Vascular Anastomosis is comprised of the joining of tissues from two separate organs after surgery for resection or any other condition where disease is present and prohibits routine organ function on an independent basis. This process has been in existence for over a century; however, improvements in surgical technique over time have reduced infection and other consequences post-surgery (Ball and Feliciano 1). In recent years, sutureless techniques using such tools as VCS clips have evolved which reduce healing times and further prevent infection in many cases (Kirsch et.al 523). When using microsurgery to accomplish this procedure, vascular tissues are less subject to compromise and are likely to improve healing on a consistent basis (Kirsch et.al 523). It is necessary for researchers and surgeons alike to determine how to best approach vascular anastomosis and to determine which technique is appropriate, combined with other factors to achieve optimal healing.
Microsurgery for vascular anastomosis allows surgeons to anastomose congruent vessels or nerves to connect and transfer tissues from other organs (Janz and Yang). In a sense, this procedure may “restore continuity” between organ sections through the connective process (Vikram et.al). From a healing perspective, the post-surgical period is critical because healing is optimal when the procedure has occurred in a normal fashion (Vikram et.al). Anastomotic healing is complex and intricate at the cellular level and supports the recovery of patients requiring vascular anastomosis (Conneely et.al 21). It is known that “A key event in tissue healing is the degranulation of mast cells with liberation of cytokinetically active products” (Conneely et.al 21). These mast cells, which are created from bone marrow tissue, serve in the capacity of stem cells to some degree and influence cell connectivity and continuity in important ways (Conneely et.al 21). Some studies indicate that erythropoietin has some influence on this process, noting that “EPO treatment improves anastomotic wound healing though decreased necrosis and inflammatory cell infiltration and increased fibroblast activity” (Turkcu et.al 135). In addition, healing after anastomoses is also dependent upon the area under consideration, such as the colon, which will be considered in the following paragraph.
The healing process is generally consistent with most injuries or wounds and requires a number of steps to promote a full recovery. In general, healing is described as follows: “In adult humans, optimal wound healing involves the following the events: (1) rapid hemostasis; (2) appropriate inflammation; (3) mesenchymal cell differentiation, proliferation, and migration to the wound site; (4) suitable angiogenesis; (5) prompt re-epithelialization (re-growth of epithelial tissue over the wound surface); and (6) proper synthesis, cross-linking, and alignment of collagen to provide strength to the healing tissue” (Guo and DiPietro 219). In evaluating this perspective, healing after anastomoses requires a similar approach, but when complications arise, it is likely that healing will either be delayed and the condition could worsen over time (Guo and DiPietro 219). Therefore, it is necessary to better understand the morphological and physiological changes which occur after microsurgery and anastomoses to evaluate the potential risks and possible outcomes associated with post-surgical healing (Guo and DiPietro 219).
Healing after a colorectal anastomosis is defined as follows: “The process of intestinal anastomotic healing can be arbitrarily divided into an acute inflammatory (lag) phase, a proliferative phase, and, finally, a remodeling or maturation phase. Collagen is the single most important molecule for determining intestinal wall strength, which makes its metabolism of particular interest for understanding anastomotic healing” (Ho et.al 1611). Under these conditions, collagen serves as a binding and restorative agent; however, the ability of the wound to properly heal is contingent upon other factors such as MMP inhibitors, which are utilized in vivo as a means of strengthening the anastomoses and limiting leakage (Ho et.al 1611).
The achievement of optimal healing in the patient post-anastomosis requires a delicate balance between smooth muscle tissue growth in the area surrounding the anastomosis and any prohibiting factors that might exist (Darius 97). However, the surgeon must possess knowledge of possible complications, such as the following: “morphological changes are characterized by medial atrophy, endothelial cell dehiscence and vessel wall fibrosis” (Darius 65). Under these conditions, it is expected that anastomosis healing will be observed as a gradual yet constant process, particularly in a weakened immune state post-surgery (Darius 65). In one research study, it was determined that morphological deformities associated with anastomoses did not contribute to stenosis or thrombosis in most cases and that blood flow volume was not disrupted (Darius 83).
In the period following anastomoses, it is known that “anastomotic leakage is a major complication that causes significant morbidity and mortality, especially in the early period of colonic anastomosis…routine use of fibrin glue or omental patch support has been recommended by some surgeons to improve colonic anastomotic security” (Ozel et.al 233). These findings suggest that there are important healing indicators associated with the prevention of leakage in the anastomotic region and that products such as TachoComb, comprised of collagen, combines with fibrinogen to facilitate wound healing in different ways (Ozel et.al 235). Nonetheless, in spite of its risks, “primary anastomosis is the contemporary preferred method of repair for colonic injuries” (Ozel et.al 235).These conditions warrant rapid decision-making to determine which surgical technique is appropriate, including microsurgery, and which steps are necessary to accomplish the desired healing process (Ozel et.al 235).
In using microsurgery for extracranial and intracranial anastomoses, it is evident that morphological changes are likely to occur in this area and in the surrounding tissues (Mehdorn et.al 91). These changes may contribute to such concerns as stenosis and atherosclerosis for this select patient population, even though the study sample is small (Mehdorn et.al 91). A study conducted by Manabe et.al demonstrates that composite grafting “eliminates the need for proximal anastomosis to the ascending aorta and conserves extra lengths of an arterial graft for additional grafting” (Manabe et.al 683). Under these conditions, it is likely that there will be significant surgical challenges associated with the composite grafting procedure when there are critical risks with this practice (Manabe et.al 683).
Healing after anastomoses requires a long waiting period to allow for collagen binding and fiber development to close the wound at the incision site. Even when the most advanced surgical techniques are used, the incision site is always cause for concern and may lead to post-surgical symptoms and side effects. With composite grafting, there is always a greater chance of cell or tissue rejection, which could lead to serious complications. It is necessary for surgeons performing this type of procedure to create an environment which promotes optimal healing at a consistent level. It is anticipated that if a patient does not experience any serious side effects, healing will be optimized, but that the healing process requires a significant amount of time, often many months post-surgery. These patients must not be placed into any type of situation that will compromise their healing and/or recovery so that they will heal without incident.
With the use of techniques involving microsurgery, it is evident that anastomoses require a significant amount of time for the post-surgical wound to heal, often over a period of months. It is expected that during this process and due to the complexity of this surgery, the affected area experiences a number of morphological changes, as well as a number of possible risks for recovery, which could be delayed over a period of time. It is important for surgeons to evaluate patients and the potential risks associated with post-surgical complications, particularly when chronic conditions are prevalent, such as diabetes. These conditions must be taken into consideration when evaluating patients in this manner and in supporting optimal recovery. Patients who also undergo composite grafts face additional risks associated with tissue transfer and the proper signaling and channeling of cells from one area to another. Patient care and treatment of the patient with anastomosis is complex and intricate on many levels and requires surgical knowledge and experience to better manage healing and recovery. There is always a greater potential for these patients to experience problems with healing when composite grafts are conducted, particularly because this practice may lead to cell and tissue rejection and vascular compromise. Therefore, it is important for vascular surgeons to evaluate individual patients in order to determine how to best move forward in selecting the appropriate surgical intervention and the optimal treatment approach. Healing must be optimized as a means of promoting successful patient outcomes because immunity within this population group is typically compromised due to the severity of the condition and the serious and intricate surgical procedure that is required. Therefore, surgical techniques must be selected that will encourage the best possible recovery for all patients.
Ball, CG, Feliciano, DV. A simple and rapid vascular anastomosis for emergency surgery: a technical report. World Journal of Emergency Surgery 2009 4(30): 1-3. Conneely, J B, Winter,D, Dowdall, J, Bouchier-Hayes, D. Mast cell function is essential to
intestinal anastomosis healing. Journal of the American College of Surgeons 2004 199(3): 21.
Darius, O. Clipped Microvascular Anastomosis: Hemodynamical, Morphological, and Surgical
Evaluation. Leuven University Press; 2004.
Guo, S., DiPietro, LA. Factors affecting wound healing. Journal of Dental Research 2010 89(3): 219-229.
Ho, YH, Tawfik Ashour, MA. Techniques for colorectal anastomosis. World Journal of
Gastroenterology 2010 16(3): 1610-1621.
Janz, BA, Yang, JC. Principles of Microsurgery. Medscape Reference [Internet]. 2013. [cited 3 February 2013]. Available from http://emedicine.medscape.com/article/1284724-
Kate, V, Kalayrasan, R, Mohta, A. Intestinal Anastomosis. Medscape Reference [Internet] 2012. [cited 3 February 2013]. Available from
Kirsch, WM, Gupta, S, Zhu, YH. Sutureless vascular anastomosis: the VCS clip. Cardiovascular Surgery 2001 9(6): 523-525.
Manabe, S, Fukui, T, Shimokawa, Tomoki, T, Minoru, K, Yuzo, M, Satoshi, Shuichiro T.
Increased graft occlusion or string sign in composite arterial grafting for mildly stenosed
target vessels. Annals of ThoracicSurgery 2010 89: 683-688.
Mehdorn, HM, Hickler, S, Venkajob, K, Reinhardt, V, Grote, W. Morphology of vessel wall
changes after microsurgical end-to-side anastomosis and their pharmacological prevention. Extra-Intracranial Vascular Anastomoses Microsurgery at the Edge of the Tentorium Advances in Neurosurgery 13 (1985): 91-97.
Ozel, SK, Kazez, A, Akpolat, N. Does a fibrin-collagen patch support early anastomotic healing in the colon? An experimental study. Technology Coloproctology 2006 10: 233-
Ozel, TU, Cakmak, GK, Demir, EO, Bakkal, H, Oner, MO, Okyay, RD, Bassorgun, IC, Ciftcioglu, MA. The effect of erythropoietin on anastomotic healing of irradiated rats. Journal of Investigative Surgery 2012 25(2): 127-135.