Delayed pull‐through coloanal anastomosis without temporary stoma: an alternative to the standard manual side‐to‐end coloanal anastomosis with temporary stoma? A comparative study in 223 patients with low rectal cancer

Abstract

Aim After total mesorectal excision (TME) for low rectal cancer, current guideline recommendations for sphincter‐saving surgery are to perform a side‐to‐end manual coloanal anastomosis (CAA) (or with J‐pouch) with a temporary stoma. Our study aimed to evaluate if delayed pull‐through coloanal anastomosis (DCAA) without a temporary stoma could represent a safe alternative in low rectal cancer. Method From 2003 to 2020, 223 consecutive patients with low rectal cancer undergoing TME were compared: CAA and diverting stoma (n = 190) versus DCAA without stoma (n = 33). Results Overall 3‐month and severe (Dindo ≥ IIIb) morbidity rates were similar in CAA versus DCAA groups: 34% (65/190) vs. 36% (12/33) and 2.6% (5/190) vs. 3% (1/33), respectively. In the DCAA group, only one patient (3%) underwent reoperation (Hartmann's procedure) at day 3 due to colon necrosis. The anastomotic leakage rate (both clinical and radiological) was significantly higher after CAA than DCAA: 28% (53/190) vs. 3% (1/33; p = 0.00138). Failure of the procedure (with return to stoma) was observed in 8% (15/190) vs. 6% (2/33) of patients after CAA and DCAA respectively (not significant). Conclusion Our comparative study suggested that in patients with low rectal cancer, DCAA without a temporary stoma could represent an interesting alternative to the actual recommended CAA with a temporary ileostomy. DCAA could offer two major advantages over CAA: a significantly lower rate of anastomotic leakage and absence of a temporary stoma and its potential complications (rehospitalization, dehydration, wound hernia after stoma closure).

Clinical Practice Guidelines in Colorectal Surgery: Do We Need to Randomize Everything?

“…There are interesting data confirmed by a study from my group using systematic use of WSCE, which reports an even higher rate of 14/111 (12.6%) occult radiologic leaks following laparoscopic coloanal anastomosis in only low rectal cancer. 6 A similar rate was noted in another study from my group evaluating the risk of local recurrence after TME following anastomotic leak: among 428 patients undergoing laparoscopic TME, radiological leak without symptoms was noted in 50 of 428 patients (11.7%). 7 These relatively high rates of radiologically asymptomatic leaks after TME can probably be explained, at least in part, by the better detection of leaks using CT scans than with only WCSE because of possible reconstruction techniques and better visualization of the posterior presacral part of the anastomosis, which is the preferential site for radiological leak.…”

Cost‐effectiveness comparison of delayed versus immediate coloanal anastomosis following ultralow anterior resection for rectal cancer

“…A recently published retrospective cohort study comparing DCAA versus ICAA with diverting stoma showed a significantly lower anastomotic leak rate with DCAA (3% vs. 28%) 19 . The authors postulated that the difference in DCAA technique may have accounted for the appreciably lower DCAA leak rate in their cohort compared to that reported in the earlier randomized trial.…”

“…TPN is not mandatory, and several units have routinely allowed diet following abdominoperineal pull‐through 19,20 . For completeness, we performed cost analyses on a range of TPN use starting from no use to usage beyond the upper limit of delay from pull‐through to the DCAA procedure, as reported in the literature.…”

Postoperative Morbidity Following Loop Ileostomy Reversal after Primary Elective or Urgent Surgery: A Retrospective Study with 145 Patients

“…Although protective loop ileostomy after TME could be avoided in selected patients using specific intraoperative strategies [ 19 , 20 ], it still has an important role in reducing the incidence and severity of the anastomotic leakage [ 6 , 7 ]. The short-term outcomes after diverting loop ileostomy closure can be affected by several factors.…”