GastrointestinalEndoscopic evaluation of clinical colorectal anastomotic leakage
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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