See discussions, stats, and author profiles for this publication at: [Link]

net/publication/287968739

Kono-S Anastomosis for Surgical Prophylaxis of Anastomotic Recurrence in

Crohn’s Disease: an International Multicenter Study

Article in Journal of Gastrointestinal Surgery · December 2015

DOI: 10.1007/s11605-015-3061-3

CITATIONS READS

138 3,076

8 authors, including:

Toru Kono Alessandro Fichera

Asahikawa Medical University University of Washington
300 PUBLICATIONS 4,376 CITATIONS 197 PUBLICATIONS 7,256 CITATIONS

SEE PROFILE SEE PROFILE

Koutarou Maeda Mikihiro Fujiya

Fujita Health University Asahikawa Medical University
248 PUBLICATIONS 3,218 CITATIONS 441 PUBLICATIONS 11,841 CITATIONS

SEE PROFILE SEE PROFILE

All content following this page was uploaded by Toru Kono on 08 February 2016.

The user has requested enhancement of the downloaded file.

Kono-S Anastomosis for Surgical
Prophylaxis of Anastomotic Recurrence
in Crohn’s Disease: an International
Multicenter Study

Toru Kono, Alessandro Fichera,

Koutarou Maeda, Yoshiharu Sakai,
Hiroki Ohge, Mukta Krane, Hidetoshi
Katsuno & Mikihiro Fujiya
Journal of Gastrointestinal Surgery

ISSN 1091-255X

J Gastrointest Surg
DOI 10.1007/s11605-015-3061-3

1 23
Your article is protected by copyright and all
rights are held exclusively by The Society for
Surgery of the Alimentary Tract. This e-offprint
is for personal use only and shall not be self-
archived in electronic repositories. If you wish
to self-archive your article, please use the
accepted manuscript version for posting on
your own website. You may further deposit
the accepted manuscript version in any
repository, provided it is only made publicly
available 12 months after official publication
or later and provided acknowledgement is
given to the original source of publication
and a link is inserted to the published article
on Springer's website. The link must be
accompanied by the following text: "The final
publication is available at [Link]”.

1 23
 Author's personal copy
J Gastrointest Surg
DOI 10.1007/s11605-015-3061-3

ORIGINAL ARTICLE

Kono-S Anastomosis for Surgical Prophylaxis of Anastomotic

Recurrence in Crohn’s Disease: an International
Multicenter Study
Toru Kono 1 & Alessandro Fichera 2 & Koutarou Maeda 3 & Yoshiharu Sakai 4 &
Hiroki Ohge 5 & Mukta Krane 2 & Hidetoshi Katsuno 3 & Mikihiro Fujiya 6

Received: 8 September 2015 / Accepted: 10 December 2015

# 2015 The Society for Surgery of the Alimentary Tract

Abstract
Introduction The Kono-S (antimesenteric functional end-to-end handsewn) anastomosis has been used for Crohn’s disease in
Japan and the USA since 2003 and 2010, respectively. This technique was designed to reduce the risk of anastomotic surgical
recurrence. This study reviews the outcomes a decade after the introduction of the Kono-S anastomosis to clinical practice.
Methods This study was conducted at five hospitals (four in Japan and one in the USA). A total of 187 patients in Japan (144
patients, group J) and the USA (43 patients, group US) who underwent Kono-S anastomosis for Crohn’s disease between
September 2003 and September 2011 were included.
Results With a median follow-up of 65 months, two surgical anastomotic recurrences have occurred in group J. Kaplan–Meier
analysis showed that 5 and 10 years surgical recurrence-free survival rate was 98.6 % in group J. No surgical anastomotic
recurrences have been detected in group US with a median follow-up of 32 months. The Kono-S anastomosis was technically
feasible and performed in all patients.
Conclusion The Kono-S anastomosis appears to be safe and effective in reducing the risk of surgical recurrence in Crohn’s disease.

Keywords Crohn’s disease . Kono-S anastomosis . Surgical Introduction

recurrence
The cumulative risk of surgical intervention in patients with
Crohn’s disease (CD) within 10 years of diagnosis is estimated
at 50 %, with high rates of anastomotic recurrence and steno-
sis necessitating repeat surgery.1 After resection, the recur-
* Toru Kono
kono@[Link]
rence rate at the anastomotic site ranges from 35 to 85 %
during the first year, with surgical recurrence as high as
–
50 % at 20 years.2 4 To date, there are no surgical strategies
,
1 proven to prevent recurrences requiring further surgery.2 5
Advanced Surgery Center, Sapporo Higashi Tokushukai Hospital,
3-1, N 33, E 14, Higashi-ku, Sapporo, Hokkaido 065-0033, Japan In September 2003, Kono and colleagues at the Asahikawa
2 Medical University Hospital in Japan introduced to clinical
Division of General Surgery, Department of Surgery, University of
Washington Medical Center, Seattle, WA, USA practice their unique surgical technique to reduce the risk of
3 anastomotic surgical recurrence (Kono-S anastomosis) in pa-
Department of Surgery, Fujita Health University, School of
Medicine, Toyoake, Aichi, Japan tients with CD involving either the small or large bowel.6
4 Their approach has subsequently been adopted at several other
Department of Surgery, Graduate School of Medicine, Kyoto
University, Kyoto, Japan medical institutions in Japan.7 In May 2010, this anastomotic
5 procedure was introduced at the University of Chicago and
Department of Infectious Diseases, Hiroshima University Hospital, ,

Hiroshima, Japan subsequently at the University of Washington.5 8

6 The purpose of this study was to investigate the short-term
Division of Gastroenterology and Hematology/Oncology,
Department of Medicine, Asahikawa Medical University, and long-term outcomes, complications, and endoscopic sur-
Asahikawa, Japan veillance findings after Kono-S anastomosis.
 Author's personal copy
J Gastrointest Surg

Materials and Methods significantly, the sutures should be spaced to evenly distribute
the surplus tissue of the larger segment, in order to achieve
From September 2003 to September 2011, a total of 187 con- good approximation and stable support for the anastomosis.
secutive patients, 144 in Japan and 43 in the USA, underwent To create the anastomosis, an antimesenteric longitudinal
Kono-S anastomosis after resection of either small or large enterotomy (or colostomy) is performed on each stump
bowel for CD at the Asahikawa Medical University Hospital (Fig. 3a), to allow a transverse lumen of 7 cm in diameter
(89 patients), Fujita Health University Hospital (17 patients), for the small bowel or closer to 8 cm for the colon, starting
Hiroshima University Hospital (29 patients), Kyoto Universi- no more than 1 cm but no less than 0.5 cm away from the
ty Hospital (9 patients), and University of Chicago Medical supporting column (Fig. 3b). Since the mesentery is divided
Center (43 patients). very close to the intestinal wall, the mesenteric defect is typ-
The medical records of all patients were retrieved. Endo- ically minimal and closure of the mesentery is usually not
scopic surveillance was scheduled postoperatively and annu- necessary.
ally thereafter by gastroenterologists. The endoscopic recur- Next, the longitudinal opening is closed transversely either
rence scoring system developed by Rutgeerts et al. was used:9 in a single layer in the Gambee manner or in two layers with
i0, no lesions; i1, five or fewer aphthous lesions; i2, more than running and interrupted sutures (Fig. 3c and d). This results in
five aphthous lesions with normal mucosa between the lesions a large anastomosis (Fig. 4). Moreover, the supporting column
or skipped areas of the larger lesions, or lesions confined to the is located immediately behind the posterior wall of the anas-
ileocolonic anastomosis; i3, diffuse aphthous ileitis with dif- tomosis (Fig. 4), providing a rigid and stable support to pre-
fusely inflamed mucosa; and i4, diffuse inflammation with vent mechanical deformation and functional constriction of
large ulcers, nodules, or narrowing. the lumen of the anastomosis.
Surgical recurrence was defined as reoperation with resec-
tion for recurrent anastomotic disease at the Kono-S anasto-
Statistical Analysis
motic site. Operation for CD at separate sites was not consid-
ered surgical recurrence.
Quantitative data are presented as medians. The range is given
when appropriate. Data were analyzed based on the intention-
Kono-S Anastomosis
to-treat principle. Statistical analysis was performed using the
GraphPad Prism 4 statistics program (GraphPad Software,
A standard Kono-S anastomosis procedure was adopted at the
San Diego, CA, USA). The Mann–Whitney U test was used
First International Consensus Conference on Kono-S Anasto-
to compare quantitative variables between the two groups.
mosis held in Kyoto, Japan, in September 201110 The Kono-S
The chi-square test with Yates’ correction or Fisher’s exact
anastomosis can be used for small or large bowel and with
test was used to compare categorical variables. Surgical recur-
laparoscopy using the extraction site or as an open procedure.
rence data were analyzed using survival analysis methods. In
Since a difference in the caliber of the intestinal segments does
this study, the surgical recurrence rate was defined as the cu-
not represent an impediment to the creation of this anastomo-
mulative proportion of patients remaining on surgical treat-
sis, the technique has also been employed in the emergency
ment at a given time point throughout the follow-up period.
setting for obstructive lesions with dilation of the proximal
The Kaplan–Meier method was used to assess surgical recur-
loop. To date, we have not identified an absolute contraindi-
rence rates. p < 0.05 was considered to indicate statistical
cation to performing the Kono-S anastomosis. No special
significance.
equipment is required.
After the bowel and the corresponding mesentery have
been mobilized, a small window in the mesentery is created
at the level of the proximal and distal resection margins. The Results
mesentery is divided using a tissue-sealing device close to the
intestinal wall to preserve vascularization and innervation, es- A total of 171 Kono-S anastomosis procedures have been
pecially at the proximal and distal resection margins (Fig. 1a). performed in 144 patients at four Japanese academic hospi-
The bowel is then divided transversely by placing a linear tals between September 2003 and September 2011 with a
stapler perpendicular to the intestinal lumen and the mesen- median age at surgery of 31 years, including 34 women
tery, exactly 90° opposite to a conventional procedure, so that (24 %). In the USA, a total of 45 Kono-S anastomosis
the mesentery is located in the middle of the staple lines procedures have been performed in 43 patients at the Uni-
(Fig. 1b and c). The corners of the two staple lines are rein- versity of Chicago between May 2010 to September 2011,
forced (Fig. 2a and b), and the two stumps are approximated including 22 women (51 %) with a median age at surgery of
using 5–7 sutures to create the Bsupporting column^ (Fig. 2c, 32 years. The surgical procedures were successfully per-
d). If the caliber of the two intestinal segments differs formed in all patients.
 Author's personal copy
J Gastrointest Surg

Fig. 1 Mesentery and bowel a

division. a The mesentery is
divided using a tissue sealing
device very close to the intestinal
wall to preserve vascularization
and innervation (red dotted line).
b The bowel is divided
transversely with a linear stapler
perpendicular to the axis of the
mesentery, exactly ninety degrees
opposite to a conventional
procedure (c) so that the b c
mesentery is located in the middle
of the staple line

Tables 1 and 2 show the demographic and clinical out- In group J, strictureplasty was simultaneously carried out at
come data of the patients undergoing Kono-S anastomosis 27 cases (19 %) and 52 sites (Table 1). In group US,
at four Japanese academic hospitals (group J) and in the strictureplasty was performed only in one case (2 %).
USA (group US). There were significant differences be-
tween group J and group US in terms of gender distribu- Factors Influencing Postoperative Recurrence
tion and the site of anastomosis (Table 1). In both groups,
the most common site of anastomosis was the ileocolic. Both groups were comparable in terms of the factors influenc-
Compared to group J, there were fewer small bowel-to- ing postoperative recurrence, such as postoperative smoking
small bowel Kono-S anastomoses in group US. status, proportion of patients who had previous bowel surgery

a c

b d

Supporting column

Fig. 2 Creation of the supporting column. a and b The corners of the two stapled lines are imbricated and reinforced. c and d The two stumps are
approximated using 5–7 stitches to create the Bsupporting column^
 Author's personal copy
J Gastrointest Surg

a c

b d

Fig. 3 Creation of the anastomosis. a An antimesenteric longitudinal 8 cm on the colon (red arrow line) c Posterior wall; d Anterior wall: The
enterotomy (or colostomy) is performed on each stump, starting no anastomosis is now performed by closing the longitudinal opening
more than 1 cm but no less than 0.5 cm away from the supporting transversely in either a single-layer Gambee manner or two layers, with
column. b A transverse lumen of 7 cm on the small bowel or closer to running and interrupted sutures

for CD, proportion of CD patients with perforation, and post- abscess, and one patient with ileus) (Table 2). In the Japanese
operative anti-TNFα therapy. patient with the duodenal ulcer, perforation occurred 2 days
after surgery and a simple omental patch closure procedure
Short-Term Complications was performed. All of the other patients recovered with con-
servative therapy.
Postoperatively, there was 1 patient in each group who devel-
oped a contained anastomotic leak that resolved with conser-
vative treatment. Other postoperative complications devel- Long-Term Outcomes
oped in ten patients (7 %) in group J (eight surgical site infec-
tion, four intra-abdominal abscess, three patients with ileus, The median follow-up duration was 65 months (range, 43–
one perianal abscess, one cholecystitis, and one patient who 138 months) in group J and 32 months (range, 12–44 months)
developed a perforated duodenal ulcer) and four patients (9 %) in group US (Table 2). In group US, 14 patients (32 %) were
in group US (two surgical site infection, one intra-abdominal lost to follow-up after their original postoperative visit.

Fig. 4 Kono-S anastomosis. The

supporting column is located
immediately behind the posterior
wall of the anastomosis. The
supporting column provides
stable support that will prevent
mechanical deformation and
functional constriction of the
lumen of the anastomosis

Supporting column
 Author's personal copy
J Gastrointest Surg

Table 1 Characteristics of 187 CD patients who underwent Kono-S anastomosis in Japan (group J) or the USA (group US) with data available for
clinical outcome analysis

Group J Group US p value Cumulative

experience

Number of patients 144 43 187

Male/female ratio 110/34 (3:1) 21/22 (1:1) p = 0.0006 131/56 (2:1)
Median age at operation (months), (range) 31 (19–62) 32 (17–58) NS 31 (17–62)
Site of anastomosis (n), (%) 171 45 p = 0.005 216
Ileocolic 93 (54 %) 38 (84 %) 131 (61 %)
Ileal/jejunal 65 (38 %) 5 (11 %) 70 (32 %)
Colonic 8 (5 %) 1 (2 %) 9 (4 %)
Ileorectal 5 (3 %) 1 (2 %) 6 (3 %)
Number of Kono-S anastomosis/patient (n), (%)
1 113 (78 %) 41 (95 %) 154 (82 %)
2 27 (19 %) 2 (5 %) 29 (16 %)
3 3 (2 %) 0 (0 %) 3 (2 %)
4 1 (1 %) 0 (0 %) 1 (1 %)
Number of simultaneous strictureplasty (n), (%) 27 (19 %) 1 (2 %) p = 0.01 28 (15 %)
Number of strictureplasty 52 1 67 (35 %)
Site of strictureplasty (small bowel/large bowel) 52/0 1/0 53/0
Factors influencing postoperative recurrence
Active smoking (ratio), (%) 35/135 (26 %) 12/36 (33 %) NS 47/171 (27 %)
Previous bowel operation (n), (%) 64 (43 %) 22 (51 %) NS 86 (46 %)
Perforation type (n), (%) 66 (45 %) 18 (45 %) NS 84 (45 %)
Postoperative medication (n), (%)
Anti-TNFα antibody 55 (37 %) 12 (28 %) NS 67 (36 %)
Short-term complications (<30 days)
Anastomotic leakage, (n) (%) 1 (0.7 %) 1 (2.3 %) NS 2 (1.1 %)
Surgical site infection, (n) (%) 8 (5.6 %) 2 (4.7 %) NS 10 (5.3 %)
Abdominal abscess, (n) (%) 4 (2.8 %) 1 (2.3 %) NS 5 (2.7 %)
Bowel obstruction, (n) (%) 3 (2.1 %) 1 (2.3 %) NS 4 (2.1 %)
Other, (n) (%) 3 (2.1 %) 0 (0 %) 3 (1.6 %)
Mortality 0 0 NS 0

Group J: patients from 4 Japanese academic hospitals from September 2003 to September 2011
US: patients from University of Chicago between May 2010 to September 2011
NS not significant

At 5 years after surgery, 30 patients who underwent follow- group J (Table 2). The 5-year cumulative surgical recurrence
up colonoscopy in group J had a median Rutgeerts score of rate was 1.7 % (95 % CI, 0–4.2 %), and the 10-year cumula-
i3.0 (range, i1–i4). In group US, a total of 18 patients tive surgical recurrence rate was also 1.7 % (95 % CI, 0–
underwent surveillance endoscopy at a median of 6 months 4.2 %) in cumulative experience (Table 2).
(range, 3–12 months). The median Rutgeerts score was i1.0 Surgical recurrence after bowel resection occurred only
(range, i0–i3). in two Japanese patients, both women, one during preg-
Kaplan–Meier graph for surgical recurrence-free survival is nancy. She presented with multiple strictures of the ileum
shown in Figure 5. The 5-year surgical recurrence-free rate and colon and underwent right colectomy and partial ileal
was 98.6 %, and the 10-year surgical recurrence-free rate resection with two Kono-S anastomoses and ileal
was also 98.6 % in group J. In the US group, no surgical strictureplasty 5 years prior. Her postoperative period
recurrence has occurred during the follow-up period of was uneventful. She was treated with mesalazine, azathi-
32 months. The 5-year cumulative surgical recurrence rate oprine, and infliximab postoperatively. However, when
was 1.8 % (95 % CI, 0–4.3 %), and the 10-year cumulative she was pregnant at 12 weeks of gestation, infliximab
surgical recurrence rate was also 1.8 % (95 % CI, 0–4.3 %) in and azathioprine were stopped and she was maintained
 Author's personal copy
J Gastrointest Surg

Table 2 Anastomotic recurrence after Kono-S anastomosis in Japan (Group J) or the USA (group US)

Group J (n = 144) Group US (n = 29) p value Cumulative

Experience (n = 173)

Median follow-up (months), (range) 65 (43–138) 32 (12–44) p = 0.003 60 (12–138)

Endoscopic recurrence i3.0 (i1–i4) i3.0 (i1–i4)
Rutgeert’s score, median (range) at 5 years, (n) (30) NA (30)
Number of surgical recurrence 2 0 2
5 years cumulative surgical recurrence, (95 % CI) 1.8 % (0.0–4.3 %) NA 1.7 % (0.0–4.2 %)
10 years cumulative surgical recurrence, (95 % CI) 1.8 % (0.0–4.3 %) NA 1.7 % (0.0–4.2 %)

Group J: patients from 4 Japanese academic hospitals from September 2003 to September 2011
US: patients from University of Chicago between May 2010 to September 2011
NA not available

on mesalazine only. Before the patient gave birth, surgical the armamentarium of surgeons dealing with luminal CD;
, ,
recurrence at the ileocolic anastomotic site occurred. lately this approach has been utilized in the USA as well.5 7 8
The other patient with surgical recurrence was a 36-year- The procedure is associated with very low mortality and
old woman with CD and multiple strictures in the ileum and morbidity. Traditionally, surgeons were concerned that a long
colon. She underwent subtotal colectomy with ileorectal anastomotic suture line may lead to higher postoperative mor-
Kono-S anastomosis and ileal strictureplasty 2 years prior. bidity and disease recurrence rates. These concerns have not
She was treated with mesalazine and azathioprine, but not been substantiated by short-term safety data for the Kono-S
–
infliximab. Surgical recurrence occurred at the ileorectal anas- anastomosis.6 8 The present study on the international multi-
tomosis site and the strictureplasty of the ileorectal anastomo- center experience with the Kono-S anastomosis offers addi-
sis was performed. tional short-term and long-term safety data and preliminary
short-term surgical recurrence rates.
The natural history of postoperative CD is that endoscopic
recurrence occurs very often at the anastomotic site after bow-
Discussion el resection, which then develops into clinical recurrence and
eventually severe complications (i.e., stenosis) requiring fur-
,
Adoption of the Kono-S anastomosis to treat luminal CD has ther surgery.4 11
steadily increased since its original description by the princi- In patients treated with bowel resection and anastomosis,
pal author.6 The procedure has now gained a defined place in endoscopic recurrence has been reported in more than 50 % of

Fig. 5 Surgical recurrence rates

after undergoing a Kono-S anas-
tomosis. Surgical recurrence rates
after undergoing a Kono-S anas-
tomosis in four Japanese Univer-
sity Hospitals (n = 144) (a) or the
University of Chicago Medical
Center (n = 29) (b), or the cumu-
lative experiences (n = 173).
Kaplan–Meyer survival curves
demonstrating the percentage of
patients remaining free of surgical
CD recurrence at the anastomosis
during follow-up
 Author's personal copy
J Gastrointest Surg

patients at 5 years and 20 to 30 % of surgical patients required recurrence at the anastomotic site.23 Recently, several studies
,
a second surgery within 5 years.3 4 Despite recent pharmaco- have suggested that clinical and surgical recurrence were as-
logical advances, there are currently no drugs that can either sociated with the presence of myenteric plexitis at the proxi-
,
alleviate fixed stenotic lesions or significantly improve the mal resection margin.24 25 Therefore, when mobilizing the
–
natural history of CD.12 15 Although preventing nearly ubiq- mesentery we divide it as close as possible to the bowel wall
uitous postoperative anastomotic site recurrence is an impor- in order to avoid any unnecessary denervation or
tant issue, no surgical strategies have been developed to pre- devascularization. A future direction of our research is to dem-
,
vent postoperative anastomotic surgical recurrence.2 5 onstrate the preservation of blood supply and innervation at
This article highlights data on the Kono-S anastomosis; the anastomotic site in CD patients with the Kono-S
there is a 5- and 10-year surgical recurrence-free survival rate technique.
of 98.6 % across all centers in Japan. In the USA, while with Unfortunately, surgery for CD is rarely curative. Most pa-
shorter follow-up and a limited number of patients that have tients will develop endoscopic and clinical recurrence at the
undergone colonoscopy to date, no surgical recurrence have anastomosis site. In population-based cohort studies, endo-
been recorded. Based on these preliminary results, we have scopic recurrence has been reported in 54 % of patients at
opened a randomized trial in the USA across three institutions 5 years.4 Clinical recurrence follows endoscopic recurrence
to provide prospective conclusive data. One explanation of and has been reported in up to 28 to 45 % of patients by
these results might be that the creation of a supporting column 5 years. Our previous single-center study from Japan showed
that maintains the diameter of the anastomosis prevents dis- that the mean endoscopic recurrence score (Rutgeerts’ score)
tortion and stenosis associated with recurrent disease at the was i2.6 at 5 years after Kono-S anastomosis, which was
anastomotic site, especially on the mesenteric side. The mes- significantly lower than that in patients after undergoing con-
enteric side of the intestine is the initial site of macroscopic ventional anastomosis procedures (i3.4).6 The present data
anastomotic recurrence. In the Kono-S anastomosis, this side (i3.0) from multiple centers in Japan is consistent with the
is positioned in the center of the posterior wall of the anasto- pervious score (i2.6), suggesting reproducibility, although
mosis, with the supporting column fixing it in position, rein- the study was retrospective. A prospective, randomized, mul-
forcing the central portion of the posterior wall suture line ticenter study is currently underway internationally.5
from the outside. Therefore, even if macroscopic recurrence Various pharmacologic strategies have been investigated to
starts on the mesenteric side of anastomosis, the supporting decrease the risk of postoperative recurrence of CD. A recent
column can prevent distortion of the lumen of the anastomo- meta-analysis demonstrated that anti-TNF therapy appears to
sis. In contrast, previous surgical prophylaxis strategies did be the most effective strategy for postoperative prophylaxis of
,
not take into account the characteristic recurrence behavior CD recurrence.12 26 In our study, 65 % of patients did not
at the anastomosis site. develop surgical recurrence after bowel resection even though
Another advantage of the Kono-S anastomosis could be they were not on anti-TNF therapy, with a median follow-up
related to the shape of the anastomosis, being fashioned like of 60 months (range, 12–138). While the role of anti-TNF
a trumpet. Therefore, the Kono-S anastomosis is a functional therapy after surgical resection remains to be proven, Kono-
end-to-end anastomosis. This may contribute to successful S anastomosis should be strongly considered in CD patients
postoperative endoscopic observation and treatment (i.e., bal- who are not candidates for anti-TNF therapy due to adverse
loon dilatation). In addition, techniques involving stapling, effects, loss of efficacy, or financial reasons.
which create uniform lumen sizes, are less flexible; they have Finally, this study has some notable limitations, primarily
a higher incidence of anastomotic bleeding, and overactive the fact that it is a non-randomized retrospective study with a
–
inflammatory responses have been reported.16 18 These disad- relatively small sample size and the shorter follow-up of the
vantages warn against the indiscriminate use of stapling tech- US group. However, we are actively evaluating this anasto-
niques. Thus, the Kono-S anastomosis for intestinal anasto- motic technique prospectively at multiple centers to better
mosis in CD uses handsewn techniques. assess its long-term efficacy.
The theoretical advantages of the Kono-S anastomosis in-
clude the preservation of innervation as well as the blood
supply, both important factors in the proper healing of the Conclusion
anastomosis. Blood flow to the intestine is reportedly de-
creased by more than 50 % in patients with CD because of The Kono-S anastomosis is a safe and feasible anastomotic
neuronal peptide vasodilator (calcitonin gene-related peptide) technique applicable to both the small and large intestines.
depletion observed in CD patients and animal models, al- Preliminary results suggest low rates of surgical recurrence.
though it remains unclear whether changes in the enteric ner- A prospective randomized trial is underway to prove that the
vous system are the cause or are secondary to Kono-S anastomosis should be considered an option to reduce
–
inflammation.19 22 Decreased blood flow is associated with surgical recurrence rates at the anastomotic site after resection.
 Author's personal copy
J Gastrointest Surg

Compliance with Ethical Standards This retrospective study protocol 13. Limketkai BN, Bayless TM. Editorial: can stenosis in ileal Crohn’s
was approved by the local ethics board of each participating institution. disease be prevented by current therapy? Am J Gastroenterol
2013;108:1755–1756.
14. Cosnes J, Bourrier A, Laharie D, et al. Early administration of
azathioprine vs conventional management of Crohn’s Disease: a
References randomized controlled trial. Gastroenterology 2013;145:758–765
e752; quiz e714-755.
1. Frolkis AD, Dykeman J, Negron ME, et al. Risk of surgery for 15. Vuitton L, Koch S, Peyrin-Biroulet L. Preventing postoperative
inflammatory bowel diseases has decreased over time: a systematic recurrence in Crohn’s disease: what does the future hold? Drugs
review and meta-analysis of population-based studies. 2013;73:1749–1759.
Gastroenterology 2013;145:996–1006. 16. Dziki AJ, Duncan MD, Harmon JW, et al. Advantages of handsewn
2. Yamamoto T, Watanabe T. Surgery for luminal Crohn’s disease. over stapled bowel anastomosis. Dis Colon Rectum 1991;34:442–
World J Gastroenterol 2014;20:78–90. 448.
3. Fichera A, Michelassi F. Surgical treatment of Crohn’s disease. J 17. Galandiuk S. Stapled and hand-sewn anastomoses in Crohn’s dis-
Gastrointest Surg 2007;11:791–803. ease. Dig Surg 1998;15:655.
4. Buisson A, Chevaux JB, Allen PB, et al. Review article: the natural 18. Resegotti A, Astegiano M, Farina EC, et al. Side-to-side stapled
history of postoperative Crohn’s disease recurrence. Aliment anastomosis strongly reduces anastomotic leak rates in Crohn’s
Pharmacol Ther 2012;35:625–633. disease surgery. Dis Colon Rectum 2005;48:464–468.
5. Michelassi F. Crohn’s recurrence after intestinal resection and anas- 19. Kono T, Kaneko A, Hira Y, et al. Anti-colitis and -adhesion effects
tomosis. Dig Dis Sci 2014;59:1352–1353. of daikenchuto via endogenous adrenomedullin enhancement in
6. Kono T, Ashida T, Ebisawa Y, et al. A new antimesenteric func- Crohn’s disease mouse model. J Crohns Colitis 2010;4:161–170.
tional end-to-end handsewn anastomosis: surgical prevention of 20. Eysselein VE, Reinshagen M, Patel A, et al. Calcitonin gene-related
anastomotic recurrence in Crohn’s disease. Dis Colon Rectum peptide in inflammatory bowel disease and experimentally induced
2011;54:586–592. colitis. Ann N Y Acad Sci 1992;657:319–327.
7. Katsuno H, Maeda K, Hanai T, et al. Novel antimesenteric func- 21. Carr ND, Pullan BR, Schofield PF. Microvascular studies in non-
tional end-to-end handsewn (Kono-S) anastomoses for Crohn’s dis- specific inflammatory bowel disease. Gut 1986;27:542–549.
ease: a report of surgical procedure and short-term outcomes. Dig 22. Hulten L, Lindhagen J, Lundgren O, et al. Regional intestinal blood
Surg 2015;32:39–44. flow in ulcerative colitis and Crohn’s disease. Gastroenterology
8. Fichera A, Zoccali M, Kono T. Antimesenteric functional end-to- 1977;72:388–396.
end handsewn (Kono-S) anastomosis. J Gastrointest Surg 2012;16: 23. Angerson WJ, Allison MC, Baxter JN, et al. Neoterminal ileal
1412–1416. blood flow after ileocolonic resection for Crohn’s disease. Gut
9. Rutgeerts P, Geboes K, Vantrappen G, et al. Predictability of the 1993;34:1531–1534.
postoperative course of Crohn’s disease. Gastroenterology 24. Misteli H, Koh CE, Wang LM, et al. Myenteric plexitis at the
1990;99:956–963. proximal resection margin is a predictive marker for surgical recur-
10. Kono T, Fichera A. Kono-S anastomosis for Crohn’s disease: nar- rence of ileocaecal Crohn’s disease. Colorectal Dis 2015;17:304–
rative—a video vignette. Colorectal Dis 2014;16:833. 310.
11. Sorrentino D. State-of-the-art medical prevention of postoperative 25. Bressenot A, Peyrin-Biroulet L. Histologic features predicting post-
recurrence of Crohn’s disease. Nat Rev Gastroenterol Hepatol operative Crohn’s disease recurrence. Inflamm Bowel Dis 2015;21:
2013;10:413–422. 468–475.
12. Singh S, Garg SK, Pardi DS, et al. Comparative efficacy of phar- 26. Carla-Moreau A, Paul S, Roblin X, et al. Prevention and treat-
macologic interventions in preventing relapse of Crohn’s disease ment of postoperative Crohn’s disease recurrence with anti-
after surgery: a systematic review and network meta-analysis. TNF therapy: a meta-analysis of controlled trials. Dig Liver
Gastroenterology 2015;148:64–76. Dis 2015;47:191–196.

View publication stats