Surgical Treatment for Crohn's Disease: A Role of Kono-S Anastomosis in the West

AbstractMore than 80% of patients with Crohn's disease (CD) will require surgical intervention during their lifetime, with high rates of anastomotic recurrence and stenosis necessitating repeat surgery. Current data show that pharmacotherapy has not significantly improved the natural history of postoperative clinical and surgical recurrence of CD. In 2003, antimesenteric hand-sewn functional end-to-end (Kono-S) anastomosis was first performed in Japan. This technique has yielded very desirable outcomes in terms of reducing the incidence of anastomotic surgical recurrence. The most recent follow-up of these patients showed that very few had developed surgical recurrence. This new approach is superior to stapled functional end-to-end anastomosis because the stumps are sutured together to create a stabilizing structure (a “supporting column”), serving as a supportive backbone of the anastomosis to help prevent distortion of the anastomotic lumen due to disease recurrence and subsequent clinical symptoms. This technique requires careful mesenteric excision for optimal preservation of the blood supply and innervation. It also results in a very wide anastomotic lumen on the antimesenteric side. The Kono-S technique has shown efficacy in preventing surgical recurrence and the potential to become the new standard of care for intestinal CD.

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Ex vivo model for a new bilateral antimesenteric V-modified side-to-side isoperistaltic anastomosis to prevent recurrence in ileocolic Crohn’s disease

Annals of The Royal College of Surgeons of England ◽

10.1308/rcsann.2019.0026 ◽

2019 ◽

Vol 101 (5) ◽

pp. 313-317 ◽

Cited By ~ 1

Author(s):

V Celentano ◽

F Luvisetto ◽

S Toh

Keyword(s):

Crohn’S Disease ◽

Small Bowel ◽

Crohn's Disease ◽

Ex Vivo ◽

High Rate ◽

Ex Vivo Model ◽

Repeat Surgery ◽

Handsewn Anastomosis ◽

Surgical Recurrence ◽

Mesenteric Border

Introduction The high rate of recurrence following ileocaecal resection for Crohn’s disease may lead to repeat surgery in 20–30% of patients at five years after surgery. Recurrence usually occurs at the anastomosis and the neoterminal ileum and the association of a strictureplasty to widen the bowel lumen in the regions immediately proximal (‘anastomotic inlet’) and distal (‘anastomotic outlet’) to the anastomosis may delay or reduce the risk of surgical recurrence. Materials and methods A side to side isoperistaltic anastomosis, with an associated V-modified strictureplasty on the anti-mesenteric border at the level of the anastomosis inlet and outlet has been designed. We produced a wet lab ex vivo model of the anastomosis and, to evaluate the different calibre of the anastomotic segments, we compared it with ex vivo models of three anastomotic configurations currently used in surgery for Crohn’s disease: i) side to side isoperistaltic anastomosis; ii) modified side-to-side isoperistaltic anastomosis with double Heineke–Mikulicz procedure (Sasaki anastomosis); iii) anti-mesenteric functional end-to-end handsewn anastomosis (Kono-S anastomosis). Results Differences were recorded at the level of the anastomosis inlet and outlet, with a larger volume estimated in the Sasaki anastomosis and in the V-modified anastomosis. The V-modified anastomosis had a larger volume compared with the Sasaki anastomosis for a longer segment of small bowel. Conclusions We have developed an experimental animal model for a new anastomotic technique which could be applied in surgery for Crohn’s disease following small-bowel or ileocolic resection.

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804 The Role of Kono-S Anastomosis and Mesenteric Resection in Reducing Recurrence After Surgery for Crohn’s Disease: A Systematic Review

British Journal of Surgery ◽

10.1093/bjs/znab259.414 ◽

2021 ◽

Vol 108 (Supplement_6) ◽

Author(s):

A Alshantti

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Risk Of Bias ◽

Cochrane Library ◽

Level Of Evidence ◽

Poor Grade ◽

Randomized Controlled ◽

Surgical Recurrence ◽

Mesenteric Excision ◽

The Impact

Abstract Aim Recurrence after surgery for Crohn’s disease is common. Anastomotic configuration may influence recurrence and the mesentery may be key.The Kono-S anastomosis and radical mesenteric excision have been proposed as methods of reducing recurrence. We analysed the literature pertaining to these novel techniques. Method We searched MEDLINE, Embase and the Cochrane Library for, studies evaluating Kono-S anastomosis and/or radical mesenteric excision in Crohn’s disease. We assessed methodological quality and risk of bias using the Cochrane tool for randomized controlled trials and the JBI tool for nonrandomized trials. A narrative synthesis was used to summarize the findings. Results Nine studies (896 patients) were identified. Apart from one randomized controlled trial with a low risk of bias the overall level of evidence was poor (Grade IV). The Kono-S anastomosis was associated with a lower incidence of endoscopic and surgical recurrence (0%–3.4% vs 15%–24.4% respectively). Complications, particularly anastomotic leak rate, were also lower (1.8% vs 9.3% respectively). Evidence from a single poor-quality study suggested that mesenteric excision may reduce surgical recurrence rates compared with mesentery preservation. Conclusions The existing literature suggests that the Kono-S anastomosis is safe and may reduce endoscopic and surgical recurrence, but level of evidence is mainly poor. One element of the Kono-S technique, preservation of the mesentery, may be detrimental to recurrence. Further, higher quality, studies are required to investigate these techniques. Such studies should consider the impact of the degree of mesenteric resection in addition to the anastomosis on disease recurrence.

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Surgical Recurrence at Anastomotic Site After Bowel Resection in Crohn’s Disease: Comparison of Kono-S and End-to-end Anastomosis

Journal of Gastrointestinal Surgery ◽

10.1007/s11605-018-4012-6 ◽

2018 ◽

Vol 23 (2) ◽

pp. 312-319 ◽

Cited By ~ 16

Author(s):

Norimitsu Shimada ◽

Hiroki Ohge ◽

Toru Kono ◽

Ayumu Sugitani ◽

Raita Yano ◽

...

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Bowel Resection ◽

Anastomotic Site ◽

Surgical Recurrence ◽

End To End

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A Warning About the Role of Extended Mesenteric Excision in Crohn’s Disease Recurrence

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjz097 ◽

2019 ◽

Vol 13 (12) ◽

pp. 1583-1583

Author(s):

Paola Caprino ◽

Franco Sacchett ◽

Luigi Sofo

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Disease Recurrence ◽

Mesenteric Excision

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Novel Antimesenteric Functional End-to-End Handsewn (Kono-S) Anastomoses for Crohn's Disease: A Report of Surgical Procedure and Short-Term Outcomes

Digestive Surgery ◽

10.1159/000371857 ◽

2015 ◽

Vol 32 (1) ◽

pp. 39-44 ◽

Cited By ~ 19

Author(s):

Hidetoshi Katsuno ◽

Koutarou Maeda ◽

Tsunekazu Hanai ◽

Koji Masumori ◽

Yoshikazu Koide ◽

...

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Linear Stapler ◽

Long Term Outcomes ◽

First Case ◽

Surgical Recurrence ◽

Bowel Continuity ◽

End To End

Introduction: Anastomotic surgical recurrence after bowel resection is a major problem in patients with Crohn's disease. The aim of this prospective observational study was to evaluate the efficacy of a novel technique for restoring bowel continuity after resection involving either the small or the large intestine. Methods: The first case was instructed by Dr. Kono at Fujita Health University. The involved bowel segment was divided transversely with a linear stapler. The edges of two stapled lines are then connected to create a supporting column, which prevented surgical recurrence from anastomotic distortion due to mesenteric longitudinal ulcers. Thereafter, an antimesenteric longitudinal enterotomy was performed on each side to create a large-sized handsewn end-to-end anastomosis. Results: Thirty consecutive patients underwent Kono-S anastomoses from December 2009 to August 2013. Neither anastomotic leakage nor surgical recurrence was observed during a median follow-up period of 35 months. Endoscopic surveillance was performed in 18 cases (69.2%) undergoing ileo-colonic or ileo-rectal anastomosis with an average Rutgeert's score of 0.78 (0-3) at a mean of 14.5 months postoperatively. Conclusion: The Kono-S anastomosis for Crohn's disease has been a safe and feasible technique. Long-term outcomes are required to confirm its advantage in preventing surgical recurrence at the anastomosis.

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Montreal classification of patient operated for Crohn's disease and identification of surgical recurrence predictors

Revista do Colégio Brasileiro de Cirurgiões ◽

10.1590/0100-69912015002006 ◽

2015 ◽

Vol 42 (2) ◽

pp. 97-104 ◽

Cited By ~ 5

Author(s):

Cristiane de Souza Bechara ◽

Antonio Lacerda Filho ◽

Maria de Lourdes Abreu Ferrari ◽

Déborah Almeida Roquette Andrade ◽

Magda Maria Profeta da Luz ◽

...

Keyword(s):

Crohn’S Disease ◽

Retrospective Study ◽

Surgical Treatment ◽

Crohn's Disease ◽

Median Time ◽

Disease Recurrence ◽

Surgical Recurrence ◽

Increased Risk

OBJECTIVE: to evaluate Crohn's disease recurrence and its possible predictors in patients undergoing surgical treatment. METHODS: We conducted a retrospective study with Crohn's disease (CD) patients undergoing surgical treatment between January 1992 and January 2012, and regularly monitored at the Bowel Clinic of the Hospital das Clínicas of the UFMG. RESULTS: we evaluated 125 patients, 50.4% female, with a mean age of 46.12 years, the majority (63.2%) diagnosed between 17 and 40 years of age. The ileum was involved in 58.4%, whereas stenotic behavior was observed in 44.8%, and penetrating, in 45.6%. We observed perianal disease in 26.4% of cases. The follow-up average was 152.40 months. Surgical relapse occurred in 29.6%, with a median time of 68 months from the first operation. CONCLUSION: The ileocolic location, penetrating behavior and perianal involvement (L3B3p) were associated with increased risk of surgical recurrence.

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P215 The effect of resection margin involvement of Crohn’s disease on the surgical and clinical recurrence after intestinal surgery

Journal of Crohn s and Colitis ◽

10.1093/ecco-jcc/jjz203.344 ◽

2020 ◽

Vol 14 (Supplement_1) ◽

pp. S249-S249

Author(s):

J H Seo ◽

J L Lee

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Confidence Interval ◽

Resection Margin ◽

Intestinal Surgery ◽

Repeat Surgery ◽

Clinical Recurrence ◽

Margin Involvement ◽

Surgical Recurrence ◽

Increased Risk

Abstract Background Approximately 80% of patients with Crohn’s disease (CD) require major intestinal surgery during their lifetime and a quarter of patients will undergo repeat surgery within 5 years of the index surgery. For this reason, operative treatment of CD has been the bowel-sparing approach for several decades. This study evaluated the effects of the Crohn’s disease involvement of resection margin on clinical and surgical recurrence. Methods This retrospective study analysed 803 patient who underwent intestinal surgery for CD between January 2006 and December 2015. The CD involvement of resection margin was defined as microscopic involvement from the pathologic reports and grossly involvement from the operative records. Anastomosis recurrence was reviewed using the operative records and radiologic findings including colonoscopy, computed tomography and magnetic resonance imaging. Results In total, 41 patients (5.1%) had an active CD in the bowel resection margin – 31 patients (3.9%) with histologically, 10 patients (1.2%) with grossly. We had 221 (26.8%) reoperation cases, of which 87 (10.6%) patients were an anastomotic recurrence. When patients were stratified by surgical recurrence at anastomosis, the increased risk was not significant in resection margin positive grossly (odds ratio [OR], 3.65; 95% confidence interval [CI], 0.93–14.41) and in microscopic (OR, 1.26; 95% CI, 0.43–3.70) comparing with negative resection margin. Also, resection margin involvement was not related with clinical recurrence grossly (OR, 0.30; 95% confidence interval [CI], 0.07–1.26) and in microscopic (OR, 0.50; 95% CI, 0.21–1.17) Conclusion The current practice suggests the CD involvement of resection margin, even grossly or microscopic, do not influence surgical and clinical recurrence.

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Surgical Strategies to Reduce Postoperative Recurrence of Crohn's Disease After Ileocolic Resection

Frontiers in Surgery ◽

10.3389/fsurg.2021.804137 ◽

2021 ◽

Vol 8 ◽

Author(s):

Ian S. Reynolds ◽

Katie L. Doogan ◽

Éanna J. Ryan ◽

Daniel Hechtl ◽

Frederik P. Lecot ◽

...

Keyword(s):

Crohn’S Disease ◽

Crohn's Disease ◽

Surgical Techniques ◽

Disease Recurrence ◽

Postoperative Recurrence ◽

Recurrence Rates ◽

Modifiable Factors ◽

Mesenteric Excision ◽

Resection And Anastomosis ◽

Symptom Recurrence

Postoperative recurrence after ileocaecal resection for fibrostenotic terminal ileal Crohn's disease is a significant issue for patients as it can result in symptom recurrence and requirement for further surgery. There are very few modifiable factors, aside from smoking cessation, that can reduce the risk of postoperative recurrence. Until relatively recently, the surgical technique used for resection and anastomosis had little or no impact on postoperative recurrence rates. Novel surgical techniques such as the Kono-S anastomosis and extended mesenteric excision have shown promise as ways to reduce postoperative recurrence rates. This manuscript will review and discuss the evidence regarding a range of surgical techniques and their potential role in reducing disease recurrence. Some of the techniques have been shown to be associated with significant benefits for patients and have already been integrated into the routine clinical practice of some surgeons, while other techniques remain under investigation. Current techniques such as resection of the mesentery close to the intestine and stapled side to side anastomosis are being challenged. It is looking more likely that surgeons will have a major role to play when it comes to reducing recurrence rates for patients undergoing ileocaecal resection for Crohn's disease.

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