Reply to: Reducing anastomotic leakage in laparoscopic low anterior resection: is it achievable by a new method?

Abstract

We wish to express our gratitude to Professor Hottenrott for his interest in our article [1]. Professor Hottenrott asked, ‘‘Is it achievable for problem of anastomotic leakage by a new method? The answer is, ‘‘No.’’ We do not think that we can resolve all issues by the examination of cases limited to a single institution. The causes of anastomotic leakage are multifactorial, as described by Professor Hottenrott. Various factors, such as level of anastomosis, perioperative radiotherapy, male gender, no diverting stoma, blood loss, nonspecialized surgeons, and diabetes mellitus, are reported as risk factors for anastomotic leakage [2–6]. To determine the causes of anastomotic leakage, a prospective multicenter study of treatment policies and surgical methods is necessary. However, the emphasis in our article is whether the peculiar anastomosis leakage in laparoscopy-assisted low anterior resection can be decreased. It appeared that there was an anastomotic leakage peculiar to the laparoscopyassisted surgery that did not exist in the open operation in our experience. When we then tried to identify the causes of anastomotic leakage, the number of stapling times was performed for rectal transections appeared to be a factor. Recently, similar results have been reported [7, 8]. Male gender, concomitant disease, and other factors are not avoided easily. The level of anastomosis depends on the nature of the disease, and perioperative radiotherapy seems to be necessary for radical cures. However, it is thought that reducing the number of times stapling was performed for rectal transections might ameliorate anastomotic leakage. In our article, anastomotic leakage rates were 11.2% (12 patients) in the group treated with multiple stapling for rectal transection and 7% (2 patients) in the group using the Y-Hood method, but there was no significant difference, probably because the number of patients was small. The number of patients has increased to 38 since contributing this article, and the present anastomotic leakage rate is 5.3%. This is not less than the 9.1% that was reported in a retrospective multicenter study in Japan [9]. It is expected that increased experience with the procedure will improve the outcome. However, it is not thought that the problem of anastomotic leakage can be resolved by this method. There is an excellent article on the technique using older equipment [10]. The authors noted that the fact that their patients were thin, were not radiated, and were operated on by very experienced laparoscopic surgeons would have contributed to their low leakage rate. Moreover, there is a suggestion that the flaking off of the rectum is not done to the limit of the adventitia, and that having surrounding fatty tissue adhering to some degree might be better with respect to blood flow. However, this has not been verified. A largescale investigation is still necessary. Professor Hottenrott mentioned that the effect of our method of medical treatment is cost reduction. The consideration of medical treatment cost is important with the development of a new procedure. We think that the decrease in the frequency of use of a device leads to the medical treatment cost reduction. A large-scale investigation of the medical treatment cost reduction and safety is necessary. S. Fujii (&) K. Watanabe C. Kunisaki Department of Surgery, Gastroenterological Center, Yokohama City University, 4-57 Urafunecho, Minami-ku, Yokohama 232-0024, Japan e-mail: u0970047@urahp.yokohama-cu.ac.jp