Evaluation of techniques to prevent colorectal anastomotic leakage

doi:10.1016/j.jss.2014.11.045

Journal of Surgical Research

Volume 194, Issue 2, April 2015, Pages 450-457

https://doi.org/10.1016/j.jss.2014.11.045 Get rights and content

Abstract

Background

Anastomotic leakage is a major complication after anterior resection for rectal cancer. The double-stapling technique (DST) is the main method for creating a colorectal anastomosis. However, the rate of anastomotic leakage after DST remains high, and the technical risk factors have not been well established.

Materials and methods

Five methods of colorectal anastomosis were performed on the porcine rectum and colon: single-stapled double-purse-string (SSDP), DST, side-to-side with a linear stapler (SS-L), side-to-side with a circular stapler (SS-C), and SS-C with hand-sewn reinforcement (n = 6 for each method). In each group, burst pressures were tested, paying special attention to the locations of the first disruptions. The anastomosis line, including staples, was embedded in polyester resin, and polished sections were examined histologically.

Results

Burst pressures were significantly higher in the SS-L and SS-C than those in the SSDP and DST groups (P < 0.001) and were higher in the SS-C with hand-sewn reinforcement than those in the SS-L and SS-C groups (P < 0.001). Remarkably, in the SSDP, DST, and SS-C groups, the first disruptions occurred on the staple line created by the circular stapler.

Conclusions

The experimentally strongest colorectal anastomosis created with instruments currently in use was a SS-C. This anastomosis does not overlap staple lines and does not require a purse-string suture. Hand-sewn reinforcement was effective in increasing the anastomotic strength.

Introduction

The double-stapling technique (DST) is the most frequently performed method for colorectal anastomosis and is the only intracorporeal method possible for lower rectal anastomosis. However, the risk of anastomosis leakage (AL) after DST remains high, and the technical risk factors have not been well established [1], [2], [3], [4], [5], [6].

In a preliminary endoscopic evaluation of anastomosis lesions after DST, we noted three characteristics of AL [1]. First, all ALs occurred on the circular anastomosis line. Second, half the ALs occurred on the overlapping stapler points, and the other half occurred between the overlapping points. Third, neither necrotic changes nor ischemic injury occurred in other locations, including the residual rectal stump. Furthermore, investigation of the technical factors related to the development of AL after DST anastomosis revealed that the anastomosis method itself may be closely associated with the development of AL. However, our endoscopic evaluation of DST assessed relatively few patients, and analyzing larger patient populations within a short period is difficult. Therefore, we chose to evaluate the technical factors of colorectal anastomosis in this animal study.

Some animal experiments on colorectal anastomosis strength have been reported. However, all preliminary experiments used the colon or small intestines [2], [5]. The present study was performed using porcine rectum, which lacks serosa and has thick muscle layers. The purpose of this experiment was to investigate the technical factors of colorectal anastomosis with stapling and to identify the most reliable method. Hand-sewn reinforcement was also examined to determine whether it was effective in increasing the anastomotic strength.

Section snippets

Animal care

Fifteen healthy female Japanese domestic pigs, 3–4 mo-old and weighing 30–42 kg, were used in this study, which was conducted in full accordance with the principles and authorization of the local Helsinki Institutional Review Board for animal studies (approval code A23-189-0, obtained from the corresponding ethical committee of Kyushu University).

Operative technique

Through a midline laparotomy, the distal rectum was transected at as low a level as possible and the proximal rectum divided at the transition between

Burst pressure

The first burst pressures were as follows: SSDP, 11.2 ± 3.9 mm Hg; DST, 13.0 ± 4.2; SS-L, 33.8 ± 2.6; SS-C, 49.8 ± 22.7; and SS-C + HR, 89.0 ± 14.3 mm Hg (n = 6). Pressures were significantly higher in the SS-L and SS-C than in the SSDP and DST groups (P < 0.001; Fig. 1A) and were higher in the SS + HR than in the SS-C and SS-L groups (P < 0.001; Fig. 1B).

Disruptions

The first disruptions in the SSDP, DST, SS-C, and SS-C + HR groups occurred on the circular anastomosis line. In the DST group, the first

Discussion

To the best of our knowledge, this is the first study of anastomosis methodology to report histologic findings of the anastomotic regions containing staples.

We chose to perform our experiments extracorporeally for two reasons. First, in the preliminary clinical results of an endoscopic evaluation of colorectal ALs after DST, all ALs occurred on the circular anastomosis line, and neither necrotic changes nor ischemic injury occurred in other locations, including the residual rectal stump [1].

Conclusions

Side-to-side anastomosis with CS is technically faultless because the staple lines do not overlap and a purse-string is not needed. However, the CS has a structure in which all the staples are tightened by only one gripping force and, when it is completed, the staple line is staggered in two rows. By performing hand-sewn suturing of the entire circumference, the anastomosis line can itself be reinforced and an ideal, strong anastomosis can be provided.

Acknowledgment

No financial support was received for this work from any company. This study was supported in part by a grant from the Scientific Research Fund of the Ministry of Education, Culture, Sports, Science, and Technology of Japan.

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

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GastrointestinalEvaluation of techniques to prevent colorectal anastomotic leakage

Abstract

Background

Materials and methods

Results

Conclusions

Introduction

Section snippets

Animal care

Operative technique

Burst pressure

Disruptions

Discussion

Conclusions

Acknowledgment

J Surg Res

Am J Surg

The effect of sealing with a fixed combination of collagen matrix-bound coagulation factors on the healing of colonic anastomoses in experimental high-risk mice models

Langenbecks Arch Surg

Morbidity and mortality after single- and double-stapled colorectal anastomoses in patients with carcinoma of the rectum

Aust N Z J Surg

Comparison of intracorporeal single-stapled and double-stapled anastomosis in laparoscopic low anterior resection for rectal cancer: a case-control study

Int J Colorectal Dis

“Dog ear” formation after double-stapled low anterior resection as a risk factor for anastomotic disruption

Dis Colon Rectum

Gastrointestinal
Evaluation of techniques to prevent colorectal anastomotic leakage