BACKGROUND: Anastomotic leak after low anterior rectal resection is a dreadful complication. Early diagnosis, prompt management of sepsis followed by closure of anastomotic defect may increase chances of anastomotic salvage. In this randomized experimental study, we evaluated two different methods of trans-anal anastomotic repair. METHODS: A model of anastomotic leak was created in 42 male pigs. Laparoscopic low anterior resection was performed with anastomosis created using a circular stapler with half of the staples removed. Two days later, animals were randomized into a TAMIS (trans-anal minimally invasive surgery) repair, endoscopic suture (ENDO) or control group with no treatment (CONTROL). Signs of intraabdominal infection (IAI), macroscopic anastomotic healing and burst tests were evaluated to assess closure quality after animals were sacrificed on the ninth postoperative day. RESULTS: Closure was technically feasible in all 28 animals. Two animals had to be euthanized due to progressive sepsis at four and five days after endoscopic closure. Healed anastomosis with no visible defect was observed in 10/14 and 11/14 animals in TAMIS and ENDO groups, respectively, versus 2/14 in CONTROL (p < 0.05). Overall IAI rate was significantly lower in TAMIS (4/14; p = 0.006) and ENDO (5/14; p = 0.018) compared to CONTROL (12/14). Burst tests confirmed sealed closure in healed anastomosis with a median failure pressure of 190 (110-300) mmHg in TAMIS and 200 (100-300) mmHg in ENDO group (p = 0.644). CONCLUSION: In this randomized experimental study, we found that both evaluated techniques are effective in early repair of dehiscent colorectal anastomosis with a high healing rate.

1st Department of Surgery The General University Hospital Prague Prague Czech Republic

Department of Hepatogastroenterology Institute for Clinical and Experimental Medicine Prague Czech Republic

Institute of Animal Physiology and Genetics Czech Academy of Science Libechov Czech Republic

Royal Lancaster Infirmary University Hospitals of Morecambe Bay NHS Foundation Trust Lancaster UK

Surgery Department 2nd Faculty of Medicine Charles University and Central Military Hospital Severovýchodní 2 580 22 Záběhlice Prague 14100 Czech Republic

Zobrazit více v PubMed

Heald RJ, Ryall RD (1986) Recurrence and survival after total mesorectal excision for rectal cancer. Lancet 1:1479–1482 DOI

Matthiessen P, Henriksson M, Hallbook O, Grunditz E, Noren B, Arbman G (2008) Increase of serum C-reactive protein is an early indicator of subsequent symptomatic anastomotic leakage after anterior resection. Colorectal Dis 10:75–80 DOI

McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC (2015) Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg 102:462–479 DOI

Kube R, Mroczkowski P, Granowski D, Benedix F, Sahm M, Schmidt U, Gastinger I, Lippert H, Study group Qualitatssicherung Kolon/Rektum-Karzinome (Primartumor) (Quality assurance in primary colorectal carcinoma) (2010) Anastomotic leakage after colon cancer surgery: a predictor of significant morbidity and hospital mortality, and diminished tumour-free survival. Eur J Surg Oncol 36:120–124 DOI

Khan AA, Wheeler JM, Cunningham C, George B, Kettlewell M, Mortensen NJ (2008) The management and outcome of anastomotic leaks in colorectal surgery. Colorectal Dis 10:587–592 DOI

Gessler B, Eriksson O, Angenete E (2017) Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery. Int J Colorectal Dis 32:549–556 DOI

Blumetti J, Chaudhry V, Cintron JR, Park JJ, Marecik S, Harrison JL, Prassad LM, Abcarian H (2014) Management of anastomotic leak: lessons learned from a large colon and rectal surgery training program. World J Surg 38:985–991 DOI

Nesbakken A, Nygaard K, Lunde OC (2001) Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg 88:400–404 DOI

Borstlap WAA, Musters GD, Stassen LPS, van Westreenen HL, Hess D, van Dieren S, Festen S, van der Zaag EJ, Tanis PJ, Bemelman WA (2018) Vacuum-assisted early transanal closure of leaking low colorectal anastomoses: the CLEAN study. Surg Endosc 32:315–327 DOI

Atallah S, Albert M, Larach S (2010) Transanal minimally invasive surgery: a giant leap forward. Surg Endosc 24:2200–2205 DOI

Adegbola SO, Sahnan K, Pellino G, Warusavitarne J (2018) Transanal minimal invasive surgery—pushing the boundaries of transanal surgery. Mini-invasive Surg 2:40 DOI

Chiu PW, Hu B, Lau JY, Sun LC, Sung JJ, Chung SS (2006) Endoscopic plication of massively bleeding peptic ulcer by using the Eagle Claw VII device: a feasibility study in a porcine model. Gastrointest Endosc 63:681–685 DOI

Stavropoulos SN, Modayil R, Friedel D (2015) Current applications of endoscopic suturing. World J Gastrointest Endosc 7:777–789 DOI

Pommergaard HC, Rosenberg J, Schumacher-Petersen C, Achiam MP (2011) Choosing the best animal species to mimic clinical colon anastomotic leakage in humans: a qualitative systematic review. Eur Surg Res 47:173–181 DOI

Swindle MM, Smith AC, Hepburn BJ (1988) Swine as models in experimental surgery. J Invest Surg 1:65–79 DOI

Simpson GS, Smith R, Sutton P, Shekouh A, McFaul C, Johnson M, Vimalachandran D (2014) The aetiology of delay to commencement of adjuvant chemotherapy following colorectal resection. Int J Surg Oncol 2014:670212 PubMed PMC

Fraccalvieri D, Biondo S, Saez J, Millan M, Kreisler E, Golda T, Frago R, Miguel B (2012) Management of colorectal anastomotic leakage: differences between salvage and anastomotic takedown. Am J Surg 204:671–676 DOI

Krarup PM, Jorgensen LN, Harling H (2014) Danish Colorectal Cancer Group. Management of anastomotic leakage in a nationwide cohort of colonic cancer patients. J Am Coll Surg 218:940–949 DOI

Nordentoft T, Sorensen M (2007) Leakage of colon anastomoses: development of an experimentalmodel in pigs. Eur Surg Res 39:14–16 DOI

Hoeppner J, Crnogorac V, Hopt UT, Weiser HF (2009) The pig as an experimental model for colonic healing study of leakage and ischemia in colonic anastomosis. J Invest Surg 22:281–285 DOI

Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, Holm T, Wong WD, Tiret E, Moriya Y, Laurberg S, den Dulk M, van de Velde C, Buchler MW (2010) Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the international study group of rectal cancer. Surgery 147:339–351 DOI

Fernández-Hevia M, Delgado S, Castells A et al (2015) Transanal total mesorectal excision in rectal cancer: short-term outcomes in comparison with laparoscopic surgery. Ann Surg 261:221–227 DOI

Perivoliotis K, Baloyiannis I, Sarakatsianou C, Tzovaras G (2020) Comparison of the transanal surgical techniques for local excision of rectal tumors: a network meta-analysis. Int J Colorectal Dis 35:1173–1182 DOI

van Vledder MG, Doornebosch PG, de Graaf EJ (2016) Transanal endoscopic surgery for complications of prior rectal surgery. Surg Endosc 30:5356–5363 DOI

Sharaiha RZ, Kumta NA, DeFilippis EM, Dimaio CHJ, Gonzalez S, Gonda T, Rogart J, Siddiqui A, Berg PS, Samuels P, Miller L, Khashab MA, Saxena P, Gaidhane MR, Tyberg A, Teixeira J, Widmer J, Kedia P, Loren D, Kahaleh M, Sethi A (2016) A large multicenter experience with endoscopic suturing for management of gastrointestinal defects and stent anchorage in 122 patients: a retrospective review. J Clin Gastroenterol 50:388–392 DOI

Callahan ZM, Su B, Kuchta K, Conati E, Novak S, Linn J, Murad FS, Carbray J, Ujiki M (2020) Endoscopic suturing results in high technical and clinical success rates for a variety of gastrointestinal pathologies. J Gastrointest Surg 24:278–287 DOI

Belfiori V, Antonini F, Deminicis SM, B, Piergallini S, Siquini W, Macarri G, (2017) Successful closure of anastomotic dehiscence after colon–rectal cancer resection using the Apollo overstitch suturing system. Endoscopy 49:823–824 DOI

Stewart D, Hunt S, Pierce R, Mao D, Frisella M, Cook K, Starcher B, Fleshman J (2007) Validation of the NITI endoluminal compression anastomosis ring (EndoCAR) device and comparison to the traditional circular stapled colorectal anastomosis in a porcine model. Surg Innov 14:252–260 DOI

Rosenberger LH, Shada A, Ritter LA, Mauro DM, Mentrikoski MJ, Feldman SH, Kleiner DE (2014) Delayed endoluminal vacuum therapy for rectal anastomotic leaks after rectal resection in a swine model: a new treatment option. Clin Transl Sci 7:121–126 DOI

Wang YF, Cai XJ, Jin RA, Liang YL, Huang DY, Peng SY (2011) Experimental study of primary repair of colonic leakage with a degradable stent in a porcine model. J Gastrointest Surg 15:1995–2000 DOI

Correa TD, Pereira AJ, Brandt S, Vuda M, Djafarzadeh S, Takala J, Jakob SM (2017) Time course of blood lactate levels, inflammation, and mitochondrial function in experimental sepsis. Crit Care 21:105 DOI