An innovative and convenient technique to reduce anastomotic leakage after double stapling anastomosis: laparoscopic demucositized suture the overlapping point of the "dog ear" area

Association Between Cross-Stapling Technique in Mechanical Colorectal Anastomosis and Short-term Outcomes

BACKGROUND

The double-stapled technique is the most common method of colorectal anastomosis in minimally invasive surgery. Several modifications to the conventional technique have been described to reduce the intersection between the stapled lines, as the resulting lateral dog-ears are considered possible risk factors for anastomotic leakage.

OBJECTIVE

This study aimed to analyze the outcomes of patients receiving conventional versus modified stapled colorectal anastomosis after minimally invasive surgery.

DATA SOURCES

A systematic review of the published literature was undertaken. PubMed/MEDLINE, Web of Science, and Embase databases were screened up to July 2023.

STUDY SELECTION

Relevant articles were searched according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Articles reporting on the outcomes of patients with modified stapled colorectal reconstruction compared with the conventional method of double-stapled anastomosis were included.

INTERVENTIONS

Conventional double-stapling colorectal anastomosis and modified techniques with reduced intersection between the stapled lines were compared.

MAIN OUTCOME MEASURES

The rate of anastomotic leak was the primary end point of interest. Perioperative details including postoperative morbidity were also appraised.

RESULTS

There were 2537 patients from 12 studies included for data extraction, with no significant differences in age, BMI, or proportion of high ASA score between patients who had conventional versus modified techniques of reconstructions. The risk of anastomotic leak was 62% lower for the modified procedure than for the conventional procedure (OR = 0.38 [95% CI, 0.26-0.56]). The incidences of overall postoperative morbidity (OR = 0.57 [95% CI, 0.45-0.73]) and major morbidity (OR = 0.48 [95% CI, 0.32-0.72]) following modified stapled anastomosis were significantly lower than following conventional double-stapled anastomosis.

LIMITATIONS

The retrospective nature of most included studies is a main limitation, essentially because of the lack of randomization and the risk of selection and detection bias.

CONCLUSIONS

The available evidence supports the modification of the conventional double-stapled technique with the elimination of 1 of both dog-ears as it is associated with a lower incidence of anastomotic-related morbidity.

The role of superior hemorrhoidal vein ectasia in the preoperative staging of rectal cancer

Objective

The prognosis of colorectal cancer has continuously improved in recent years thanks to continuous progress in both the therapeutic and diagnostic fields. The specific objective of this study is to contribute to the diagnostic field through the evaluation of the correlation between superior hemorrhoidal vein (SHV) ectasia detected on computed tomography (CT) and Tumor (T), Node (N), and distant metastasis (M) examination and mesorectal fascia (MRF) invasion in the preoperative staging of rectal cancer.

Methods

Between January 2018 and April 2022, 46 patients with histopathological diagnosis of rectal cancer were retrospectively enrolled, and the diameter of the SHV was evaluated by CT examination. The cutoff value for SHV diameter used is 3.7 mm. The diameter was measured at the level of S2 during portal venous phase after 4× image zoom to reduce the interobserver variability. The parameters evaluated were tumor location, detection of MRF infiltration (defined as the distance < 1 mm between the tumor margins and the fascia), SHV diameter, detection of mesorectal perilesional lymph nodes, and detection of metastasis.

Results

A total of 67.39% (31/46) of patients had SHV ectasia. All patients with MRF infiltration (4/46, 7.14%) presented SHV ectasia (average diameter of 4.4 mm), and SHV was significantly related with the development of liver metastases at the moment of primary staging and during follow-up.

Conclusion

SHV ectasia may be related to metastasis and MRF involvement; therefore, it could become a tool for preoperative staging of rectal cancer.

Single-stapling technique versus hand-sewn anastomosis in inter-sphincteric resection with transanal total mesorectal excision (Super SST): protocol for a multicentre randomized clinical trial

BACKGROUND

Currently, hand-sewn anastomosis is the standard procedure for inter-sphincteric resection (ISR); however, distal purse-string suturing during transanal total mesorectal excision (TaTME) has allowed a single-stapling technique (SST). Although it was originally intended for cases requiring anastomosis of 2 cm or more above the anorectal junction (ARJ), SST could be safely performed in ISR. The aim of this trial is to determine the superiority of SST over hand-sewn anastomosis in ISR with TaTME.

METHODS

The Super SST trial is a multicentre randomized clinical trial comparing stapled and hand-sewn anastomoses in ISR with TaTME. The trial will recruit patients scheduled for TaTME with anastomosis below the ARJ, who will be allocated 1:1 to receive either hand-sewn or stapled anastomosis. The primary endpoint is anastomosis-related complications within 30 postoperative days. Secondary endpoints include all early and late complications, operating time, reoperation, mortality rate, length of postoperative hospital stay, readmission, incidence of anal pain and rectal mucosal prolapse, length of temporary stoma retention, the proportion of patients with a temporary stoma at 1 year after surgery, and anorectal function at 1 year after surgery.

CONCLUSION

This trial will provide important clinical insights for new and promising anastomotic options for patients with very low rectal cancer. Registration number: UMIN000047818 (https://www.umin.ac.jp/ctr/index-j.htme).

Novel surgical procedure for preventing anastomotic leakage following colorectal cancer surgery: A propensity score matching study

Hypoperfusion is the main cause of anastomotic leakage (AL) following colorectal surgery. The conventional method for evaluating anastomotic perfusion is to observe color change and active bleeding of the resection margin of the intestine and the pulsation of mesenteric vessels. However, the accuracy of this method is low, which may be due to insufficient observation time. A novel surgical procedure that separates the mesentery in advance at the intended transection site can delay the observation of anastomotic perfusion, and can potentially detect more anastomotic sites with insufficient vascular supply and reduce the rate of AL. This study aimed to investigate the effects of a novel surgical procedure on AL following sigmoid colon and rectal cancer surgeries. A total of 343 patients who underwent rectal and sigmoid colon cancer surgeries were included in the study. From August 2021 to June 2022, patients with sigmoid colon or rectal cancer underwent a new surgical procedure of pre-division of the mesentery (PDM) at the intended transection site (PDM group). Patients with colorectal cancer who underwent conventional surgical procedures from August 2018 to July 2021 were categorized as the non-PDM group. Symptomatic AL (SAL) within 30 days and other outcomes were retrospectively analyzed using propensity score matching and compared between the two groups. The incidences of SAL were 1.3% and 11.3% in the PDM and non-PDM groups, respectively. PDM significantly reduced the SAL rate in sigmoid colon and rectal cancer surgeries (P = 0.009). The incidence of total postoperative complications (P < 0.05) was significantly lower in the PDM group than that in the non-PDM group. There were no significant differences between the two groups for operative time (P = 0.662), intraoperative blood loss (P = 0.651), intraoperative blood transfusion (P = 0.316), and intensive care rate (P = 1). The length of postoperative hospital stay (P = 0.010) and first exhaust (P = 0.001) and defecation time (P < 0.05) were shorter in the PDM group than in the non-PDM group. PDM can effectively prevent AL, and this procedure can be safely performed in sigmoid colon and rectal cancer surgeries.