Techniques for colorectal anastomosis

Table 1 Characteristics of the four main compression devices

	BAR	AKA-2	CAC	EndoCAR27
Absorbable	Yes	No	No	No
Application	Laparoscopy, laparoscopy, transanal	Transanal	Laparotomy, laparoscopy, hand-assisted lap	Laparotomy, laparoscopy, hand-assisted lap
Internal Lumen	11-20	25, 28, 31	8	One ring size (27 mm) replaces a number of competitive sizes (25-34 mm)
Average time to expulsion (d)	14-21	4-6	7	7-10
Type of surgery
Elective/emergency	Yes/yes	Yes/yes	Yes/no	Yes/no
Foreign body reaction	No	Possible to metal pins	No	No
Tissue healing	Extensive fibrosis/may cause stricture	Extensive fibrosis/may cause stricture	Primary intention/no strictures reported	Primary intention/no strictures reported (recovery of multi-layer lumen structure)
Anastomotic index	Lumen capacity depends upon standardized ring size		Full lumen capacity within 8-12 wk
Efficacy	Safe and secure and can be applied to achieve multiple anastomosis (in case requiring rapidity and security)
Learning curve1	Technically difficult than the other three devices	Technically simple after education
Cost2	About $600	NA	About $3	NA (however higher than conventional staples)
Tissue thickness accommodation	Selecting ring size to be compatible with diameter and thickness of bowel wall	Same as BAR	Only one size, shape memory alloy that accommodates varies tissue thickness. Unique thermo-mechanical properties and super elasticity
Type of anastomosis	End-to-end, end-to-side, side-to-side		Side-to-side	End-to-end
Site of anastomosis	Suitable for intestinal, colonic and rectal anastomosis	Distal colon and rectal only	Intestinal, colonic and rectal anastomosis

¹Galizia et al[47] described a learning curve of nine patients for BAR anastomosis. A meta-analysis of over 500 cases in North America, Europe and Israel, 75% of surgeons rated the CAR²⁷ device to be very easy or easy to use[83];

²Cost-effectives depend upon a number of factors namely learning curve and post operative morbidity. However, as multiple staplers are used for construction of most colonic/rectal anastomosis, there might be a cost advantage for compression devices. BAR: Biofragmentable anastomotic ring; CAC: Compression anastomotic clip.

Table 2 Compression anastomosis: clinical experience and complications

Study	Device	Emergency/elective	Anastomotic leakage	Obstruction	Stricture
Bubrick et al[34]	BAR	0/395	12 (3.2%)	18 (5%)	-
Cahill et al[35]	BAR	0/101	2 (2%)	4 (4%)	-
Corman et al[36]	BAR	0/222	6 (2.7%)	9 (4%)	2 (0.9%)
Gullichsen et al[37]	BAR	-	-	13 (16%)	-
Seow-Choen et al[39]	BAR	-	0	0	2 (10%)
Di Castro et al[49]	BAR	90/424	17	0	4 (1%)
Thiede et al[33]	BAR	0/1360	34 (2.5%)	-	-
Pahlman et al[38]	BAR	24/26	2 (4%)	3 (6%)	-
Ghitulescu et al[53]	BAR	23/136	7 (4.2%)	13 (7.9%)	3 (1.8%)
Kim et al[45]	BAR	101/515	5 (0.8%)	13 (2.1%)	1 (0.5%)
Wullstein et al[40]	AKA-2	70/372	11 (2.5%)	-	2 (0.5%)
Nudelman et al[43]	CAC	0/5	0	0	0
Nudelman et al[42]	CAC	0/30	0	0	0
Nudelamn et al[44]	CAC	0/10	0	0	0
Liu et al[59]	CAC	0/33	0	0	0

Table 3 List of reinforcement materials[64]

	Material	Stapler type	Company
Non-absorbable	ePTFE	Linear	W.L. Gore, Elkton, MD, USA
Semi-absorbable	Bovine pericardium (peristrips dry)	Circular linear	Synovis Life Technologies, Inc.
	Porcine small bowel (surgisis)	Linear	Cook Biotech Inc.
Absorbable	Polyglycolic acid:trimethylene carbonate (seamguard bioabsorbable)	Linear circular	W.L. Gore & Associates, Inc.
	Cellulose (Xcell)	Linear	Xylos Corp.
	Knitted calcium alginate (foreseal)	Linear	Laboratoires Brothier, Nanterre, France