Advances in Colorectal Anastomoses

Abstract Anastomotic leak (AL) remains a major source of morbidity in colorectal surgery, with leak rates showing little change despite advances in technique and perioperative care. This persistent risk has prompted the development of novel technologies and strategies targeting different aspects of anastomotic construction and healing. This article summarizes current evidence on emerging approaches, including compression and magnetic compression anastomosis (MCA), intraoperative fluorescence angiography (FA), robotic-assisted techniques, and modulation of the intestinal microbiome. These innovations vary substantially in maturity and clinical impact. Among device-based approaches, the nickel–titanium compression anastomosis ring is the most established compression device, with outcomes comparable to conventional stapling. In contrast, MCA remains limited in colorectal practice to a salvage role for recanalization of strictures and atresia rather than an alternative for primary anastomosis. FA has been evaluated extensively, with meta-analyses suggesting a potential reduction in AL rates, particularly for left-sided and low rectal anastomoses, although variability in its interpretation persists. Robotic platforms have facilitated intracorporeal anastomosis and expanded technical capabilities, while the intestinal microbiome has emerged as a modifiable factor influencing anastomotic healing; notably, combined mechanical and oral antibiotic bowel preparation remains the only intervention with consistent clinical evidence of leak reduction. Together, these advances address complementary components of anastomotic success—construction, perfusion, access, and healing—yet none independently eliminates risk. Current evidence supports selective integration into practice while highlighting important gaps, including the need for standardized protocols and high-quality prospective trials to define their role in improving outcomes.