Dehiscence of colorectal anastomosis is a serious complication that is associated with increased mortality, impaired functional and oncological outcomes. The hypothesis was that anastomosis reinforcement and vacuum trans-anal drainage could eliminate some risk factors, such as mechanically stapled anastomosis instability and local infection. Patients with rectal cancer within 10 cm of the anal verge and low anterior resection with double-stapled technique were included consecutively. A stapler anastomosis was supplemented by trans-anal reinforcement and vacuum drainage using a povidone-iodine-soaked sponge. Modified reinforcement using a circular mucosa plication was developed and used. Patients were followed up by postoperative endoscopy and outcomes were acute leak rate, morbidity, and diversion rate. The procedure was successfully completed in 52 from 54 patients during time period January 2019-October 2020. The mean age of patients was 61 years (lower-upper quartiles 54-69 years). There were 38/52 (73%) males and 14/52 (27%) females; the neoadjuvant radiotherapy was indicated in a group of patients in 24/52 (46%). The mean level of anastomosis was 3.8 cm (lower-upper quartiles 3.00-4.88 cm). The overall morbidity was 32.6% (17/52) and Clavien-Dindo complications ≥ 3 grade appeared in 3/52 (5.7%) patients. No loss of anastomosis was recorded and no patient died postoperatively. The symptomatic anastomotic leak was recorded in 2 (3.8%) patients and asymptomatic blind fistula was recorded in one patient 1/52 (1.9%). Diversion ileostomy was created in 1/52 patient (1.9%). Reinforcement of double-stapled anastomosis using a circular mucosa plication with combination of vacuum povidone-iodine-soaked sponge drainage led to a low acute leak and diversion rate. This pilot study requires further investigation.Registered at ClinicalTrials.gov.: Trial registration number is NCT04735107, date of registration February 2, 2021, registered retrospectively.

Department of Gastroenterology Jessenius Medical Faculty in Martin Comenius University in Bratislava University Hospital Martin Martin Slovak Republic

Department of Surgery and Transplant Centre Jessenius Medical Faculty in Martin Comenius University in Bratislava University Hospital Martin Martin Slovak Republic

Department of Surgery Faculty Hospital Žilina Žilina Slovak Republic

Františka Komárka 865 6 503 11 Hradec Králové Czech Republic

Laboratory of Bioinformatics and Biostatistics Jessenius Medical Faculty in Martin Biomedical Center Martin Comenius University in Bratislava Martin Slovak Republic

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Smith JD, Butte JM, Weiser MR, D’Angelica MI, Paty PB, Temple LK, et al. Anastomotic leak following low anterior resection in stage IV rectal cancer is associated with poor survival. Ann Surg Oncol. 2013;20:2641–2646. doi: 10.1245/s10434-012-2854-9. PubMed DOI

Hain E, Maggiori L, Manceau G, Mongin C, Prost ADJ, Panis Y. Oncological impact of anastomotic leakage after laparoscopic mesorectal excision. Br J Surg. 2017;104:288–295. doi: 10.1002/bjs.10332. PubMed DOI

Karim A, Cubas V, Zaman S, Khan S, Patel H, Waterland P. Anastomotic leak and cancer-specific outcomes after curative rectal cancer surgery: a systematic review and meta-analysis. Tech Coloproctol. 2020;24:513–525. doi: 10.1007/s10151-020-02153-5. PubMed DOI

Zhou X, Wang B, Li F, Wang J, Fu W. Risk factors associated with nonclosure of defunctioning stomas after sphincter-preserving low anterior resection of rectal cancer: a meta-analysis. Dis Colon Rectum. 2017;60:544–554. doi: 10.1097/DCR.0000000000000819. PubMed DOI

Ashraf SQ, Burns EM, Jani A, Altman S, Young JD, Cunningham C, et al. The economic impact of anastomotic leakage after anterior resections in English NHS hospitals: are we adequately remunerating them? Colorectal Dis. 2013;15:e190–198. doi: 10.1111/codi.12125. PubMed DOI

Hammond J, Lim S, Wan Y, Gao X, Patkar A. The burden of gastrointestinal anastomotic leaks: an evaluation of clinical and economic outcomes. J Gastrointest Surg. 2014;18:1176–1185. doi: 10.1007/s11605-014-2506-4. PubMed DOI PMC

Borly L, Ellebaek MB, Qvist N. Leakage after surgery for rectum cancer: inconsistency in reporting to the danish colorectal cancer group. Surg Res Pract. 2015;2015:376540. doi: 10.1155/2015/376540. PubMed DOI PMC

Olsen BC, Sakkestad ST, Pfeffer F, Karliczek A. Rate of anastomotic leakage after rectal anastomosis depends on the definition: pelvic abscesses are significant. Scand J Surg. 2019;108:241–249. doi: 10.1177/1457496918812223. PubMed DOI

Draginov A, Chesney TR, Quereshy HA, Chadi SA, Quereshy FA. Association of high ligation versus low ligation of the inferior mesenteric artery on anastomotic leak, postoperative complications, and mortality after minimally invasive surgery for distal sigmoid and rectal cancer. Surg Endosc. 2020;34:4593–4600. doi: 10.1007/s00464-019-07203-0. PubMed DOI

Sparreboom CL, van Groningen JT, Lingsma HF, Wouters M, Menon AG, Kleinrensink GJ, et al. Different risk factors for early and late colorectal anastomotic leakage in a nationwide audit. Dis Colon Rectum. 2018;61:1258–1266. doi: 10.1097/DCR.0000000000001202. PubMed DOI

Cong ZJ, Hu LH, Bian ZQ, Ye GY, Yu MH, Gao YH, et al. Systematic review of anastomotic leakage rate according to an international grading system following anterior resection for rectal cancer. PLoS ONE. 2013;8:e75519. doi: 10.1371/journal.pone.0075519. PubMed DOI PMC

Borstlap WAA, Westerduin E, Aukema TS, Bemelman WA, Tanis PJ, Dutch Snapshot Research Group Anastomotic leakage and chronic presacral sinus formation after low anterior resection: results from a large cross-sectional study. Ann Surg. 2017;266:870–877. doi: 10.1097/SLA.0000000000002429. PubMed DOI

Meyer J, Naiken S, Christou N, Liot E, Toso C, Buchs NC, et al. Reducing anastomotic leak in colorectal surgery: the old dogmas and the new challenges. World J Gastroenterol. 2019;25:5017–5025. doi: 10.3748/wjg.v25.i34.5017. PubMed DOI PMC

Kawada K, Sakai Y. Preoperative, intraoperative and postoperative risk factors for anastomotic leakage after laparoscopic low anterior resection with double stapling technique anastomosis. World J Gastroenterol. 2016;22:5718–5727. doi: 10.3748/wjg.v22.i25.5718. PubMed DOI PMC

Qu H, Liu Y, Bi DS. Clinical risk factors for anastomotic leakage after laparoscopic anterior resection for rectal cancer: a systematic review and meta-analysis. Surg Endosc. 2015;29:3608–3617. doi: 10.1007/s00464-015-4117-x. PubMed DOI

Rink AD, Kienle P, Aigner F, Ulrich A. How to reduce anastomotic leakage in colorectal surgery-report from German expert meeting. Langenbecks Arch Surg. 2020;405:223–232. doi: 10.1007/s00423-020-01864-5. PubMed DOI

Garcia-Granero E, Navarro F, Santacruz CC, Frasson M, Garcia-Granero A, Marinello F, et al. Individual surgeon is an independent risk factor for leak after double-stapled colorectal anastomosis: an institutional analysis of 800 patients. Surgery. 2017;162:1006–1016. doi: 10.1016/j.surg.2017.05.023. PubMed DOI

Kim JC, Lee JL, Kim CW, Lim SB, Alsaleem HA, Park SH. Mechanotechnical faults and particular issues of anastomotic complications following robot-assisted anterior resection in 968 rectal cancer patients. J Surg Oncol. 2019;120:1436–1445. doi: 10.1002/jso.25765. PubMed DOI

Garg PK, Goel A, Sharma S, Chishi N, Gaur MK. Protective diversion stoma in low anterior resection for rectal cancer: a meta-analysis of randomized controlled trials. Visc Med. 2019;35:156–160. doi: 10.1159/000497168. PubMed DOI PMC

European Society of Coloproctology Collaborating Group An international multicentre prospective audit of elective rectal cancer surgery; operative approach versus outcome, including transanal total mesorectal excision (TaTME) Colorectal Dis. 2018;20(Suppl 6):33–46. doi: 10.1111/codi.14376. PubMed DOI

Hajibandeh S, Hajibandeh S, Eltair M, George AT, Thumbe V, Torrance AW, et al. Meta-analysis of transanal total mesorectal excision versus laparoscopic total mesorectal excision in management of rectal cancer. Int J Colorectal Dis. 2020;35:575–593. doi: 10.1007/s00384-020-03545-7. PubMed DOI

Guel-Klein S, Biebl M, Knoll B, Dittrich L, Weiss S, Pratschke J, et al. Anastomotic leak after transanal total mesorectal excision: grading of severity and management aimed at preservation of the anastomosis. Colorectal Dis. 2019;21:894–902. doi: 10.1111/codi.14635. PubMed DOI

Vallance A, Wexner S, Berho M, Cahill R, Coleman M, Haboubi N, et al. A collaborative review of the current concepts and challenges of anastomotic leaks in colorectal surgery. Colorectal Dis. 2017;19:O1–O12. doi: 10.1111/codi.13534. PubMed DOI

Lu Z, Peng J, Li C, Wang F, Jiang W, Fan W, et al. Efficacy and safety of a NiTi CAR 27 compression ring for end-to-end anastomosis compared with conventional staplers: a real-world analysis in Chinese colorectal cancer patients. Clinics. 2016;71:264–270. doi: 10.6061/clinics/2016(05)04. PubMed DOI PMC

Crafa F, Smolarek S, Missori G, Shalaby M, Quaresima S, Noviello A, et al. Transanal inspection and management of low colorectal anastomosis performed with a new technique: the TICRANT Study. Surg Innov. 2017;24:483–491. doi: 10.1177/1553350617709182. PubMed DOI

Bakker IS, Morks AN, Ten Cate Hoedemaker HO, Burgerhof JGM, Leuvenink HG, van Praagh JB, et al. Randomized clinical trial of biodegradeable intraluminal sheath to prevent anastomotic leak after stapled colorectal anastomosis. Br J Surg. 2017;104:1010–1019. doi: 10.1002/bjs.10534. PubMed DOI

Schardey HM, Wirth U, Strauss T, Kasparek MS, Schneider D, Jauch KW. Prevention of anastomotic leak in rectal cancer surgery with local antibiotic decontamination: a prospective, randomized, double-blind, placebo-controlled single center trial. Int J Colorectal Dis. 2020;35:847–857. doi: 10.1007/s00384-020-03544-8. PubMed DOI

Hyoju SK, Klabbers RE, Aaron M, Krezalek MA, Zaborin A, Wiegerinck M, et al. Oral polyphosphate suppresses bacterial collagenase production and prevents anastomotic leak due to Serratia marcescens and Pseudomonas aeruginosa. Ann Surg. 2018;267:1112–1118. doi: 10.1097/SLA.0000000000002167. PubMed DOI PMC

Gaines S, Hyoju S, Williamson AJ, van Praagh JB, Zaborina O, Rubin DT, et al. Infliximab does not promote the presence of collagenolytic bacteria in a mouse model of colorectal anastomosis. J Gastrointest Surg. 2020 doi: 10.1007/s11605-019-04486-5. PubMed DOI PMC

Matsuda M, Tsuruta M, Hasegawa H, Okabayashi K, Kondo T, Shimada T, et al. Transanal drainage tube placement to prevent anastomotic leakage following colorectal cancer surgery with double stapling reconstruction. Surg Today. 2016;46:613–620. doi: 10.1007/s00595-015-1230-3. PubMed DOI

Shigeta K, Okabayashi K, Baba H, Hasegawa H, Tsuruta M, Yamafuji K, et al. A meta-analysis of the use of a transanal drainage tube to prevent anastomotic leakage after anterior resection by double-stapling technique for rectal cancer. Surg Endosc. 2016;30:543–550. doi: 10.1007/s00464-015-4237-3. PubMed DOI

Maeda K, Nagahara H, Shibutani M, Ohtani H, Sakurai K, Toyokawa T, et al. Efficacy of intracorporeal reinforcing sutures for anastomotic leakage after laparoscopic surgery for rectal cancer. Surg Endosc. 2015;29:3535–3542. doi: 10.1007/s00464-015-4104-2. PubMed DOI

Wenger FA, Szucsik E, Hoinoiu BF, Cimpean AM, Ionac M, Raica M. Circular anastomotic experimental fibrin sealant protection in deep colorectal anastomosis in pigs in a randomized 9-day survival study. Int J Colorectal Dis. 2015;30:1029–1039. doi: 10.1007/s00384-015-2260-4. PubMed DOI

Placer C, Enriquez-Navascues JM, Elorza G, Timoteo A, Mugica JA, Borda N, et al. Preventing complications in colorectal anastomosis: results of a randomized controlled trial using bioabsorbable staple line reinforcement for circular stapler. Dis Colon Rectum. 2014;57:1195–1201. doi: 10.1097/DCR.0000000000000207. PubMed DOI

Baek SJ, Kim J, Kwak J, Kim SH. Can trans-anal reinforcing sutures after double stapling in lower anterior resection reduce the need for a temporary diverting ostomy? World J Gastroenterol. 2013;19:5309–5313. doi: 10.3748/wjg.v19.i32.5309. PubMed DOI PMC

Wu Z, Vakalopoulos KA, Kroese LF, Boersema GS, Kleinrensink GJ, Jeekel J, et al. Reducing anastomotic leakage by reinforcement of colorectal anastomosis with cyanoacrylate glue. Eur Surg Res. 2013;50:255–261. doi: 10.1159/000350383. PubMed DOI

Altomare DF, Delrio P, Shelgyn Y, Rybakov E, Vincenti L, De Fazio M, et al. Transanal reinforcement of low rectal anastomosis versus protective ileostomy after total mesorectal excision for rectal cancer. Preliminary results of a randomized clinical trial. Colorectal Dis. 2021 doi: 10.1111/codi.15685. PubMed DOI

Ferko A, Rejholoc J, Škrovina M, Tachecí I, Sirák I. Colorectal anastomosis dehiscence: a call for more detailed morphological classification. Wideochir Inne Tech Maloinwazyjne. 2020 doi: 10.5114/wiitm.2020.97367. PubMed DOI PMC

Son GM, Kim TU, Park BS, Jung HJ, Lee SS, Yoon JU, et al. Colonic hypoperfusion following ligation of the inferior mesenteric artery in rectosigmoid colon cancer patients. Ann Surg Treat Res. 2019;97:74–82. doi: 10.4174/astr.2019.97.2.74. PubMed DOI PMC

Guo Y, Wang D, He L, Zhang Y, Zhao S, Zhang L, et al. Marginal artery stump pressure in left colic artery-preserving rectal cancer surgery: a clinical trial. ANZ J Surg. 2017;87:576–581. doi: 10.1111/ans.13032. PubMed DOI

Sakorafas GH, Zouros E, Peros G. Applied vascular anatomy of the colon and rectum: clinical implications for the surgical oncologist. Surg Oncol. 2006;15:243–255. doi: 10.1016/j.suronc.2007.03.002. PubMed DOI

Son GM, Kwon MS, Kim Y, Kim J, Kim SH, Lee JW. Quantitative analysis of colon perfusion pattern using indocyanine green (ICG) angiography in laparoscopic colorectal surgery. Surg Endosc. 2019;33:1640–1649. doi: 10.1007/s00464-018-6439-y. PubMed DOI PMC

Tulchinsky H, Kashtan H, Rabau M, Wasserberg N. Evaluation of the NiTi shape memory BioDynamix ColonRing in colorectal anastomosis: first in human multi-center study. Int J Colorectal Dis. 2010;25:1453–1458. doi: 10.1007/s00384-010-0985-7. PubMed DOI

Braunschmid T, Hartig N, Baumann L, Dauser B, Herbst F. Influence of multiple stapler firings used for rectal division on colorectal anastomotic leak rate. Surg Endosc. 2017;31:5318–5326. doi: 10.1007/s00464-017-5611-0. PubMed DOI PMC

Kim JH, Kim HY, Lee IK, Oh ST, Kim JG, Lee YS. Intra-operative double-stapled colorectal or coloanal anastomotic complications of laparoscopic low anterior resection for rectal cancer: double-stapled anastomotic complication could result in persistent anastomotic leakage. Surg Endosc. 2015;29:3117–3124. doi: 10.1007/s00464-014-4035-3. PubMed DOI

Vallicelli C, Pirrera B, Alagna V, Fantini E, Palini GM, Zanini N, et al. Intraoperative endoscopy with immediate suture reinforcement of the defect in colorectal anastomosis: a pilot study. Updates Surg. 2020 doi: 10.1007/s13304-020-00746-1. PubMed DOI

Velnar T, Bailey T, Smrkolj V. The wound healing process: an overview of the cellular and molecular mechanisms. J Int Med Res. 2009;37:1528–1542. doi: 10.1177/147323000903700531. PubMed DOI

Borstlap WAA, Musters GD, Stassen LPS, van Westreenen HL, Hess D, van Dieren S, et al. Vacuum-assisted early transanal closure of leaking low colorectal anastomoses: the CLEAN study. Surg Endosc. 2018;32:315–327. doi: 10.1007/s00464-017-5679-6. PubMed DOI PMC

Javed AA, Teinor J, Wright M, Ding D, Burkhart RA, Hundt J, et al. Negative pressure wound therapy for surgical-site infections. Ann Surg. 2019;269:1034–1040. doi: 10.1097/sla.0000000000003056. PubMed DOI

Murphy PB, Knowles S, Chadi SA, Vogt K, Brackstone M, Koughnett JAV, et al. Negative pressure wound therapy use to decrease surgical nosocomial events in colorectal resections (NEPTUNE): a randomized controlled trial. Ann Surg. 2019;270:38–42. doi: 10.1097/SLA.0000000000003111. PubMed DOI

Labler L, Rancan M, Mica L, Harter L, Mihic-Probst D, Keel M. Vacuum-assisted closure therapy increases local interleukin-8 and vascular endothelial growth factor levels in traumatic wounds. J Trauma. 2009;66:749–757. doi: 10.1097/TA.0b013e318171971a. PubMed DOI

Kuper TM, Murphy PB, Kaur B, Ott MC. Prophylactic negative pressure wound therapy for closed laparotomy incisions: a meta-analysis of randomized controlled trials. Ann Surg. 2020;271:67–74. doi: 10.1097/SLA.0000000000003435. PubMed DOI

Patmo AS, Krijnen P, Tuinebreijer WE, Breederveld RS. The effect of vacuum-assisted closure on the bacterial load and type of bacteria: a systematic review. Adv Wound Care (New Rochelle) 2014;3:383–389. doi: 10.1089/wound.2013.0510. PubMed DOI PMC

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NCT04735107