1993 to 2003
Endoscopic observation one year after Kono-S anastomosis
Analysis of endoscopic recurrence at the anastomosisafter undergoing S anastomosis (Group S) or conventional anastomoses (Group C) 3.4 P=0.008 2.6
Comparison of surgical recurrence for anastomotic restenosis between S anastomoses and conventional anastomoses 100 Group S N = 84 90 Group S Group C N = 73 80 70 Group C P = 0.0004 60 50 40 30 20 10 0 0 12 24 36 48 60 72 84 96 108 120 132 months
Surgical recurrence rates after undergoing an S anastomosis (Group S) or conventional anastomoses (Group C). With or without postoperative Infliximab % patients remaining free of surgical recurrence 100 Infliximab + n = 42 Group S Infliximab - n = 42 90 Infliximab + n = 12 Group C Infliximab - n = 61 80 *, ** Logrank Test *p = 0.0041 Logrank Test **p = 0.0006 70 60 0 12 24 36 48 60 72 84 96 108120132 Time in MonthsGroup S combined with postoperative infliximab therapy (infliximab +), no infliximab (infliximab -),and Group C combined with postoperative infliximab therapy (infliximab +), no infliximab (infliximab -).Group S infliximab + vs. Group C infliximab -: P = 0.0041. Group S infliximab - vs. Group C infliximab -: P = 0.0006.
Comparison of anastomotic restenosis recurrence between S ansatomosis and conventional anastomosesNo postoperative administration of Infliximab/Adalimumab 100 Group S 90 80 Group C 70 60 0 12 24 36 48 60 72 84 96 108 120 132 Time in Months
ConclusionKono-S anastomosis, a new antimesenteric functional end toend hand-sewn anastomosis, may be effective for preventingpostoperative anastomotic stenosis, even if infliximabpostoperative therapy is not administered. Pisa