Anastomotic leak after transanal total mesorectal excision: grading of severity and management aimed at preservation of the anastomosis

Abstract

Aim The transanal approach to total mesorectal excision (TaTME) as an alternative to conventional anterior resection offers an improved view to otherwise restricted anatomical regions in obese and narrow male pelves and unfavourable tumour locations. Guidelines for the management of anastomotic leakage (AL) following low rectal resections are scarce. Patients and methods Prospectively collected data of all consecutive patients undergoing TaTME between December 2014 and April 2017 in our centre were analysed retrospectively. Existing classification systems for AL were modified with regard to transanal anastomotic‐preserving management. Results TaTME was performed in 66 patients with a median age of 56.2 years. The overall incidence of AL was 12.1% (n = 8). AL grading was differentiated in Grades I to V according to the severity of necrosis and abscess development. Two patients suffered from AL Grade II, one patient from Grade III, three patients from Grade IV and two patients from Grade V. Preservation of the anastomosis following AL was achieved by the damage control concept in six of eight patients (75%) with a median duration of hospital stay of 36 days. Two patients received a Hartmann procedure (Grades IV and V). Conclusion Our study demonstrates that management of AL following TaTME is challenging but definitely amenable to strategies aimed at preserving the anastomosis by appropriate damage control. The modified classification system might serve as guidance for anastomosis‐preserving management.

Experience beyond the learning curve of transanal total mesorectal excision (taTME) and its effect on the incidence of anastomotic leak

“…Anastomotic failure after the construction of a colorectal anastomosis is associated with significant morbidity and mortality; the risk of permanent stoma after AL is more than 60% and oncologic results, including overall survival, disease-free survival, and cancer-specific survival, are definitively less favorable [18]. In a retrospective analysis, Kang et al identified the overall AL rate after low anterior resection (open and laparoscopic) to be 13.7%, and a higher overall mortality in those cases was also identified in this study [16,19]. According to the most recent publication by the international registry, on 1594 patients, the main risk factors for AL after taTME surgery included male sex, obesity, tumors > 25 mm, excessive intraoperative blood loss, manual anastomosis, and prolonged perineal operative time [17].…”

“…Experience and volume seem to have a significant impact on most of the major short-term postoperative outcomes after taTME surgery, including oncologic results and postoperative complications such as anastomotic leak (AL) [14,15]. A persistent concern is the potential marginal increase of AL related to the procedure, which, according to recent literature, could be up to 12-15% overall and close to 8% in the 30 days following surgery [16,17]. Anastomotic failure after the construction of a colorectal anastomosis is associated with significant morbidity and mortality; the risk of permanent stoma after AL is more than 60% and oncologic results, including overall survival, disease-free survival, and cancer-specific survival, are definitively less favorable [18].…”

Controversies and consensus in transanal total mesorectal excision (taTME): Is it a valid choice for rectal cancer?

“…A recent meta-analysis 28 that involved 899 patients also showed no significant differences in overall postoperative complications (p = .39) and AL (p = .60). In another retrospective study by Guel-Klein et al, 29 eight episodes of AL among 66 patients were reported, and the overall incidence of AL was 12.1%, which is comparable with the results of laTME. Most studies concluded that taTME would not lead to a higher rate of postoperative complications and confirmed the noninferiority of its short-term outcomes.…”

Transanal Ileal Pouch-Anal Anastomosis for Ulcerative Colitis - A Retrospective Single-Center Study Regarding Anastomotic Leakage and Episodes of Pouchitis in the Long-Term

“…While eAL could be treated only with endosponge therapy, lAL required a multimodal approach consisting of endosponge therapy, transanal suture and reopening of diverting loop-ileostomy. Our therapeutic approach relies on our experiences after TaTME for rectal carcinoma, where we developed a differentiated therapy strategy for AL (20). Endosponge therapy for AL after IPAA has not yet been widely researched, but the few studies existing show non-inferiority in comparison to conventional treatment and high rates of pouch preservation (21,29).…”

“…The multimodal treatment procedures of AL management include -depending on the extent of ALantibiotic therapy, radiological or endoscopic interventions as well as reoperation with the intend to preserve continuity, as recently shown by different groups for AL for rectal cancer and in ammatory bowel disease (19)(20)(21).…”