Aspects Towards the Anastomotic Healing in Crohn's Disease: Clinical Approach and Current Gaps in Research

Abstract

Anastomotic leakage is a major complication in gastrointestinal and colorectal surgery and its occurrence increases morbidity and mortality. Its incidence is even higher in Crohn's disease surgeries. Several authors have identified factors involved in the pathophysiology of anastomotic leak in the literature, aiming to reduce its occurrence and, therefore, improve its surgical treatment. Surgical technique is the most discussed topic in studies on guiding the performance of side-to-side stapled anastomosis. Preoperative nutritional therapy also has been shown to reduce the risk of anastomotic leakage. Other factors remain controversial - immunomodulator use and biologic therapy, antibiotics, and gut microbiota - with studies showing a reduction in the risk of complication while other studies show no correlation. Although mesenteric adipose tissue has been related to disease recurrence, there is no evidence in the literature that it is related to a higher risk of anastomotic leakage. Further exploration on this topic is necessary, including prospective research, to support the development of techniques to prevent anastomotic leakage, in this way benefiting the inflammatory bowel disease patients who have to undergo a surgical procedure.

Keywords: Crohn’s disease; anastomosis; anastomotic healing; inflammatory bowel disease; mesenteric adipose tissue; postoperative complications/prevention & control; surgical complications; suture techniques.

Figure 1

Aspects of an anastomosis followed by an enterectomy for Crohn’s disease (CD). (A) Surgical aspect of the ileum affected by CD. (B) Surgical specimen showing a longitudinal deep ulcer in the inflamed intestinal mucosa by the disease. (C) Side-to-side anastomosis. Source of the photographs: Colorectal Surgery Unit, Unicamp.

Figure 2

Check-list to guide surgeons to avoid complications in Crohn’s disease abdominal surgeries that require intestinal resection and anastomosis.

Figure 3

Factors that may influence the effective healing of anastomosis. Several factors may act directly on the correct healing of anastomoses, such as nutritional factors, intestinal microbiota, medications, and the tissues nearby the intestinal affected area such as the mesenteric adipose tissue. Created with BioRender.com.