Validation of an endoscopic anastomotic grading score as an intraoperative method for assessing stapled rectal anastomoses.

Abstract

Anastomotic leak is a dreaded complication of colorectal surgery. An endoscopic grading score of the perianastomotic mucosa has been previously developed at our institution (UCI) to assess colorectal anastomotic integrity. The objective of this study is to validate the UCI anastomotic score and determine its impact in anastomotic failure. As a follow-up study of the UCI grading score implementation during 2011 to 2014, patients undergoing stapled colorectal anastomoses after sigmoidectomy or proctectomy at a single institution from 2015 to 2018 were retrospectively reviewed. Patients were grouped into three tiers based on endoscopic appearance (grade1, circumferentially normal mucosa; grade2, ischemia/congestion < 30% of circumference; grade3, ischemia/congestion > 30% of circumference). On the basis of endoscopic mucosal evaluation, grade1 anastomosis was observed in 299 patients (94%), grade2 anastomosis in 14 patients (4.4%), and grade3 anastomosis in 5 patients (1.6%). All grade3 classifications were immediately and successfully revised intraoperatively with reclassification as a grade1 anastomosis. The anastomotic leak rate of the follow-up study period from 2015 to 2018 was 6.4% which was lower compared to the anastomotic leak rate of 12.2% in the original study period from 2011 to 2014 (p = 0.07). Anastomotic leak rate for the entire patient series was 8.5%. A grade2 anastomosis was associated with higher anastomotic leak rate compared to a grade1 anastomosis (35.7% vs. 7.4%, p < 0.05). None of the five grade3 anastomoses resulted in an anastomotic leak upon revision. This study further validates the anastomotic grading score and suggests that its systematic implementation can result in a reduction in anastomotic leaks.