Utility of intra‐operative flexible sigmoidoscopy to assess colorectal anastomosis: a systematic review and meta‐analysis

Abstract

Background Anastomotic leak (AL) after colorectal resection leads to increased oncological and non‐oncological, morbidity and mortality. Intra‐operative assessment of a colorectal anastomosis with intra‐operative flexible sigmoidoscopy (IOFS) has become increasingly prevalent and is an alternative to conventional air leak test. It is thought that intra‐operative identification of an AL or anastomotic bleeding (AB) allows for immediate reparative intervention at the time of anastomosis formation itself. We aim to assess the available evidence for the use of IOFS to prevent complications following colorectal resection. Methods Following Preferred Reporting Items for Systematic Reviews and Meta‐analyses guidelines, a systematic review of the literature between January 1980 and June 2020 was performed. Comparative studies assessing IOFS versus conventional air leak test were compared, and outcomes were pooled. Results A total of 4512 articles were assessed, of which eight were found to meet the inclusion criteria. A total of 1792 patients were compared; 884 in the IOFS arm and 908 in the control arm. IOFS was associated with an increase in the rate of positive leak test (odds ratio (OR) 5.21, P > 0.001), a decrease in AL (OR 0.45, P = 0.006) and a decrease in post‐operative AB requiring intervention (OR 0.40, P = 0.037). Conclusion In a non‐randomized meta‐analysis, IOFS increases the likelihood of identifying an anastomotic defect or bleeding intra‐operatively. This allows for immediate intervention that decreases the rate of AL and AB. This adds impetus for performing routine IOFS after a left‐sided colorectal resection with anastomosis and highlights the need for randomized controlled trial to confirm the finding.

Utility of intra‐operative flexible sigmoidoscopy to assess colorectal anastomosis: A systematic review and meta‐analysis

“…We read with great interest the article by Krishnaswamy and Krawitz, which was published in your esteemed journal. 1 We congratulate the authors for reporting such a compelling case. We would also like to add a few pertinent details that you may find relevant.…”

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The Colorectal Anastomosis: A Timeless Challenge

“…It may be used to guide rectal dissection, ensure adequate margin, or to examine the fresh anastomosis. It was recently validated in a meta-analysis, 133 demonstrating increased identification of anastomotic defect (OR ¼ 5.21), as well as decreased incidence of anastomotic leak (OR ¼ 0.45) and anastomotic bleeding (OR 0.40). Endoscopy also facilitates measurement of the distance between the anastomosis and anal verge which is important for internal housekeeping, complete documentation, and compliance with National Accreditation Program for Rectal Cancer (NAPRC) standards.…”

An Observational Analysis of a Novel Digital Rectoscope

“…LumenEye® inspection of a colorectal anastomosis allows both air leak testing, an essential step in forming an anastomosis [9], and direct inspection of the anastomosis, with digital images available for the notes. Intraoperative inspection of a colorectal anastomosis has been shown to improve the detection rate of anastomotic defects, reducing anastomotic leak (OR 0.45) and post-operative anastomotic bleeding requiring intervention (OR 0.40) when using flexible sigmoidoscopy rather than conventional air leak testing [10]. The LumenEye® offers similar image quality and recording technology to flexible sigmoidoscopy.…”