1. First International Consensus Conference on Kono-S anastomosis, Kyoto 2011
A new antimesenteric functional end to end hand-sewn anastomosis
Surgical prevention of anastomotic recurrence in Crohn’s disease.
Diseases of the Colon & Rectum 2010
Asahikawa (1 hour 40 min flight from Tokyo)
Toru Kono
Division of Gastroenterologic and General Surgery
Department of Surgery, Asahikawa Medical College
Tokyo
Kyoto
Mt. Taisetu National Park, Asahikawa,
(Scenery from the window of my office)

2. Anastomotic recurrence and surgical recurrence of CD
(1993 to 2003)
Autumn in Kyoto, Kinkakuji temple

3. 5-year postoperative cumulative recurrence-free survival
(ulcerative changes)
below 10% in historical CD cases
> 90% recurrence within 5 years
Cumulative recurrence-free survival (Kaplan-Meier analysis)
1
Mean time to recurrence (mo.)
0.8 25% 6.4
50% 12.3
0.6 75% 38.6
0.4
5 years
0.2
0
0 20 40 60 80 100 120 140 (mo)
N=84

4. Postoperative (POP) stenosis at anastomotic sites
POP 11 months POP 40 months POP 52 months

5. 5-year postoperative cumulative surgical recurrence
increased to 26% in historical CD cases
Cumulative surgical recurrence
(Kaplan-Meier analysis)
Mean time to reoperation (mo.)
1
25% 56.8
0.8 50% 104.0
0.6
0.4
0.2
0
0 20 40 60 80 100 120 140 (mo)
N=84

6. The S anastomosis technique was developed in 2003 at
the Asahikawa Medical University Hospital
Dept. Surgery
Asahikawa Medical University hospital

7. Concept
• Anastomotic recurrence site, which usually start
at mesenteric side of the anastomosing the ends
of the remnant intestine. However, conventional
anastomoses do not pay attention to this,
besides the size of the anastomosis site. We
designed an anastomotic technique to avoid the
stenosis at the anastomosing the ends of the
remnant bowel by creating a supporting column,
like a stent.
• It is also important that the blood flow and
nervous system should be preserved when a
resected intestine and its mesentery is divided,
because both are important factors for ulcer
healing and are etiologically abnormal in CD
intestine.

8. Submucosal nervous system is damaged due to
repeated inflammation and can not fully recover
in Crohn’s disease
Normal ileum Crohn’s disease ileum
Red : nervous fiber and cell, Blue: DAPI indicate cell nucleus

9. Selective loss of neuropeptide CGRP, but not ADM,
in Crohn’s disease model and human
Ann N Y Acad Sci. 1992;657:319-27. Dig Dis. 2008;26:149-55.
CGRP ADM
100 1.5
CGRP ( ng / g tissue weight )
ADM ( ng / g tissue weight )
80 1.2
60 0.9
40 0.6
**
20 0.3
0 0.0
Control CD Model Control CD Model
Kono T. et al J Gastroenterology 2011 (in press)
It has been reported that blood flow is decreased by more than
50% in the terminal ileum and colon of Crohn’s disease patients
Gastroenterology. 1977;72:388-96. Gut. 1986;27:542-9.

10. Blood flow is decreased in Crohn’s disease because of
depletion of neuronal peptide (CGRP),
a potent vasodilatator, in human and animal models.
Blood 0.14
normal colon
Flow 0.12
TNBS treated colon
0.10
0.08
CV
0.06
0.04
0.02
0.00
0 15 30 45 60 75 90
min
Kono T. et al J Gastroenterology 2011 (in press)

11. Crohn’s disease and intestinal
blood flow
Slovenia

12. Blood flow is a very important factor in
pathogenesis of Crohn’s disease
Ileal ulcers tend to occur along the mesenteric margin of
the bowel wall in CD and experimental models of CD
J Clin Pathol. 1997;50:1013-7.
Aliment Pharmacol Ther. 1999;13:531-5.
Aliment Pharmacol Ther. 2000;14:241-5.
Florida Everglade

13. Crohn’s disease ileum
Mesenteric side
Mesenteric side
Mesenteric side
stenosis
stenosis

14. Who can answer the prepotency of the
Crohn’s disease?
Hypothesis:
Primary pathological abnormality in
Crohn’s disease is in the mesenteric
blood supply
Lancet. 1989;2:1057-62.

15. Schematic diagram of human small intestine in Crohn’s disease
Normal Remission Mucosal barrier Active
flora
vessel
bacteria
inflammation
* granuloma ulcer
Mesenteric Mesenteric
margin margin
long artery
short artery
CGRP glanulomatous
Blood flow vasculitis
Lancet. 1989;2:1057-62.
No connection between the submucosal plexuses derived from short artery and long artery
*
The association might well be explained in terms of granulomatous vasculitis
affecting small end-arteries that specifically supply the mesenteric margin

16. How to do Kono-S anastomosis
Kyoto Darumaji

17. Intraoperative endoscopy
Intraoperative endoscopy
Transection
of intestine ulcer stenosis
mesentery
The whole bowel was inspected carefully for diseased segments using an endoscopic fiber via
enterotomy at a nearby obvious stenosis site in all cases.
Before resection of the diseased intestine, the surgeon and the gastroenterologist ensure by
intraoperative endoscopy or direct observation there are no apparent mucosal lesions at the site of
the intestine designated for anastomosis.

18. How to divide “mesentery”
The nearby mesentery of the intestinal loop which is to be excised is divided
using the LigaSure system (Valleylab) in order to avoid an unnecessary
neurectomy as well as blood vessel dissection
diseased
intestine
blood vessel nerve fiber

19. Kono-S anastomosis: resection
diseased anastomosis
diseased diseased
intestine Resected area
intestine intestine
Resected area
blood Nerve
vessel fiber
Conventional anastomosis: resection
anastomosis
diseased diseased diseased
intestine intestine intestine
Resected area
blood Nerve
vessel fiber

20. How to make a “Supporting Column”
the intestine designated Kono-S resection with LS Conventional resection with LS
for anastomosis
Diseased
intestine Mesenteric
side
Linear stapler (LS)
the intestine designated
Multiple stenosis at ileum for anastomosis Diseased ileum
specimen
Diseased ileum

21. The reason : Both ends of the stump are reinforced with 3/0 Vicryl (Ethicon) , when a
linear staple cutter is used.
End of the stump has a risk (leakage)
for sealing with single stapling,
therefore reinforcement is needed at the both ends.
3/0 Vicryl control-release

22. The reason : Both threads of the ends of stumps are firstly tied for adjusting some
differences of the size of the stump, when a supporting column is made.
Mesenteric side
relapse
starting point
at mesenteric side
Both stumps are united with 3 or 4 threads.

23. “Supporting Column” avoids stenosis
Supporting column
Before anastomosis, both stumps are securely sutured in order to create a
Supporting Column that can maintain the shape of the anastomosis
The creation of a supporting column that maintains the shape of the
anastomosis in order to prevent distortion due to relapse at the anastomotic site.

24. Longitudinal enterotomy is performed in the antimesenteric side 1cm from the
supporting column so as to obtain the optimal effect of the supporting column on
the anastomosis, and the incision is opened across the intestinal longitudinal
axis, resulting in a large anastomosis resembling the Heineke-Mikulicz type. The
length of the opened incision across the longitudinal axis should be 7-8 cm, and
it is closed to the length of the intestinal circumference.

25. Antimesenteric functional end to end hand-sewn anastomosis
A side-to-side enteroenteric transverse anastomosis is performed by a
handsewn, single-layer Gambee manner, using 3/0 Vicryl running sutures.
Supporting column
Resembles anastomosing the bottom ends of two flasks

26. Videotape on Kono-S anastomosis technique
34 years old. male
Reoperation for anastomotic stenosis within 6 years of initial surgery
Ileocolic anastomosis + ileoileal anastomosis

27. Results of Kono-S anastomosis
84 consecutive cases of intestinal resection for CD
from 2003 to 2010
Asahikawa Medical University Hospital
S anastomosis at 107 sites
Ileal/jejunal: 44 Ileocolic: 57 Colonic: 6
Comparative analysis with 73 historical CD patients
who underwent conventional anastomoses
from 1993 to 2003

28. a b
c
d

29. Kono-S anastomosis (1 year)
Endoscopy

30. Endoscopic observation one year after Kono-S anastomosis

31. Analysis of endoscopic recurrence at the anastomosis
after undergoing S anastomosis (Group S) or conventional anastomoses (Group C)
3.4
P=0.008
2.6

32. Comparison of surgical recurrence for anastomotic restenosis
between S anastomoses and conventional anastomoses
100
Group S N = 84
90 Group S
Group C N = 73
80
70 Group C
P = 0.0004
60
50
40
30
20
10
0
0 12 24 36 48 60 72 84 96 108 120 132 months

33. Surgical recurrence rates after undergoing an S anastomosis (Group S)
or conventional anastomoses (Group C).
With or without postoperative Infliximab
% patients remaining free of surgical recurrence 100
Infliximab + n = 42
Group S Infliximab - n = 42
90 Infliximab + n = 12
Group C Infliximab - n = 61
80 *, **
Logrank Test *p = 0.0041
Logrank Test **p = 0.0006
70
60
0 12 24 36 48 60 72 84 96 108120132
Time in Months
Group S combined with postoperative infliximab therapy (infliximab +), no infliximab (infliximab -),
and Group C combined with postoperative infliximab therapy (infliximab +), no infliximab (infliximab -).
Group S infliximab + vs. Group C infliximab -: P = 0.0041. Group S infliximab - vs. Group C infliximab -: P = 0.0006.

34. Comparison of anastomotic restenosis recurrence
between S ansatomosis and conventional anastomoses
No postoperative administration of Infliximab/Adalimumab
100
Group S
90
80
Group C
70
60
0 12 24 36 48 60 72 84 96 108 120 132
Time in Months

35. Conclusion
Kono-S anastomosis, a new antimesenteric functional end to
end hand-sewn anastomosis, may be effective for preventing
postoperative anastomotic stenosis, even if infliximab
postoperative therapy is not administered.
Pisa