Abstract
The main serious risks of anastomotic construction in the colon and rectum include dehiscence and stricture formation. There is a resurgence of interest in sutureless anastomoses formed by compression elements since the introduction of shape memory alloy (SMA) systems, which evoke minimal early inflammatory response whilst maintaining anastomotic integrity. Currently, the most commonly used SMA is the nickel–titanium (NiTi) alloy that is highly biocompatible, returning to its pre-deformed stable (austenite) shape under different mechanical and thermal loads for use in humans. Pre-clinical data for shape memory alloy systems in colorectal anastomoses are limited, but it appears to be safe in porcine and canine models with limited leakage and reduced stricture formation. There does not appear to be any difference in tissue biochemistry of inflammatory markers when compared with conventional stapled techniques, although the few studies available show a markedly reduced early inflammatory response at the anastomotic site with the NiTi device. The majority of the clinical data concerning compression anastomoses are derived from the biofragmentable anastomotic ring device. This device has fallen out of use because of reported leaks, instrumental failure and problems with device expulsion. A novel SMA device, the NiTi anastomotic ring, permits construction of a low rectal anastomosis construction during open or laparoscopic procedures. The preliminary data demonstrate a safety comparable to conventional staple technology. This device also provides the potential of benefit of reduced anastomotic inflammation, because the compression ring results in direct serosa-to-serosa (or alternatively serosa-to-muscularis propria) apposition without the persistence of residual foreign material. This type of construction could lead to a reduced incidence of early anastomotic leakage and/or the development of anastomotic stenosis. Randomized clinical trials employing a NiTi arm for elective, emergency and high-risk colorectal anastomoses are required to determine its indications and clinical profile as well as to assess whether such technology may selectively obviate the need for proximal diversion in low colorectal anastomoses.
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References
Graffner H, Andersson L, Lowenhielm P, Walther B (1984) The healing process of anastomoses of the colon. A comparative study using single, double-layer or stapled anastomosis. Dis Colon Rectum 27:767–771
Matthiessen P, Halböök O, Andersson M, Rutegård J, Sjödahl R (2004) Risk factors for anastomotic leakage after anterior resection of the rectum. Colorectal Dis 6:462–469
Bannura GC, Cumsille MA, Barrera AE, Contreras JP, Melo CL, Soto DC (2004) Predictive factors of stenosis after stapled colorectal anastomosis: prospective analysis of 179 consecutive patients. World J Surg 28:921–925
Aggarwal R, Darzi A (2005) Compression anastomoses revisited. J Am Coll Surg 201:965–971
Thompson SK, Chang EY, Jobe BA (2006) Healing in gastrointestinal anastomosis, part I. Microsurgery 26:131–136
Martens MF, Hendricks T (1991) Postoperative changes in collagen synthesis in intestinal anastomoses of the rat: differences between small and large bowel. Gut 32:1482–1487
Syk I, Agren MS, Adawi D, Jeppsson B (2001) Inhibition of matrix metalloproteinases enhances breaking strength of colonic anastomoses in an experimental model. Br J Surg 88:228–234
De Hingh IH, de Man BM, Lomme RM, van Goor H, Hendriks T (2003) Colonic anastomotic strength and matrix metalloproteinase activity in an experimental model of bacterial peritonitis. Br J Surg 90:981–988
Hardy KJ (1990) Non-suture anastomosis: the historical development. Aust N Z J Surg 60:625–633
Amat C (1895) Appareils a sutures: Les viroles de denans; les points de Bonnier; Les boutons de Murphy. Arch Med Pharmacie Militaires Paris 25:273–285
Murphy JB (1892) Cholecysto-intestinal, gastro-intestinal, entero-intestinal anastomosis and approximation without sutures. Med Rec N Y 42:665–676
McCue JL, Phillips RK (1991) Sutureless intestinal anastomoses. Br J Surg 78:1291–1296
Lembert A (1826) Mémoire sur l’entéroraphie avec la description d’un procédé nouveau pour pratiquer cette opération chirurgicale. Répertoire général d’anatomie et de physiologie pathologiques, Paris 2:10–107
Senn N (1893) Enterorrhaphy: its history, technique and present status. JAMA 21:215–235
Hardy TG, Pace WG, Maney JW, Katz AR, Kaganov AL (1985) A biofragmentable ring for sutureless bowel anastomosis: an experimental study. Dis Colon Rectum 28:484–490
Hardy TG, Aguilar PS, Stewart WRC et al (1987) Initial clinical experience with a biofragmentable ring for sutureless bowel anastomosis. Dis Colon Rectum 30:55–61
Chen T-C, Ding K-C, Yang M-J, Chang C-P (1994) New device for biofragmentable anastomotic ring in low anterior resection. Dis Colon Rectum 37:834–836
Bubrick MP, Corman ML, Cahill CJ, Hardy TG Jr, Nance FC, Shatney CH (1991) Prospective, randomized trial of biofragmentable anastomosis ring. The BAR Investigational Group. Am J Surg 161:136–142
Forde KA, McLarty AJ, Tsai J, Ghalili K, Delany HM (1993) Murphy’s button revisited. Clinical experience with the biofragmentable anastomotic ring. Ann Surg 217:78–81
Kanshin NN, Lytkin MI, Knysh VI, Klur VI, Khamidov AI (1984) First experience with application of compression anastomoses with the apparatus AKA-2 in operations on the large intestine. Vestn Khir Im I I Grek 132:52–57
Khanevich MD, Karapetian AR (2001) Restorative operations in colostomy patients with short stump of the rectum. Vestn Khir Im I I Grek 160:46–48
Pirogov AI, Kanshin NN, Morkhov IuK, Dzhabbarov MM, Tuleuov AE (1987) Experimental development of compression esophagogastric anastomoses using the AKA-2 apparatus and the SPTU modified apparatus. Grudn Khir 5:62–65
Patiutko II, Pedchenko VV, Lagoshnyĭ AT, Efimov ON (1991) Experience in the use of the AKA-2 device in the formation of esophago-intestinal anastomosis. Klin Khir 5:31–35
Wullstein C, Gross E (2000) Compression anastomosis (AKA-2) in colorectal surgery: results in 442 consecutive patients. Br J Surg 87:1071–1075
Rosati R, Rebuffat C, Pezzuoli G (1988) A new mechanical device for circular compression anastomosis. Preliminary results of animal and clinical experimentation. Ann Surg 207:245–252
Malthaner RA, Hakki FZ, Saini N, Andrews BL, Harmon JW (1990) Anastomotic compression button: a new mechanical device for sutureless bowel anastomosis. Dis Colon Rectum 33:291–297
Cope C (1995) Evaluation of compression cholecystogastric and cholecystojejunal anastomoses in swine after peroral and surgical introduction of magnets. J Vasc Interv Radiol 6:546–552
Vicol C, Eifert S, Oberhoffer M, Boekstegers P, Reichart B (2006) Mid-term patency after magnetic coupling for distal bypass anastomosis in coronary surgery. Ann Thorac Surg 82:1452–1456
Jamshidi R, Stephenson JT, Clay JG, Pichakron KO, Harrison MR (2009) Magnamosis: magnetic compression anastomosis with comparison to suture and staple techniques. J Pediatr Surg 44:222–228
Pichakron KO, Jelin EB, Hirose S et al (2011) Magnamosis II: magnetic compression anastomosis for minimally invasive gastrojejunostomy and jejunojejunostomy. J Am Coll Surg 212:42–49
Tarniţă D, Tarniţă DN, Bîzdoacă N, Mîndrilă I, Vasilescu M (2009) Properties and medical applications of shape memory alloys. Rom J Morphol Embryol 50:15–21
Zablotskii V, Pérez-Landazábal JI, Recarte V, Gómez-Polo C (2010) Temperature dependence of magnetic susceptibility in the vicinity of martensitic transformation in ferromagnetic shape memory alloys. J Phys: Condens Matter 22:316004
Nudelman I, Fuko V, Waserberg N et al (2005) Colonic anastomosis performed with a memory-shaped device. Am J Surg 190:434–438
Mantovani D (2000) Shape memory alloys: properties and biomedical applications. J Miner Met Mater Soc 52:36–44
Wu S, Wayman C (1987) Martensitic transformations and the shape memory effect in Ti50Ni10Au40 and Ti50Au50 alloys. Metallography 20:359
Braun JT, Akyuz E, Ogilvie JW, Bachus KN (2005) The efficacy and integrity of shape memory alloy staples and bone anchors with ligament tethers in the fusionless treatment of experimental scoliosis. J Bone Joint Surg Am 87:2038–2051
Barras CD, Myers KA (2000) Nitinol—its use in vascular surgery and other applications. Eur J Vasc Endovasc Surg 19:564–569
Migliavacca F, Petrini L, Massarotti P, Schievano S, Auricchio F, Dubini G (2004) Stainless and shape memory alloy coronary stents: a computational study on the interaction with the vascular wall. Biomech Model Mechanobiol 2:205–217
Hoh DJ, Hoh BL, Amar AP, Wang MY (2009) Shape memory alloys: metallurgy, biocompatibility, and biomechanics for neurosurgical applications. Neurosurgery 64:199–215
Ryhänen J (1999) Biocompatibility evolution of nickel-titanium shape memory alloy. Academic Dissertation, Faculty of Medicine, University of Oulu, Finland
Duerig TW, Pelton AR, Stöckel D (1996) The utility of superelasticity in medicine. Biomed Mater Eng 6:255–266
Monassevitch LA, BenDov-Laks N, Tyagunov N et al. (2006) Design principles of shape memory devices for compression anastomosis in the digestive system. In: Proceedings of international conference on shape memory and superelastic technologies, Pacific Grove, pp 703–713
Weizman A, Monassevitch L, Greenberg K, Millis S, Harari B, Dar I (2011) FE analysis of Nitinol leaf springs used in a compression anastomosis device. J Mater Eng Perform [Epub Ahead of Print]
Maney JW, Katz AR, Li LK, Pace WG, Hardy TG (1988) Biofragmentable bowel anastomosis ring: comparative efficacy studies in dogs. Surgery 103:56–62
Bundy CA, Zera RT, Onstad GA, Bilodeau LL, Bubrick MP (1992) Comparative surgical and colonoscopic appearance of colon anastomoses constructed with sutures, staples, and the biofragmentable anastomotic ring. Surg Endosc 6:18–22
Croston JK, Jacobs DM, Kelly PH et al (1990) Experience with the biofragmentable anastomotic ring (BAR) in bowel preoperatively irradiated with 6000 rad. Dis Colon Rectum 33:222–226
Smith AD, Bubrick MP, Mestitz ST et al (1988) Evaluation of the biofragmentable anastomotic ring following preoperative irradiation to the rectosigmoid in dogs. Dis Colon Rectum 31:5–9
Ryan S, Seim H, MacPhail C, Bright R, Monnet E (2006) Comparison of biofragmentable anastomosis ring and sutured anastomoses for subtotal colectomy in cats with idiopathic megacolon. Vet Surg 35:740–748
Gross E, Schaarschmidt K, Donhuijsen K, Beyer M, Eigler FW (1986) Die nahtlose anastomose—histologische, biomechanische und mikroangiographische untersuchungen am colon der ratte. Langenbecks Arch Chir Suppl Chir Forum 277–281
Hendrix H, Gross E, Schaarschmidt K, Donhuijsen K, Haralambie Eigler FW (1988) Die nahtlose anastomose unter bedingungen der experimentellen peritonitis am rattencolon. Langenbecks Arch Chir Suppl Chir Forum 453–457
Mimuro A, Tsuchida A, Yamanouchi E et al (2003) A novel technique of magnetic compression anastomosis for severe biliary stenosis. Gastrointest Endosc 58:283–287
Cope C, Clark TW, Ginsberg G, Habecker P (1999) Stent placement of gastroenteric anastomoses formed by magnetic compression. J Vasc Interv Radiol 10:1379–1386
Erdmann D, Sweis R, Heitmann C et al (2004) Side-to-side sutureless vascular anastomosis with magnets. J Vasc Surg 40:505–511
Muraoka N, Uematsu H, Yamanouchi E et al (2005) Yamanouchi magnetic compression anastomosis for bilioenteric anastomotic stricture after living-donor liver transplantation. J Vasc Interv Radiol 16:1263–1267
Jansen A, Keeman JN, Davies GA, Klopper PJ (1980) Early experiences with magnetic rings in resection of the distal colon. Neth J Surg 32:20–27
Jansen A, Brummelkamp WH, Davies GA, Klopper PJ, Kemman JM (1981) Clinical applications of magnetic rings in colorectal anastomosis. Surg Gynecol Obstet 153:537–545
Nudelman I, Guko VV, Morgenstern S, Giler S, Lelcuk S (2000) Gastrointestinal anastomosis with the Nickel-Titanium double ring. World J Surg 24:874–877
Kopelman D, Lelcuk S, Sayfan J et al (2007) End-to-end compression anastomosis of the rectum: a pig model. World J Surg 31:532–537
Kopelman Y, Siersema PD, Nir Y et al (2009) Endoluminal compression clip: full-thickness resection of the mesenteric bowel wall in a porcine model. Gastrointest Endosc 70:1146–1157
Stewart D, Hunt S, Pierce R et al (2007) Validation of the NiTi™ Endoluminal Compression Anastomotic Ring (ColonRing™) device and comparison to the traditional circular stapled colorectal anastomosis in a porcine model. Surg Innov 14:252–260
Chun JS, Stewart DB, Lee D et al (2008) Evaluation of the safe and effective performance of the compression anastomosis ring (ColonRing™) for colorectal anastomosis in comparison to circular stapler in a porcine model. ASCRS Meeting Chicago, Poster
Zühlke HV, Lorenz EM, Straub EM, Savvas V (1990) Pathophysiology and classification of adhesions. Langenbecks Arch Chir Suppl II Verh Dtsch Ges Chir 1009–1016
Chun J, Parikh P, Lee D, Fleshman J (2011) Safety of the NiTi EndoCAR following cheomradiation in a porcine model. Surg Innov Mar 7. [EPub ahead of print]
Chen T-C, Yang M-J, Chang C-P (1995) New anastomotic gun for biofragmentable anastomotic ring in low anterior resection. Dis Colon Rectum 38:1214–1216
Lünstedt B, Sundermann H (1995) Transanal compression anastomosis in the lower rectum with a biofragmentable anastomosis ring (Valtrac): surgical technique and initial clinical experiences [Transanale Kompressionsanastomose im tiefen Rectum mit einem biofragmentierbaren Anastomosenring (Valtrac®): Operationstechnik und erste klinische Erfahrungen]. Chirurg 66:715–718
Coleman J (1995) Future developments of Valtrac® with particular reference to transanal and enteral delivery of BAR. In: Engemann R, Thiede A (eds) Compression anastomosis by biofragmentable rings. Proceedings of the second European workshop. Springer, Berlin, pp 44–57
Thiede A, Geiger D, Dietz UA et al (1998) Overview on compression anastomoses: biofragmentable anastomosis ring multicenter prospective trial of 1666 anastomoses. World J Surg 22:78–87
Kim SH, Choi HJ, Park KJ et al (2005) Sutureless intestinal anastomosis with the biofragmentable anastomosis ring: experience of 632 anastomoses in a single institute. Dis Colon Rectum 48:2127–2132
Corman ML, Prager ED, Hardy TG, the Valtrac Bar Study Groups (1989) Comparison of the Valtrac biofragmentable anastomosis ring with conventional suture and stapled anastomosis in colon surgery. Results of a prospective, randomized clinical trial. Dis Colon Rectum 32:183–187
Glavić Z, Kovacić D, Skegro M, Rahelić V, Begić L (2000) Anastomosis of the colon using the Valtrac biofragmentable ring. Lijec Vjesn 122:136–139
Chua CL (1993) Colonic anastomosis with sutureless biofragmentable rings. Singap Med J 34:541–544
Walfish S, Twena M, Avinoah E, Charuzi I (1993) Experience with biofragmentable anastomotic rings. Harefuah 125:263–264
Debus ES, Sailer M, Geiger D, Dietz UA, Fuchs KH, Thiede A (1999) Long-term results after 75 anastomoses in the upper extraperitoneal rectum with the biofragmentable anastomosis ring. Dig Surg 16:55–59
Påhlman L, Ejerblad S, Graf W et al (1997) Randomized trial of a biofragmentable bowel anastomosis ring in high-risk colonic resection. Br J Surg 84:1291–1294
Galizia G, Lieto E, Castellano P et al (1999) Comparison between the biofragmentable anastomosis ring and stapled anastomoses in the extraperitoneal rectum: a prospective, randomized study. Int J Colorectal Dis 14:286–290
Cahill CJ, Betzler M, Gruwez JA, Jeekel J, Patel JC, Zederfeldt B (1989) Sutureless large bowel anastomosis: European experience with the biofragmentable anastomosis ring. Br J Surg 76:344–347
Luukkonen P, Järvinen HJ, Haapiainen R (1990) Early experience with biofragmentable anastomosis ring in colon surgery. Acta Chir Scand 156:765–769
Debus ES, Engemann R, Thiede A (1995) Tools to facilitate Valtrac anastomosis. In: Engemann R, Thiede A (eds) Compression anastomosis by biofragmentable rings. Proceedings of the second European workshop. Springer, Berlin, pp 35–43
Schneider IH, Schneider C, Thaler K, Reck T, Köckerling F (1994) Intraperitoneal colon anastomosis with laparoscopic purse string suture clamp and Valtrac ring. Langenbecks Arch Chir 379:188–192
Köckerling F, Schneider C, Reck T (1995) Laparoskopische Anastomosierungsverfahren am Dickdarm: Kritische Bewertung aus Tierexperiment und klinischer Praxis. Chir Gastroenterol 11:246–251
Eigler FW, Gross E (1986) Mechanical compression anastomosis (AKA-2) of the colon and rectum. Results of a prospective clinical study. Chirurg 57:230–235
Matos D, Phillips RK (1993) Initial experience with the AKA-2 and AKA-4 device for intestinal compression anastomosis in colorectal surgery. Rev Assoc Med Bras 39:8–11
Gross E, Köppen HO (1993) The AKA-2 sutureless compression anastomosis of the colon and rectum. Zentralb Chir 118:459–465
Zakharash MP, Tkachenko FH, Poǐda OI, Zhel’man VO, Kryvoruk MI, Dubovyǐ VA (2001) Application of apparatus AKA-2 in the reconstructive-restorative surgery of the left half of the colon and rectum. Klin Khir 3:31–33
Nudelman I, Fuko V, Rubin M, Lelcuk S (2004) A nickel-titanium memory-shape device for colonic anastomosis in laparoscopic surgery. Surg Endosc 18:1085–1089
D’Hoore A, Hompes D, Folkesson J, Penninckx F, Påhlman L (2008) Circular ‘superelastic’ compression anastomosis: from the animal lab to clinical practice. Minimally Invasive Ther 17:172–175
Dauser B, Herbst F (2009) NiTi™ endoluminal compression anastomosis ring (ColonRing™): a breakthrough in compression anastomoses? Eur Surg 41:116–119
Dauser B, Winkler T, Lonscar G, Herbst F (2011) Compression anastomosis revisited: prospective audit of short- and medium-term outcomes in 62 rectal anastomoses. World J Surg [EPub ahead of print]. doi:10.1007/s00268-011-1135-2
Tulchinsky H, Kashtan H, Rabau M, Wasserberg N (2010) Evaluation of the NiTi shape memory BioDynamix Colon Ring™ in colorectal anastomosis: first in human multi-center study. Int J Colorect Dis 25:1453–1458
Gross E (2010) The sutureless compression anastomosis CAR 27 in colon and rectum. Results in 46 patients. In: 5th ESCP Meeting, Sorrento, 625 (A)
Shteinberg D, Sroka G, Misharsky F, Matter I (2010) Nitinol compression anastomosis ring for restoration of intestinal continuity after recto-sigmoid resections. SAGES restoration of intestinal continuity after recto-sigmoid resections. 12th World Congress of Endoscopic Surgery, Landover, ETP34 (A)
Buchberg BS, Masoomi H, Bergman H, Mills SD, Stamos MJ (2011) The use of a compression device as an alternative to hand-sewn and stapled colorectal anastomoses: is three a crowd? J Gastrointest Surg 15:304–310
Masoomi H, Mills S, Carmichael JC, Senagore AJ, Stamos MJ (2011) Compression anastomosis ring device in colorectal anastomosis: a review of 1,180 patients. Eurasian Colorectal Technologies Association meeting, June 15th–17th, Turin, Italy
Spirev V, Plotnikov V, Vlasov A, Nazarova D (2011) Compression ileocolic anastomosis for colon cancer surgery. Eurasian Colorectal Technologies Association meeting, June 15th–17th, Turin, Italy. Tech Coloproctol 15:223
Vlasov A, Vazhenin A, Plotnikov V, Spirev V, Nazarova D (2011) Clinical application of a new placement device for the NiTi compression anastomosis ring in rectal cancer surgery. Eurasian Colorectal Technologies Association meeting, June 15th–17th, Turin, Italy. Tech Coloproctol 15:229
Koo EJ, Choi HJ, Woo JH et al. (2011). Anastomosis by use of compression anastomosis ring (CAR™ 27) in laparoscopic surgery for left-sided colonic tumor. Int J Colorectal Dis [EPub ahead of Print]
Jun J-A, Chun H-K, Cho YB, Yun SH, Kim HC, Lee WY (2011) Validation of NiTi Shape Memory ColonRingTM in colonic anastomosis for curative anterior resection: prospective, non-comparative, single centre study. 6th ESCP meeting 24–26th September, Copenhagen, OP 22 (A)
Avgoustou C, Penlidis P, Tsakpini A, Sioros C, Fountas S, Giannousis D (2011) Compression anastomoses in colorectal surgery with the NiTi ColonRingTM. 6th ESCP meeting, 24–26th September, Copenhagen, OP 51 (A)
Avgoustou C, Penlidis P, Sioros C et al (2011) Colon to colon, small bowel to colon and colorectal anastomoses with the compression anastomotic ring NiTi CAR™ 27. Clinical study. Hellenic J Surg 83:126–132
Avgoustou C, Penlidis P, Tsakpini A, Sioros C, Giannousis D (2012) Compression anastomosis in colon and rectal surgery with the NiTi ColonRing™. Tech Coloproctol 16:29–35
Gullichsen R, Ovaska J, Havia T, Yrjänä J, Ekfors T (1993) What happens to the Valtrac® anastomosis of the colon? A follow-up study. Dis Colon Rectum 36:362–365
Song C, Frank T, Cuschieri A (2005) Shape memory alloy clip for compression colonic anastomosis. J Biomech Eng 127:351–354
Czerny V (1896) Über den Einsatz der Darmnaht durch den Murphyknopf. Centralb Chir 10:121
Frank J (1897) Intestinal anastomosis. JAMA 28:1163
Garampazzi C (1897) Un nuovo bottone (alla Murphy) scomponibilie. Riforma Med 4:27
Boari A (1897) Modificazioni al bottone anastomotico di Murphy. Arch Atti Soc Ital Chir 1:45
Izbicki JR, Gawad KA, Quirrenbach S et al (1998) Is the stapled suture in visceral surgery still justified? A prospective, controlled, randomized study of cost effectiveness of manual and stapler suture. Chirurg 69:725–734
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AP Zbar, M Rabau and A Senagore are NiTi consultants. Y Nir and A Weizman are NiTi employees.
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Zbar, A.P., Nir, Y., Weizman, A. et al. Compression anastomoses in colorectal surgery: a review. Tech Coloproctol 16, 187–199 (2012). https://doi.org/10.1007/s10151-012-0825-6
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DOI: https://doi.org/10.1007/s10151-012-0825-6