Incidence and Risk Factors for Anastomotic Failure in 1594 Patients Treated by Transanal Total Mesorectal Excision

Lee

Journal of Surgical Oncology

et al. 2019

Background As most risk factors for anastomotic complications (AC) in rectal cancer patients appear to be noncorrectable, it is needed to find the correctable causes. Additionally, the outcomes of indocyanine‐green fluorescence imaging (IFI) and robot‐stapled anastomosis have yet been undetermined. Methods This study retrospectively analyzed 968 consecutive patients with rectal cancer, who underwent curative robot‐assisted anterior resections between 2010 and 2018. IFI parameters and stapling features in the surgical records were reviewed, and reconfirmed. Results AC occurred in 54 patients (5.6%), 34 (3.5%) with anastomotic leakage (AL) and 24 (2.5%) with anastomotic stenosis (AS). Mechanotechnical faults including defective stapling configurations, including angles lesser than or equal to 150° and outer deviation (more than half from the center of the circle) of linear staples, between the two linear staples were independently associated with AL (P < .001 each). IFI significantly reduced AL rate (2.5% vs 5.3%, P = .029) and AS rate (2% vs 18.8%, P = .006), respectively. Robot linear stapling enabled to maintain the obtuse angle during consecutive staplings and reduced console time. AL and AS were independent risk factors for disease‐free survival (P = .02) and local recurrence (P = .03), respectively. Conclusions AC were associated with some correctable causes, namely, mechanotechnical errors and lack of use of IFI.

Section: Discussionsupporting

confidence: 92%

Mechanotechnical faults and particular issues of anastomotic complications following robot‐assisted anterior resection in 968 rectal cancer patients

Lee

Journal of Surgical Oncology

et al. 2019

“…This study supports the use of a TaTME approach for rectal cancer resection, with comparable postoperative outcomes and pathological safety compared to other approaches. This is in line with recent evidence on TaTME delivery across Europe . The leak rate was higher than previously reported, at 12.9%, which at univariable level was significantly higher than other techniques.…”

Section: Discussionsupporting

confidence: 92%

An international multicentre prospective audit of elective rectal cancer surgery; operative approach versus outcome, including transanal total mesorectal excision (TaTME)

Kamarajah¹,

Pinkney²,

El‐Hussuna³

et al. 2018

Colorectal Disease

Introduction Transanal total mesorectal excision (TaTME) has rapidly emerged as a novel approach for rectal cancer surgery. Safety profiles are still emerging and more comparative data is urgently needed. This study aimed to compare indications and short‐term outcomes of TaTME, open, laparoscopic, and robotic TME internationally. Methods A pre‐planned analysis of the European Society of Coloproctology (ESCP) 2017 audit was performed. Patients undergoing elective total mesorectal excision (TME) for malignancy between 1 January 2017 and 15 March 2017 by any operative approach were included. The primary outcome measure was anastomotic leak. Results Of 2579 included patients, 76.2% (1966/2579) underwent TME with restorative anastomosis of which 19.9% (312/1966) had a minimally invasive approach (laparoscopic or robotic) which included a transanal component (TaTME). Overall, 9.0% (175/1951, 15 missing outcome data) of patients suffered an anastomotic leak. On univariate analysis both laparoscopic TaTME (OR 1.61, 1.02–2.48, P = 0.04) and robotic TaTME (OR 3.05, 1.10–7.34, P = 0.02) were associated with a higher risk of anastomotic leak than non‐transanal laparoscopic TME. However this association was lost in the mixed‐effects model controlling for patient and disease factors (OR 1.23, 0.77–1.97, P = 0.39 and OR 2.11, 0.79–5.62, P = 0.14 respectively), whilst low rectal anastomosis (OR 2.72, 1.55–4.77, P < 0.001) and male gender (OR 2.29, 1.52–3.44, P < 0.001) remained strongly associated. The overall positive circumferential margin resection rate was 4.0%, which varied between operative approaches: laparoscopic 3.2%, transanal 3.8%, open 4.7%, robotic 1%. Conclusion This contemporaneous international snapshot shows that uptake of the TaTME approach is widespread and is associated with surgically and pathologically acceptable results.

“…as well as of Penna et al . who reported successful non‐operative treatment of AL in 73% and 82%, respectively . Furthermore, anastomosis‐preserving management of AL was achieved in six patients in the AL group (75%), which may be considered as promising especially for AL in comparison to reported permanent stoma rates in up to 56%–68% of patients with AL .…”

Section: Discussionmentioning

confidence: 92%

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

et al. 2019

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.