Gastrointestinal
Endoscopic evaluation of clinical colorectal anastomotic leakage

https://doi.org/10.1016/j.jss.2014.07.009Get rights and content

Abstract

Background

Anastomotic leakage (AL) is a major complication after anterior resection. However, its therapeutic strategies and technical risk factors have not been well established. Therefore, we endoscopically evaluated anastomotic regions after laparoscopic colorectal anastomosis using a double-stapling technique (DST) for determination of treatment and investigation of technical factors.

Methods

In total, 191 consecutive patients underwent laparoscopic anterior resection with a DST from September 2008–January 2013. Anastomotic regions were endoscopically evaluated in patients suspected to have AL after surgery.

Results

Anastomotic dehiscence was observed in 19 patients, and AL was diagnosed in 18 (9.3%). Of the 19 patients, 12 were treated by creation of an intestinal stoma and 7 were treated conservatively based on their clinical status and endoscopic findings. Twenty-three dehiscences were observed among 19 anastomotic regions; all 23 were observed on the circular stapler anastomosis lines. Of these 23 dehiscences, 13 (56.5%) were located at the point at which the anastomosis lines of the circular and linear staplers overlapped, and 10 (43.5%) were located on the circumferential aspect between the overlapping points.

Conclusions

Endoscopic evaluation of anastomotic regions is safe and useful for the determination of therapeutic strategies. The DST anastomotic technique itself may be closely related to the development of AL.

Introduction

Anastomotic leakage (AL) is a major problem following laparoscopic surgery in patients with rectal cancer. This complication contributes not only to postoperative morbidity and mortality but to local recurrence and poor prognosis [1], [2], [3], [4], [5], [6], [7], [8], [9], [10], [11]. The introduction of circular staplers in the 1970s and the double-stapling technique (DST) in the 1980s have resulted in a relatively safe method of end-to-end low colorectal anastomosis [12], [13], [14], [15], reducing the rate of AL compared with hand-sewn anastomoses [15], [16], [17]. Nevertheless, the rate of AL after laparoscopic surgery has been found to range from approximately 5%–19%, which is higher than that observed after other gastrointestinal anastomosis techniques [1], [2], [3], [4], [5], [6], [7], [8].

Factors associated with AL include patient-, surgery-, and instrument-associated factors. The most important patient-associated factors include older age, male sex, smoking, diabetes, obesity, larger tumor size, lower tumor level, and preoperative radiation and chemotherapy. Surgery-associated factors include perioperative complications such as total mesorectal excision, incomplete anastomosis, excessive tension on the anastomosis, blood circulation disorders, and bleeding in an anastomotic region. Instrument-associated factors in laparoscopic surgery include the number of linear staples and the size of circular staples [18], [19], [20].

Comparatively, little is known, however, about the effects of technical factors of the DST itself [21]. Therefore, we endoscopically evaluated anastomotic regions to determine the characteristics that can be used for the diagnosis of AL, determination of the therapeutic strategies for AL, and investigation of technical factors after laparoscopic intracorporeal colorectal anastomosis using a DST.

Section snippets

Patients

We retrospectively evaluated a total of 191 consecutive patients who underwent laparoscopic rectal anterior resection with a DST for rectal cancer from September 2006–December 2012 at our institutions. No prophylactic covering stoma was created in any patients. AL occurred in 18 (9.3%) of these 191 patients. The anastomotic regions were examined in 41 patients suspected to have postoperative AL.

Eight of the 41 patients were strongly suspected to have AL based on severe clinical findings

Details of endoscopic examination

Forty-one patients underwent a total of 66 rectosigmoidoscopy sessions. None experienced obvious endoscopic complications, and none showed rapidly worsening symptoms after endoscopy. Each endoscopic examination was completed in <10 min. Scheduled endoscopy was feasible and safe in all patients and was completed without severe discomfort (Fig. 1).

Endoscopic findings of anastomotic regions in 41 patients

Eight patients were strongly suspected to have AL based on severe clinical findings. Their anastomosis sites were endoscopically examined and confirmed

Discussion

To our knowledge, no previous study has used endoscopy to examine the onset of AL around low anterior anastomotic sites. Endoscopic evaluation of anastomosis sites has three primary goals: early exclusion-based diagnosis or early definitive diagnosis, therapeutic decision-making, and investigation of the technical causes of AL after colorectal anastomosis with a DST.

Three characteristics of the AL after DST anastomosis were noted in this early postoperative endoscopic evaluation. First, all ALs

Acknowledgment

Authors' contributions: T.I. and M.M. contributed to the study conception and design. T.I., M.M., and M.H. did the data analysis and interpretation. T.I., R.K., K.T., K.O., Y.K., T.A., H.S., and E.O. did the data collection. T.I. did the writing and critical revision of the article. T.I., R.K., K.T., K.A., Y.K., T.A., H.S., and E.O. did the funding acquisition. Y.M. did the total instruction.

No financial support was received for this work from any company. This study was supported in part by a

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