Colorectal anastomosis during cytoreductive radical surgery in patients with peritoneal surface malignancies. Validation of a new technique (without stoma) to prevent anastomosis leakage in more than 1000 procedures.

ABSTRACT

OBJECTIVE: To describe a novel end-to-end "true" reinforced stapling colorectal anastomosis and to assess surgical outcomes in a large case series of advanced cancer patients undergoing this procedure. Anastomotic leakage (AL) remains the main concern following surgery for colorectal cancer. METHODS: Between September 2006 and May 2018, in the context of the Catalonian Program of Peritoneal Carcinomatosis, 1193 consecutive patients with advanced abdominal and/or pelvic tumors were included in a prospective single-center study. They underwent cytoreductive radical surgery (CRS) in most cases combined with hyperthermic intraperitoneal chemotherapy (HIPEC). Among other surgical procedures, 374 patients underwent rectal resection and colorectal/ileorectal anastomosis, whether alone or associated to other digestive anastomosis. Key aspects of colorectal anastomosis technique were (1) complete dissection and mobilization of the distal third of the rectum, (2) placement of a stitch that included both ends of the linear stapling of the rectal stump that was knotted on the anvil of the circular stapler, (3) "cleaning" the fatty tissue of the intestinal ends, (4) adjustment of the height of staples to the thickness of the intestinal wall, and (5) a second layer of interrupted nonperforating sutures placed circumferentially to reinforce the stapled anastomoses. A diverting stoma was not performed. RESULTS: According to clinical criteria, of the 1193 patients included, 296 cases underwent CRS (group 1) and 897 cases CRS + HIPEC (group 2). In group 1, 332 surgical procedures were performed, with 248 digestive anastomoses, of which 98 (39.5%) were colorectal anastomoses, associated to other digestive anastomosis in 37 cases. In group 2, 972 surgical procedures were performed, with 707 digestive anastomoses, of which 263 were colorectal (37.2%), 116 were associated with other digestive anastomosis. Ileocolic anastomosis was the most frequently associated digestive anastomosis. 71 major urinary reconstructions, 283 radical hysterectomies and no diverting stoma were performed. Globally, there was only three colo-ileorectal AL (3/374 = 0.8%). The overall 90-day mortality rate was 0.25%. CONCLUSIONS: A technical modification to create a "true" end-to-end and completely circular reinforced anastomosis effectively prevents anastomotic leakage in patients with advanced tumors undergoing radical resection of the rectum, with no need of diverting stoma.