Mucosal blood flow in the remaining rectal stump is more affected by total than partial mesorectal excision in patients undergoing anterior resection: a key to understanding differing rates of anastomotic leakage?

Abstract

Purpose Anterior resection is the procedure of choice for tumours in the mid and upper rectum. Depending on tumour height, a total mesorectal excision (TME) or partial mesorectal excision (PME) can be performed. Low anastomoses in particular have a high risk of developing anastomotic leakage, which might be explained by blood perfusion compromise. A pilot study indicated a worse blood flow in TME patients in an open setting. The aim of this study was to further evaluate perianastomotic blood perfusion changes in relation to TME and PME in a predominantly laparoscopic context. Method In this prospective cohort study, laser Doppler flowmetry was used to evaluate the perianastomotic colonic and rectal perfusion before and after surgery. The two surgical techniques were compared in terms of mean differences of perfusion units using a repeated measures ANOVA design, which also enabled interaction analyses between type of mesorectal excision and location of measurement. Anastomotic leakage until 90 days after surgery was reported for descriptive purposes. Results Some 28 patients were available for analysis: 17 TME and 11 PME patients. TME patients had a reduced blood perfusion postoperatively compared to PME patients in the aboral posterior area (mean difference: −57 vs 18 perfusion units; p = 0.010). An interaction between mesorectal excision type and anterior/posterior location was detected at the aboral level (p = 0.007). Two patients developed a minor leakage, diagnosed after discharge. Conclusion Patients operated on using TME have a decreased blood flow in the aboral posterior quadrant of the rectum postoperatively compared to patients operated on using PME. This might explain differing rates of anastomotic leakage. Trial registration ClinicalTrials.gov Identifier: NCT02401100

Risk Factors and Preventive Measures for Anastomotic Leak in Colorectal Cancer

“…In another study, the blood flow measurements with laser Doppler flowmetry were made preoperatively and postoperatively, aiming to compare blood flow changes around the anastomosis in relation to total mesorectal excision (TME) and partial mesorectal excision (PME). 67 The results showed that TME group had a decreased blood flow of the rectum postoperatively than PME group, which may indicate the different AL rates in TME and PME.…”

Splenic flexure mobilization and anastomotic leakage in anterior resection for rectal cancer: A multicentre cohort study

“…Adequate perfusion is essential for a successful colorectal anastomosis, where excessive tension would decrease blood flow and subsequently risk ischemia. Numerous endeavors have strived to show how marginal artery bleeding, 20 colonic perfusion by fluorescence angiography, 21 and rectal laser Doppler flowmetry 22,23 can be utilized to detect insufficient blood flow. While some of these methods are promising, sufficient data do not exist to prove any clinical benefit of their use.…”

Risk factors, quality of life, and oncological effects of refractory anastomotic leakage for laparoscopic intersphincteric resection

“…Firstly, the lower anastomosis means higher risk of anastomotic dehiscence; secondly, the wider gap and fewer tissues surrounding the supra‐levator ani space can contribute to making AL difficult to localize and be wrapped. Additionally, for ISR, there are few arterial branches in the distal rectum, 31 and surgical procedures will inevitably damage the blood supply of the distal rectum, 32 resulting in chronic ischemia of the distal rectum that can be strikingly unfavorable for anastomosis healing. Therefore, AL after ISR will be more critical and less likely to heal spontaneously, and persistent infection will lead to chronic presacral sinus formation or perforation of adjacent tissues forming rectoperineal fistula, rectovesical fistula, and even rectourethral fistula.…”