Anastomotic Techniques for Crohn’s Surgery

Surgery plays a pivotal role in Crohn’s disease treatment. More than 75% of Crohn’s disease patients will eventually need surgical intervention despite medical therapy. The surgical approach in Crohn’s disease should follow the principles of bowel sparing and minimal invasiveness. Optimal timing and indications for surgery should be defined in a multidisciplinary setting including at least a surgeon, a gastroenterologist, and a radiologist. The stage of disease, operative map, clinical and drug patient history and conditions are the main factors to be considered in selecting the ideal surgical strategy. The most common scenario is ileocecal resection for terminal ileitis. When considering restorative surgery, different anastomotic techniques have been proposed, and, even after many studies, the debate is open regarding whether a specific type of anastomosis prevents disease recurrence at the anastomotic site. A wide lumen side-to-side stapled anastomosis is the most commonly used technique, but clear evidence is lacking on the advantages of a specific technique over another. Encouraging results are increasingly reported on the possible advantages of the functional antimesenteric end-to-end anastomosis described by Kono et al. in terms of reduced site-specific recurrence. Regarding bowel-sparing approaches, strictureplasties are commonly used in Crohn’s surgery. Various types of strictureplasty have developed in the past century, including conventional procedures (i.e. Heinecke-Mickulicz), intermediate procedures (i.e., Finney), and enteroenterostomies (i.e. Michelassi strictureplasty and its modifications). In the literature over 15 types of strictureplasty techniques have been described. Among Crohn’s disease specific techniques, many are currently routine surgical practices, and others remain under investigation. Future research should aim to identify interrelated factors that could define the most suitable procedures for the right patient, minimizing bowel resection and limiting the risk for complications and recurrence.