Persistent Asymptomatic Anastomotic Leakage After Laparoscopic Sphincter-Saving Surgery for Rectal Cancer: Can Diverting Stoma Be Reversed Safely at 6 Months?

ABSTRACT

BACKGROUND: Anastomotic leakage after rectal cancer surgery raises the problem of the timing of diverting stoma reversal. OBJECTIVE: The purpose of this study was to assess whether stoma reversal can be safely performed at 6 months after laparoscopic sphincter-saving surgery for rectal cancer with total mesorectal excision in patients with persistent asymptomatic anastomotic leakage. DESIGN: This was a retrospective analysis of a prospective database. SETTINGS The study was conducted at a tertiary colorectal surgery referral center. PATIENTS All of the patients with anastomotic leakage were treated conservatively after sphincter-saving laparoscopic total mesorectal excision for rectal cancer. MAIN OUTCOME MEASURES: The main study measure was postoperative morbidity. RESULTS: A total of 110 (26%) of 429 patients who presented with anastomotic leakage and were treated conservatively were diagnosed only on CT scan (60 symptomatic (14%) and 50 asymptomatic (12%)). During follow up, 82 (75%) of 110 anastomotic leakages healed spontaneously after a mean delay of 16 ± 6 weeks (range, 4-30 weeks). Among these patients, 7 (9%) of 82 developed postoperative symptomatic pelvic sepsis after stoma reversal. Among the 28 patients remaining, 3 died during follow-up. The remaining 25 patients (23%) presented with persistent asymptomatic anastomotic leakage with chronic sinus >6 months after rectal surgery. Stoma reversal was performed in 19 asymptomatic patients, but 3 (16%) of 19 developed postoperative symptomatic pelvic sepsis after stoma reversal (3/19 vs 7/82 patients; p = 0.217), requiring a redo surgery with transanal colonic pull-through and delayed coloanal anastomosis (n = 2) or standard coloanal anastomosis (n = 1). Regarding the 6 final patients, abdominal redo surgery was performed because of either symptoms or anastomotic leakage with a large presacral cavity. LIMITATIONS: This study was limited by its small sample size. CONCLUSIONS: In the great majority of patients with persistent anastomotic leakage at 6 months after total mesorectal excision, stoma reversal can be safely performed.