Surgical technique and considerations about transanal transection and single-stapled (TTSS) anastomosis: the search for a perfect anastomosis

The evaluation of preventivemeasures and risk factors for anastomotic leakage has been a constant concern among colorectal surgeons. In this context, the description of a new way to perform a colorectal, coloanal or ileoanal anastomosis, known as transanal transection and single-stapled (TTSS) anastomosis, deserves an appreciation of its qualities, and a discussion about its properties and technical details. In the present paper, the authors review themost recent efforts aiming to reduce anastomotic dehiscence, and describe the TTSS technique in a patient submitted to laparoscopic total proctocolectomy with ileal pouch-anal anastomosis for familial adenomatous polyposis. Surgical perception raises important advantages such as distal rectal transection under visualization, elimination of double-stapling lines (with cost-effectiveness and potential protection against suture dehiscence), elimination of dog ears, and the opportunity to be accomplished via a transanal approach after open, laparoscopic, or robotic colorectal resections. Future studies to confirm these supposed advantages are needed. (AU)

Postoperative outcomes and functional results after Deloyer's procedure - a retrospective cohort study / Desfechos pós-operatórios e resultados funcionais após o procedimento de Deloyer ­ um estudo de coorte retrospectivo

ABSTRACT Introduction: The objective of our study was to describe surgical outcomes of Deloyers procedure in our referral center, and to compare the results of patients with and without protective ileostomy. Methods: Patients undergoing a Deloyers procedure from 2013 to 2016 were prospectively included. General characteristics, intraoperative variables, postoperative course, and functional outcomes were analyzed. Patients were compared into two groups: group (1) patients undergoing Deloyers procedure without ileostomy, and group (2) Deloyers procedure with protective ileostomy. Results: Sixteen patients undergoing isoperistaltic transposition of the right colon remnant were included, of which 9 (63%) were males with a median age of 47 (range 22-76) years. The main surgical indication was the restoration of bowel transit (62.5%). There was higher major morbidity rate in the Deloyers procedure with protective ileostomy group, but without statistical significance (20% vs. 9%, p = 0.92). No leaks or deaths were reported. The length of hospital stay was 7 days. The mean number of bowel movements per day was 4 at 18 months of follow up. Only four (25%) patients used irregularly loperamide. Conclusions: The Deloyers procedure has satisfactory results and is reproducible with low morbidity. The major and minor morbidity rates were similar between groups, suggesting that the costs and risks of a second procedure can be avoided by providing a safe primary anastomosis.

RESUMO Introdução: O objetivo de nosso estudo foi descrever os resultados cirúrgicos do procedimento de Deloyer em nosso centro de referência e comparar os resultados de pacientes com e sem ileostomia de proteção. Métodos: Pacientes submetidos ao procedimento de Deloyer de 2013 a 2016 foram incluídos prospectivamente. Foram analisadas as características gerais, as variáveis intraoperatórias, o curso pós-operatório e os desfechos funcionais. Os pacientes foram comparados em dois grupos: Grupo 1) pacientes submetidos ao procedimento de Deloyer (PD) sem ileostomia, e grupo 2) procedimento de Deloyer com ileostomia de proteção (IP). Resultados: Foram incluídos 16 pacientes submetidos à transposição isoperistáltica da porção remanescente do cólon direito, dos quais 9 (63%) eram do sexo masculino com idade média de 47 anos (variação de 22-76) anos. A principal indicação cirúrgica foi a restauração do trânsito intestinal (62,5%). Houve maior morbidade maior no grupo IP, mas sem significância estatística (20% vs. 9%, p = 0,92). Nenhum vazamento ou óbito foi relatado. A duração da hospitalização foi de 7 dias. O número médio de evacuações por dia foi 4, aos 18 meses de seguimento. Apenas quatro (25%) pacientes utilizaram irregularmente a loperamida. Conclusões: O procedimento de Deloyer tem resultados satisfatórios e é reprodutível com baixa morbidade. As taxas de morbidades maiores e menores foram semelhantes entre os grupos, sugerindo que os custos e riscos de um segundo procedimento podem ser evitados proporcionando-se uma anastomose primária segura.

Scheduled maturation in low colorectal and coloanal anastomoses / Maturação programada em anastomoses colorretais baixas e coloanais

Introduction: Anastomotic dehiscence is the main complication after low colorectal and coloanal anastomoses. The techniques commonly used are the double-stapling and hand-sewn anastomoses, both are made with immediate maturation. These techniques do not prevent pelvic sepsis in many patients and are not feasible in all cases. Objective: The study aim is to report the technical details and results with the use of scheduled maturation anastomosis in ten patients. Surgical technique: The scheduled maturation anastomosis is done in two steps. The first step is the closure of colonic stump in a way that keeps the mucosa layer in everted position. The second step is the union of the colon and rectum ends by transanal access. All the sutures are made with 2/0 polyglactin. A diverting stoma must be done in all cases. After 30 days, begins spontaneous opening of the anastomosis. Results: Ten patients underwent this technique. There were two cases of stenosis that were treated with digital dilatation in office. All patients had their diverting ostomy closed. Conclusion: The scheduled maturation anastomosis is feasible in difficult cases and may prevent pelvic sepsis in low colorectal and coloanal anastomoses.

Introdução: A deiscência anastomótica é a principal complicação após anastomoses colorretais baixas e coloanais. As técnicas comumente usadas são o duplo grampeamento e a anastomose manual, ambas são feitas com maturação imediata. Estas técnicas não impedem a sepse pélvica em muitos pacientes e não são exequíveis em todos casos. Objetivo: O estudo mostra os detalhes da técnica e os resultados do uso da anastomose com maturação programada em dez pacientes. Técnica cirúrgica: A anastomose com maturação programada é feita em duas etapas. A primeira fase é o fechamento do coto cólico com pontos que mantém a mucosa evertida. A segunda fase é a união das extremidades do cólon e reto pela via transanal. Todas as suturas são feitas com poliglactina 00. Um estoma para derivação deve ser feito em todos os casos. Após 30 dias, inicia-se a abertura espontânea da anastomose. Resultados: Dez pacientes foram submetidos a esta técnica. Ocorreram dois casos de estenose que foram tratados com dilatação digital em consultório. Todos pacientes tiveram fechamento de sua ostomia de derivação. Conclusão: A anastomose com maturação programada é factível em casos difíceis e pode prevenir a sepse pélvica em anastomoses colorretais baixas e coloanais.

Resección mesorrectal total y anastomosis coloanal con reservorio colónico en J para el tratamiento de los cánceres de recto medio y bajo / Total mesorectum resection and coloanal anastomosis with J colonic reservoir for treatment of medium and low rectum cancer

INTRODUCCIÓN. La proctosigmoidectomía con resección mesorrectal total, reservorio en J y anastomosis coloanal es útil en los pacientes con cánceres de recto medio y bajo, para evitar la colostomía terminal definitiva. El objetivo de este trabajo fue analizar la factibilidad de dicha técnica quirúrgica, el tratamiento integral multidisciplinario y los resultados obtenidos. MÉTODOS. Se estudiaron 15 pacientes que padecían adenocarcinomas de recto medio y bajo, tratados entre enero de 1996 y diciembre de 2002 en el servicio de Cirugía Esplácnica del Instituto Nacional de Oncología y Radiobiología de La Habana. El tratamiento consistió en una combinación de radioterapia más quimioterapia concurrentes neoadyuvantes, seguidas de cirugía y quimioterapia adyuvante. RESULTADOS. La edad promedio de los pacientes fue de 56 años. El adenocarcinoma fue el tipo histológico diagnosticado en todos los pacientes. La estadificación de los tumores fue la siguiente: T1 y T2, 4 pacientes (27 por ciento, respectivamente); T3, 7 pacientes (46 por ciento). Cuatro pacientes (20 por ciento) se complicaron como consecuencia del tratamiento radiante y 5 (33,3 por ciento), a causa del tratamiento quirúrgico. La mortalidad quirúrgica fue de 1 paciente (6,6 por ciento) y 11 pacientes (73,3 por ciento) sobrevivieron más de 5 años. Ningún paciente presentó recidiva tumoral pélvica ni de la anastomosis coloanal. Se logró buena continencia esfinteriana. CONCLUSIONES. La resección mesorrectal total y anastomosis coloanal con reservorio colónico en J evita la colostomía terminal definitiva, cura a un alto porcentaje de pacientes con cánceres de recto medio y bajo, no transgrede los principios de la cirugía oncológica, es bien aceptada por los pacientes y es factible en nuestro medio(AU)

INTRODUCTION: Proctosigmoidectomy with total mesorectum resection, reservoir in J and colorectal is useful in patients with low and middle rectum cancer, to avoid the definite terminal colostomy. The aim of present paper was to analyze the feasibility of such surgical technique, the multidisciplinary integral treatment and the results obtained. METHODS: Fifteen patients were studied suffering of low and middle adenocarcinoma treated between January, 1996 and December, 2002 in Splanchnic Surgery Service of National Institute of Oncology and Radiobiology of La Habana City. Treatment included a combination of radiotherapy plus neocoadjuvant concurrent chemotherapy, followed by adjuvant chemotherapy and surgery. RESULTS: Mean age of patients was of 56 years. The adenocarcinoma was the histological type diagnosed in all patients. Tumor staging the following: T1 and T2, in four patients (27 percent, respectively); T3 in seven patients (46 percent). Four patients (20 percent) had complications due to radiation treatment and five (33,3 percent), by surgical treatment. Surgical mortality occurred in one patient (6,6 percent) and eleven patients (73,3 percent) survived over 5 years. Neither patient had pelvic tumor relapse or by colorectal anastomosis. There was good sphincter continence. CONCLUSIONS: Total mesorectum resection and colorectal anastomosis with a colonic reservoir in J prevent the definite terminal colostomy, to cure a high percentage of patients with low and middle rectum cancer without respecting the oncology surgery principles, is well accepted by patients and it is feasible in our practice(AU)

Effects of preoperative pelvic irradiation on colonic anastomosis healing: an experimental study in rats / Efeito da radioterapia pélvica pré-operatória na cicatrização de anastomoses colônicas: estudo experimental em ratos

PURPOSE: Colorectal anastomosis is a constant worry-issue among surgeons because of high rates of complications, specially the dehiscence. The preoperative irradiation on cancer surgeries might interfere in the healing process, leading to an unfavorable outcome. METHODS: In the present study, two groups of rats were irradiated previously to a colorectal anastomosis surgery, with intervals of 4 and 8 weeks between the procedures. Seven days after the surgery, healing process was evaluated for dehiscence presence and histologic inflammatory characteristics. Also, levels of hydroxyproline, metalloproteinases and vascular endothelial growth factor were measured. RESULTS: Our results showed a higher incidence of dehiscences on the animals submitted to irradiation, compared to controls, with a reduced inflammatory activity in the healing tissue. DISCUSSION: Comparing both irradiated groups, those irradiated 8 weeks before surgery showed higher levels of hydroxyproline and metalloproteinases, indicating higher efficiency of the healing process. In conclusion, preoperative irradiation interferes with intestinal anastomosis healing and a larger time interval between both procedures is safer in terms of the healing quality.

INTRODUÇÃO: As anastomoses colorretais são motivos constante de preocupação por parte dos cirurgiões, em virtude do alto índice de complicações, principalmente as deiscências. O uso da radioterapia previamente à cirurgia, nos casos de doença neoplásica, pode interferir no processo cicatricial das anastomoses, e levar a uma evolução desfavorável. MÉTODOS: Os autores estudaram dois grupos de ratos, submetidos a radioterapia e à confecção de uma anastomose no cólon, com intervalo de 04 e de 08 semanas entre os dois procedimentos, comparando com um grupo controle. Após 07 dias da cirurgia, estudaram-se vários aspectos do processo cicatricial: presença de deiscência, características inflamatórias do tecido, dosagem de hidroxiprolina, de mateloproteinase e de VEGF. RESULTADOS: Os autores detectaram maior índice de deiscência nos animais submetidos à radioterapia, com prejuízo da atividade inflamatória característica de um tecido em cicatrização. DISCUSSÃO: Dentre os dois grupos irradiados, aquele com intervalo de oito semanas entre a radioterapia e a confecção da anastomose teve dosagem mais alta de hidroxiprolina e metaloproteinase, demonstrando maior eficiência do processo cicatricial. CONCLUSÃO: A radioterapia prévia interfere no processo de cicatrização das anastomoses intestinais, e que um maior intervalo de tempo entre os dois procedimentos é melhor para garantia de uma cicatrização satisfatória.

Value of double stapling technique with curved cutter stapler in low colorectal anastomosis / 上海第二医科大学学报

Objective To evaluate the value of double stapling technique with curved cutter stapler in colorectal anastomosis,especially in low colorectal anastomosis. Methods The clinical data of 168 cases of rectal carcinomas treated with double stapling technique with curved cutter stapler were retrospectively reviewed.The intraoperative condition,postoperative complications and findings during follow up were analysed. Results During the operations,the processes of closure and anastomosis of all the patients were satisfactory,and no operative death occurred.After the operations,4 cases(2.4%) had anastomotic leakage,3 cases(1.8%) had anastomotic bleeding,and 2 cases(1.2%) had rectovaginal fistula.All the complications were cured.There was no anastomotic stricture. Conclusion Double stapling technique with curved cutter stapler may help to accomplish low colorectal anastomosis which is a difficult task for handed suture.