Low Colorectal Anastomosis Research Articles

Prophylactic endoscopic vacuum therapy in low colorectal anastomosis: potential benefit and possible risks.

Prophylactic endoscopic vacuum therapy in low colorectal anastomosis: potential benefit and possible risks.

(Babcock or Soave Baulieux) Procedure for Coloanal Anastomosis: 03 Cases

The Soave Baulieux procedure is a surgical technique for performing a coloanal anastomosis in cases of pathological colorectal conditions. A coloanal anastomosis is performed through a sleeve of rectal muscularis after a two-stage mucosectomy. In the first stage, the colonic tube is exteriorised through the anal canal, and a few days later a direct coloanal anastomosis is performed in the second stage. This is a salvage operation and its results are not well documented in the literature. This is a study of three (03) consecutive patients, hospitalised and operated on using the Babcock or Soave Baulieux technique at the Department of Visceral Surgery A of the Hassan II University Hospital in Fez, Morocco. The objectives of this study were to evaluate the indications, operative results, postoperative morbidity and mortality, and long-term functional results. Our study concerns three (03) patients with colorectal cancer. In 66.7% of cases, the decision to perform the Soave Baulieux technique was taken preoperatively to avoid other complications related to the low colorectal anastomosis. After the operation, 66.7% of patients had a simple post-operative course and only one patient (33.3%) was re-operated after a complication (necrosis of the anastomosis from the distal segment to the anus). Only one patient had a permanent stoma. Quality of life and functional results were satisfactory in 66.7% of our patients.

Colorectal eversion technique combined with modified single-stapled double-purse-string low colorectal anastomosis.

Total mesorectal excision with adequate free margins is the gold standard for rectal surgery. Applying a linear stapler in a narrow pelvis can be challenging and the proper distal margin difficult to assess. In selected cases the colorectal eversion technique combined with single-stapled double-purse-string anastomosis (SSDP) can be a practical solution. Eleven patients, six men and five women, mean body mass index 27 ± 1.3 kg/m2, underwent total mesorectal excision with the colorectal eversion technique combined with modified SSDP between September 2022 and January 2023. The mean operative time was 190 min. The mean hospital stay was 4 days. There were no postoperative complications. The final histology showed complete mesorectal resection, circumferential resection margin negative, free distal resection margin, anastomotic doughnuts negative. At 7 ± 3 months follow-up there was no evidence of local recurrence or distant metastasis. The colorectal eversion technique combined with modified SSDP is a reproducible and safe technique in selected patients. Prospective randomized trials with large patient series are needed to confirm our preliminary results.

Transanal Intubation for Preventing Colorectal Anastomotic Failure.

Failure of low colorectal anastomosis remains challenging in surgical oncology, necessitating the exploration of new methods and improvements in existing preventive measures. This prospective study was conducted in two stages: intraluminal pressure in the colon was monitored in 32 patients by manometry and sonography over a 5-day postoperative period; 213 patients who underwent anterior resection of the rectum were analyzed, of whom 126 and 87 underwent diverting stoma (DS) and transanal intubation (TAI), respectively. The effectiveness of the recommended technique for applying and removing transanal intubation (TAI) to prevent pneumo hydro strike (≥15 kPa) on the anastomosis line was analyzed in 87 patients and compared with imposed DS. TAI showed better borderline statistical significance (p = 0.051). The incidence of repeat surgery for anastomotic failure (AL) was seven (5.55%) and four (4.59%) in the DS and TAI groups, respectively. The distance of the anastomosis from the dentate line <60 mm was associated with a higher risk of AL occurrence (odds ratio (OR), 1.012; 95% confidence interval (CI), 1.007-1.017; p < 0.001; area under the curve (AUC) = 0.82). DS is recommended for men, as the risk of AL is significantly lower among women (OR, 0.41; 95% CI, 0.16-1.04; p = 0.062; AUC, 0.61; 95% CI, 0.54-0.67). Although TAI is advantageous over DS for preventing AL, surgeons select the method for the preventive approach based on the preoperative and intraoperative results.

Bowel function after anterior rectal resection for cancer: short and long-term prospective evaluation with low anterior rectal syndrome (LARS) score in a cohort of Cameroonian patients.

bowel dysfunction is the most common and disabling complication after anterior rectal resection (ARR) for cancer. We aimed to evaluate these complications in a cohort of Cameroonian patients, using the low anterior rectal syndrome (LARS) score. we conducted a descriptive and analytical cross-sectional study, in two university hospitals of Yaoundé (Cameroon). Prospectively, we collected the records of all patients aged at least 18 years who had an ARR indicated for rectal cancer from January 2015 to March 2018. Alive patients among them were subsequently received in consultation at 1 and 3 years after surgery, for short and long-term assessment of their digestive function using the LARS score. during the study period, 28 patients underwent anterior rectal resection for rectal cancers. Short-term bowel function was evaluated in 23 patients. Their mean age was 48.42 ± 12.2 years and 14 were males. LARS was present in 10 of them (43.47%) and classified as "minor" in the majority of cases (n=6). The commonest bowel dysfunction at this term was splitting of stool (56.53%). Long-term digestive function was evaluated in 11 patients; LARS was found in 3 of them (27,27%) and classified as minor in all cases. Perfect continence was significantly improved (p=0.003) in the long term compared to the short-term status. Continence (p=0.049) and urgency (p=0.048) were better in patients who had a low colorectal anastomosis compared to those who had a colo supra-anal anastomosis. after ARR for cancer, there is a high prevalence of LARS in the short term with an improvement in the long term.

Stapled side-to-side anastomosis for ileostomy reversal: a simple and reproducible technique with video.

Protective diverting ileostomy is commonly performed in rectal surgery to avoid septic complications of low colorectal anastomosis. Ileostomy closure usually occurs three months after the surgery and can be realized in two ways: hand sewn or stapled. Existing randomized studies comparing the two techniques showed no difference in terms of complications. Our study describes the standard technique of ileostomy reversal as done in Bordeaux University Hospital in 10 steps individually illustrated and with an explicative video. We also collected data concerning the 50 last patients who underwent an ileostomy reversal in our center from June 2021 to June 2022. Mean duration of the ileostomy closure was 46.8 minutes, and the mean total hospital stay was 4.66 days. Five of 50 (10%) patients had a post-operative bowel obstruction, 2/50 (4%) patients had a post-operative bleeding, 1/50 (2%) patient had a wound infection, and there was no anastomotic leakage observed. Stapled side-to-side anastomosis is a rapid, simple, and reproducible technique for ileostomy reversal. There are no more complications compared to hand-sewn anastomosis. It engenders an additional cost compensated by the gain in operating time which altogether saves money.

Плановые лапароскопические резекции кишечника у детей с болезнью Крона

Currently, laparoscopic operations are widely used in pediatric surgical practice (both emergency and elective surgery). Separately, it is worth noting the difficulty of performing reconstructive surgical interventions using endovideosurgical technologies in pediatric coloproctology and surgery of inflammatory bowel diseases (Crohn's disease, ulcerative colitis, etc.). Objective. Present the experience of performing laparoscopic reconstructive surgical interventions in pediatric patients with Crohn's disease. Patients and methods. For the period from 2005 to 2023, 64 children with various forms of Crohn's disease on the basis of the FNCC of children and adolescents of the FMBA of Russia (Moscow), Morozovskaya DGKB (Moscow) underwent planned reconstructive laparoscopic interventions: ileocecal resection, resection of the small and large intestine with equipment side-to-side anastomosis, rectal resection with manual low colorectal anastomosis, subtotal colectomy. Results. The average surgery time was 150 minutes. In the postoperative period, complications developed in 6 children (9.4%). The duration of postoperative hospitalization averaged 7 days. In 6 cases, postoperative complications were noted, in 4 cases (inflammatory changes from the umbilical wound and the formation of the intestinal fistula here) it was possible to resolve them conservatively through antibacterial therapy and local treatment. But in the 2 remaining cases, repeated interventions were required due to the failure of the hardware suture and the formed stricture in the anastomosis zone. Conclusion. Treatment of children with complicated forms of Crohn's disease should be carried out in specialized centers with the participation of a multidisciplinary team of specialists at all stages of treatment. With the correct selection of patients and the timing of surgery, the laparoscopic technique allows efficient and safe resection and restoration of intestinal continuity at any location and length of strictures. Key words: Crohn's disease, inflammatory bowel disease, apparatus anastomosis, children, laparoscopy, laparoscopic resection

Mesorectal failure after chemoradiotherapy for squamous cell carcinoma of the anus: is sphincter-saving surgery reasonable?

Abdominoperineal resection (APR) is today the standard treatment for improving survival in case of mesorectal failure without anal canal recurrence after chemoradiotherapy (CRT) for squamous cell carcinoma of the anus (SCC). The aim of this study was to assess if a sphincter-saving surgery is a safe alternative to classical salvage APR in these patients. A retrospective study was conducted on all patients who had total mesorectal excision (TME) with sphincter-saving surgery either with coloanal or low colorectal anastomosis, for mesorectal failure after CRT for SCC between 2012 and 2020 at our institution. The main endpoint of our study was oncological results at the end of follow-up. Postoperative morbidity and mortality were secondary endpoints. There were 10 patients, (8 women, median age 55years [range 45-61years]). On TME specimens, R0 resections were noted in five (50%), R1 resection in four (40%) and R2 resection in one (10%). After a median follow-up of 42months (4-74months), five patients were alive, and four (40%) were alive at 5-year follow-up. During follow-up, locoregional failure after TME was noted in two patients (20%), distant relapse in three patients (30%) and both locoregional plus distant failure in two patients (20%). Only two patients (20%) had anal recurrence, one in the anal canal, the other in the peri-anastomotic area. Long- term local control was achieved in 2 of the 5 patients (40%) who underwent R0 resection versus only 1/4 patients (25%) with R1 resection. Our preliminary study suggested that sphincter-saving surgery could be proposed in selected patients with SCC presenting mesorectal failure after CRT, providing a feasible R0 resection.

The Comparison of Hand Sewn and Stapled Anastomoses

Objective: To compare hand-sewn and stapled sutures and the influence of intestinal excision on postoperative complications.&#x0D; Study Design: Retrospective comparative study.&#x0D; Place and Duration of Study: General Surgery Department of CMH Peshawar, from Jan 2020 to Jan 2021.&#x0D; Methodology: Once receiving consent, all individuals hospitalized in the medical facility for ileostomy closure were included in our investigation. In a questionnaire, postoperative complications were documented.&#x0D; Result: This study involved a total of 60 subjects. Individuals were scheduled for surgery after receiving clearances and a loopogram distally. Thirty patients had their wounds hand-sewn shut, while 30 others had their wounds stapled shut. The mean operating time for the hand-sewn method was 2.46 ± 0.29 hours, compared to 1.86 ± 0.17 hours mean for the stapled method. In both categories, the anastomotic leak was comparable. Thirty patients in the hand-sewn group took a mean of 2.42 ± 0.25 days to return bowel sounds after surgery, whereas it took 1.83 ± 0.20 days to return bowel sounds.&#x0D; Conclusion: The stapler method greatly decreases the duration of surgery, promotes rapid recovery, and has a lower fatality rate. Stapling is a simple procedure that can be performed in inaccessible locations, such as a low colorectal anastomosis. In elective gastrointestinal procedures, stapler anastomosis can be utilized safely and successfully.

Could Stoma Be Avoided after Laparoscopic Low Anterior Resection for Rectal Cancer? Experience with Transanal Tube in 195 Cases.

Anastomotic leakage is the most-feared complication of rectal surgery. Transanal devices have been suggested for anastomotic protection as an alternative to defunctioning stoma, although evidence is conflicting, and no single device is widely used in clinical practice. The aim of this paper is to investigate the safety and efficacy of a transanal tube for the prevention of leakage following laparoscopic rectal cancer resection. A transanal tube was used in the cases of total mesorectal excision with low colorectal or coloanal anastomosis, undamaged doughnuts, and negative intraoperative air-leak test. The transanal tube was kept in place until the seventh postoperative day. A total of 195 consecutive patients were retrieved from a prospective surgical database and included in the study. Of these, 71.8% received preoperative chemoradiotherapy. The perioperative mortality rate was 1.0%. Anastomotic leakage occurred in 19 patients, accounting for an incidence rate of 9.7%. Among these, 13 patients underwent re-laparoscopy and ileostomy, while 6 patients were managed conservatively. Overall, the stoma rate was 6.7%. The use of a transanal tube may be a suitable strategy for anastomotic protection following restorative rectal cancer resection. This approach could avoid the burden of a stoma in selected patients with low anastomoses.

Quality of life in patients with rectal cancer with permanent stoma and low colorectal anastomosis

In recent decades, not only the oncological results of surgical treatment of rectal cancer have been actively studied, but also the impact that it has on the quality of life of patients. In the minds of a wide range of medical specialists, the idea that the presence of a permanent stoma is the factor that has the most adverse effect on the quality of life in the long term after a surgical intervention has become stronger. However, a significant number of modern studies are not supporting this point of view, not finding a significant difference in the quality of life in patients with a permanent stoma and a low colorectal anastomosis.

Endoluminal vacuum-assisted therapy to treat rectal anastomotic leakage: A critical analysis.

Endoluminal vacuum-assisted therapy (EVT) has been introduced recently to treat colorectal anastomotic leaks in clinically stable non-peritonitic patients. Its application has been mainly reserved to low colorectal and colo-anal anastomoses. The main advantage of this new procedure is to ensure continuous drainage of the abscess cavity, to promote and to accelerate the formation of granulation tissue resulting in a reduction of the abscess cavity. The reported results are promising allowing a higher preservation of the anastomosis when compared to conventional treatments that include trans-anastomotic tube placement, percutaneous drainage, endoscopic clipping of the anastomotic defect or stent placement. Nevertheless, despite this procedure is gaining acceptance among the surgical community, indications, inclusion criteria and definitions of success are not yet standardized and extremely heterogeneous, making it difficult to reach definitive conclusions and to ascertain which are the real benefits of this new procedure. Moreover, long-term and functional results are poorly reported. The present review is focused on critically analyzing the theoretical benefits and risks of the procedure, short- and long-term functional results and future direction in the application of EVT.

Redo surgery after low anterior resection for chronic pelvic sinus and anastomotic disruption. Could pull-through procedure with delayed anastomosis be a feasible alternative? Case reports and narrative review.

IntroductionA considerable step forward in low rectal cancer resection has been done in the last decades. Maintaining total mesorectal excision as the gold standard treatment, new techniques such as Trans-Anal Mini-Invasive Surgery (TAMIS) and Trans-Anal Total Mesorectal Excision (TATME), which have been added to improve skills in laparoscopic and robotic surgery, currently represent the advancement of this procedure. Despite improvements in surgical techniques, complications after low anterior resection for rectal cancer still remain a challenge. Drainage and colostomy are the main treatments used to overcome the problem caused by anastomosis failure, and most patients will never been restored. Different techniques of redo surgery could be proposed to deal complex cases, although remaining high risk procedures.Case presentationWe present two clinical cases with a late complication of the colorectal anastomosis: one with a late leakage of low colorectal anastomoses, treated with Hartman procedure, that developed a pelvic chronic sinus; the another one with complete anastomotic disruption after massive suture bleeding; both treated with delayed pull-through anastomosis, according to Turnbull-Cutait technique. We also made a review of relative literature, in order to back our therapeutic iters.DiscussionBoth the procedures were carried out satisfactorily, with restoration of intestinal continuity and good anastomotic result. It allows the resolutions of the chronic sepsis caused by the pelvic sinus and maintenance of intestinal continuity with a good Wexner incontinence score. Literary review demonstrated that this procedure still remains undervalued and not widely exploited.ConclusionDelayed pull-through coloanal anastomosis could be considered as a valid option, in order to preserve intestinal continuity in septic or complicated low colorectal anastomosis.

Dealing with Complications of Colorectal Surgery Using the Transanal Approach-When and How?

The transanal approach is a new and exciting addition to the surgeons' repertoire to deal with complications after colorectal surgery. Improved exposure, accessibility, and visibility greatly facilitate adequate dissection of the affected area with potential increase in effectiveness and reduced morbidity. An essential component in salvaging anastomotic leaks of low colorectal, coloanal, or ileoanal anastomoses is early diagnosis and early treatment, especially when starting with endoscopic vacuum therapy, followed by early surgical closure (endoscopic vacuum-assisted surgical closure). Redo surgery using a transanal minimally invasive surgery platform for chronic leaks after total mesorectal excision surgery or surgical causes of pouch failure successfully mitigates limited visibility and exposure by using a bottom-up approach.

Evaluation of the SafeHeal Colovac+ Anastomosis Protection Device: A Preclinical Study.

BackgroundThe protective ostomy is the current standard of care to protect a low colorectal anastomosis from leakage, but exposes patients to complications requiring an alternative strategy. The Colovac+ is a vacuum-based intraluminal bypass device designed to shield the anastomosis from fecal content, preventing the clinical outcomes of anastomotic leakage. The objective of this study was to evaluate the preliminary efficacy, safety, and technical feasibility of the Colovac+ in a porcine model. Methods: Twelve pigs received a colorectal anastomosis with Colovac+ implantation. The device was left in situ for 10 days and then retrieved endoscopically. Six pigs were to be sacrificed immediately after device retrieval and the other 6 were to be sacrificed on day 38. Clinical, endoscopic, and histopathological examinations were performed to evaluate the following endpoints: prevention of contact between the anastomosis and fecal content, device migration, feasibility of the implantation and retrieval procedure, collateral damage to the colonic wall, colon healing after device retrieval, and systemic toxicity related to the device. Results: Eleven pigs completed the study. One pig died prematurely due to a surgical complication unrelated to the device (bladder damage with uroperitoneum). There was no evidence of contact between the anastomosis and fecal content, none of the pigs developed symptomatic anastomotic leakage, there were no significant device migrations, and there was no evidence of systemic toxicity. Colovac+ implantation was easily performed in all cases except 1 (due to an inappropriate lubricant). Colovac+ retrieval was achieved successfully in all cases. Postretrieval examinations on day 10 revealed ulcerations at the anchoring site in 4 cases indicating mechanical damage caused by the stent. However, in the recovery group, no ulcerations were observed on day 38, and the colonic wall had properly healed in all animals. Conclusions: The Colovac+ is a technically feasible, safe, and efficient device for the protection of a colorectal anastomosis in a porcine model. The device holds promise for clinical use and warrants further research.

Morbidity of Temporary Loop Ileostomy in Patients with Colorectal Cancer.

Leakage of low colorectal anastomoses after total mesorectal excision is a dreaded complication. Hence, an ileostomy is commonly performed during anterior resection especially in patients who have received neoadjuvant radiation. The aim of this study was to quantify the temporary loop ileostomy-related benefits as well as morbidity in patients with colorectal cancer. We did a retrospective study including all patients who underwent anterior resection with diversion ileostomy for biopsy-proven rectal carcinoma at our institute from 1 Jan 2016 to 31 Dec 2017 with follow-up of 2years. A total of 104 patients were included in the study. In our series, 6.7% patients had an anastomotic dehiscence which precluded patients from stoma reversal. 12.5% of the patients had a stoma-related complication. 5.7% patients had complications following a stoma reversal. Eighty percent of the patients who developed clinically evident dehiscence in the immediate postoperative period were managed conservatively because of the presence of stoma. We did not have any mortality related to the stoma. 18.3% patients did not have their stomas reversed. The stoma non-reversal due to anastomotic dehiscence or stricture could be attributed to in 7.7% patients. 3.8% had to have their ileostomies converted to a permanent colostomy due to either a rectovaginal fistula or dehiscence or stricture. The complications associated with ileostomy are not insignificant. In our study, the tumor location in lower rectum was the only significant factor for non-reversal. We have to objectively identify patients who are at low risk for leakage and avoid ileostomy in them, and also try to minimize the morbidity of ileostomy by methods like early closure.

Effectiveness of negative pressure wound therapy with instillation and dwelling after stoma closure: a retrospective and propensity score matching analysis

The use of temporary diverting stoma has become more common in low colorectal anastomosis to reduce anastomotic complications. Surgical site infection (SSI) at the stoma closure site has been one of the most frequent postoperative complications. The aim of this study was to compare the short-term outcomes between conventional primary suture closure and negative pressure wound therapy with instillation and dwelling (NPWTi-d) therapy following purse-string suturing, using propensity score matching analysis. We retrospectively evaluated the medical records of 107 patients who underwent stoma closure between January 2016 and October 2020. The primary outcome was the proportion of SSI. The secondary outcome was the day of postoperative length of stay. Propensity score matching with one-to-one match was performed for reducing treatment selection bias. Of a total of 107 patients, 67 patients had been treated with conventional primary closure and 40 with NPWTi-d therapy. The propensity score matching derived 37 pairs. The respective SSI proportions were 0% and 16.2% in the groups with NPWTi-d and primary closure (P = 0.025). The respective median days of postoperative hospital stay were 9.0 and 10.0 in the groups with NPWTi-d and primary closure (P = 0.453). NPWTi-d therapy with purse-string suturing was effective in reducing SSI after stoma closure.

ASO Visual Abstract: Tailored Management with Highly Selective Diversion for Low Colorectal Anastomosis—Biochemical Postoperative Follow-Up and Long-Term Results from a Single-Institution Cohort

ASO Visual Abstract: Tailored Management with Highly Selective Diversion for Low Colorectal Anastomosis—Biochemical Postoperative Follow-Up and Long-Term Results from a Single-Institution Cohort

Efficacy of a transanal drainage tube versus diverting stoma in protecting colorectal anastomosis: a systematic review and meta-analysis.

Anastomotic leakage (AL) is the most fearsome complication in low rectal resection. The temporary diverting stoma (DS) is recommended to prevent AL, but it may cause relevant morbidity and needs a second surgical procedure to be closed. Therefore, the use of a transanal drainage tube (TDT) has been proposed as an alternative. We performed a systematic review and meta-analysis concerning the peri-operative outcomes in patients undergoing elective anterior rectal resection (ARR) with TDT alone or DS alone. Six studies were meta-analyzed, including a total of 735 patients. The meta-analysis showed that the incidences of AL, surgery-related complications, infective complications, and 30-day reoperation after ARR with low colorectal or coloanal anastomosis did not differ significantly between patients undergoing positioning of TDT and those undergoing DS. Furthermore, overall complications were significantly rarer in patients undergoing TDT. A meta-analysis of the randomized control trial (RCT) and no-RCT subgroups did not detect any statistically significant differences in any outcomes. These results suggest that it might be reasonable to employ a TDT in place of a DS to protect low colorectal and coloanal anastomosis, with consequent considerable advantages in terms of the short- and long-term post-operative outcomes. However, more well-designed RCTs are needed to definitively assess this issue.

Tailored Management with Highly-Selective Diversion for Low Colorectal Anastomosis: Biochemical Postoperative Follow-Up and Long-Term Results from a Single-Institution Cohort.

Defunctioning stoma (DS) can decrease the rate of symptomatic anastomotic leakage (AL). Since 2010, we have used tailored, highly selective DS management for low colorectal anastomosis (LCRA). In total, 433 rectal cancer patients underwent the same standardized procedure. Non-stoma (NS) management was used in patients with no surgical difficulties as well as good colonic preparation and quality of anastomoses. In all other cases, DS was used. C-reactive protein was measured during postoperative follow-up. Imbalance in the initial population was adjusted using propensity-score matching according to sex, age, body mass index, tumor location, and American Society of Anesthesiologists score. Rate of AL within 30 days, 5-year overall survival, local relapse-free survival, and disease-free survival were recorded. Anastomosis was mostly ultra-low and was performed equally by laparoscopy or robotic surgery. The overall rate of AL was 13.4%, with no significant differences between groups (DS, 12.2%; NS, 14.6%; p=0.575). Operative time, blood loss, and hospital stay were significantly lower for NS patients. The rate of secondary stoma was 11.4% overall. Pathological results were similar, with a 98% R0 resection rate. With a median follow-up of 5.5 years for the NS and DS groups, the overall survival was 84.9% and 73.4%, respectively (p=0.064), disease-free survival was 67.0% and 55.8%, respectively (p=0.095), and local relapse-free survival was 95.2% and 88.7%, respectively (p=0.084). The long-term, stoma-free rate was 89.1% overall. Tailoring DS for LCRA seems safe and could provide potential benefits in postoperative morbidity with the same long-term oncological results in NS patients. Prospective, multicentric studies should validate this approach.