Reduction of anastomotic failure in laparoscopic colorectal surgery using antitraction sutures

Clinical efficacy of anastomotic reinforcement suture in preventing anastomotic leakage after rectal cancer surgery: a systematic review and meta-analysis

PURPOSE

Anastomotic leakage (AL) is a common postoperative complication of rectal cancer, with an incidence of about 10%, and the efficacy of reinforced sutures for preventing AL remains contentious. This study investigated the safety and effectiveness of reinforcement sutures for preventing AL after rectal cancer surgery.

METHODS

The present authors conducted a systematic search in the PubMed, Embase, Cochrane Library, Sinomed, Web of Science, Wanfang, VIP, and CNKI databases for randomized controlled trials (RCTs) and nonrandomized studies up to June 2023. We performed a meta-analysis to evaluate the efficacy of anastomotic reinforcement sutures after rectal cancer surgery. The primary outcome measures were AL, anastomotic bleeding, and infection rates.

RESULTS

Eleven articles (1921 subjects) were analyzed, with 912 and 1009 cases in the reinforced and unreinforced suture groups, respectively. The reinforced suture group showed a lower AL incidence (odds ratio [OR]=0.25, 95% CI 0.17-0.37, P< 0.00001), lower infection rate (OR=0.41, 95%CI 0.19-0.89, P<0.05), shorter hospital stay (mean difference [MD]=-0.57, 95%CI -1.15-0.00, P≤0.05), and earlier anal exhaust (MD=-0.12, 95%CI -0.23-0.00, P<0.05). However, the operative time (MD=18.25, 95% CI 12.20-24.30, P<0.00001) was longer for reinforced sutures than for unreinforced sutures. There were no significant differences between the suture techniques in intraoperative blood loss MD=2.74, 95% CI -4.50-9.97, P>0.05), incidence of anastomotic bleeding (OR=0.49, 95%CI 0.12-1.97, P>0.05), and incidence of intestinal obstruction (OR=0.65, 95%CI 0.27-1.61, P>0.05).

CONCLUSION

Existing articles indicate that anastomotic reinforcement sutures can significantly reduce AL incidence. However, this conclusion still requires confirmation based on multicentre, high-quality RCTs with large sample sizes.

Intracorporeal reinforcement with barbed suture is associated with low anastomotic leakage rates after laparoscopic low anterior resection for rectal cancer: a retrospective study

Background

Anastomotic leakage (AL) is one of most severe postoperative complications following low anterior resection (LAR) for rectal cancer, and has an adverse impact on postoperative recovery. The occurence of AL is associated with several factors, while few studies explored the role of intracorporeal barbed suture reinforcement in it.

Methods

Consecutive cases underwent laparoscopic LAR for rectal cancer from Mar. 2018 to Feb. 2021 in our center were retrospectively collected. Cases were classified into the intracorporeal barbed suture reinforcement group and the control group according to whether performing intracorporeal reinforcement with barbed suture, and AL incidences were compared between two groups. Propensity score matching (PSM) was then performed based on identified risk factors to reduce biases from covariates between two groups. AL incidences in the matched cohort were compared.

Results

A total of 292 cases entered into the study, and AL incidences were significantly lower in the intracorporeal barbed suture reinforcement group compared with the control group (10.00% vs 2.82%, P = 0.024). Sex, BMI, preoperative adjuvant chemoradiotherapy and anastomotic level were chose for PSM analyses based on previous studies. In the matched cohort, the AL incidences were still significantly lower in the intracorporeal barbed suture reinforcement group (10.57% vs 2.44%, SD = 0.334).

Conclusions

Intracorporeal barbed suture reinforcement is associated with low AL incidences after laparoscopic LAR for rectal cancer, which is a potential procedure for reducing AL and worthy of application clinically.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12893-022-01782-x.

Efficacy of staple line reinforcement by barbed suture for preventing anastomotic leakage in laparoscopic rectal cancer surgery

BACKGROUND

Anastomotic leakage (AL) is a severe complication in rectal cancer surgery. Various methods, including intracorporeal reinforcing suturing, have been used to reduce the incidence of AL. However, little is known about the efficacy of staple-line reinforcement by barbed suture for preventing AL.

AIM

To evaluate the efficacy of staple-line reinforcement using barbed suture for preventing AL in laparoscopic surgery for rectal cancer.

METHODS

We retrospectively reviewed the clinical datum of 319 patients undergoing laparoscopic low anterior resection combined with double stapling technique between May 1, 2017 and January 31, 2021. All surgeries were performed by the same surgical team specializing in colorectal surgery. Patients were divided into two groups depending on whether they received reinforcing sutures. Patients’ baseline characteristics did not show any significant difference between the two groups. We analyzed patient-, tumor-, as well as surgery-related variables using univariate and multivariate logistic analyses.

RESULTS

There were 168 patients in the reinforcing suture group and 151 patients in the non-reinforcing suture group. AL occurred in 25 cases (7.8%). Its incidence was significantly higher in the non-reinforcing suture group than in the reinforcing suture group (4.8% vs 11.3%, P = 0.031). The multivariate analyses demonstrated that the tumor site, tumor size and presence of staple-line reinforcement were independent risk factors for AL. We divided these patients into two risk groups based on the combination of tumor site and tumor size. Patients without any risk factor were assigned to the low-risk group (n = 177), whereas those having one or two risk factors were assigned to the high-risk group (n = 142). In the high-risk group, the AL incidence considerably decreased in the reinforcing suture group compared with that in the non-reinforcing suture group (P = 0.038). Nonetheless, no significant difference was found in the low-risk group between the two groups.

CONCLUSION

Staple-line reinforcement by barbed suture may decrease the incidence of AL. A large-scale prospective randomized controlled trial is needed for evaluating the efficacy of staple-line reinforcement for preventing AL.

[Prevention of colorectal anastomotic leakage using its reinforcement (results of the randomized study)]

OBJECTIVE

To reduce the incidence of postoperative complications via reinforcement of colorectal anastomosis.

MATERIAL AND METHODS

A randomized prospective study included 115 patients. In the main group (n=60), anterior resections were followed by reinforcement of colorectal anastomosis via suturing the muscular and serous layers at 2, 4, 6, 8, 10, 12 o'clock. In case of low anterior resection, all layers of intestinal wall were transanally sutured at the above-mentioned points. Reinforcement was not performed in the control group (n=55).

RESULTS

In the main group, overall incidence of anastomotic leakage was 8.3% (5/60), in the control group - 25.5% (14/55) (p=0.01). We also analyzed the subgroups of anastomoses with high and low risk of leakage. In case of transabdominal reinforcement, incidence of anastomotic leakage was 11% (2/18) in the main group and 0% (0/14) in the control group (p=0.6). Transanal reinforcement was followed by anastomotic leakage in 7% (3/42) of patients in the main group and 34% (14/41) of patients in the control group (p=0.005).

CONCLUSION

Reinforcement of colorectal instrumental anastomosis by additional sutures reduces the incidence of postoperative complications associated with anastomotic leakage.

New Anastomosis Technique to Prevent Anastomotic Leakage in Laparoscopic Anterior Resection for Rectal Cancer, Especially Upper Rectal Cancer

BACKGROUND/AIM

Anastomotic leakage (AL) is a major problem in rectal cancer surgery. To prevent AL, we developed a side-to-side anastomosis technique using a circular stapler and termed it the circular side stapling technique (CST). We herein report the method and outcome of the CST.

PATIENTS AND METHODS

In this study, we analyzed 154 patients with stage 0 to III rectal cancer who underwent curative laparoscopic low anterior resection. Perioperative factors and complications were compared between the CST and usual double stapling technique (DST).

RESULTS

The CST was performed in 110 of the 154 patients. When comparing the outcomes of patients with upper rectal cancer. AL occurred in no patients in the CST group and in three patients in the DST group (p=0.011). The CST prevented AL in all patients with upper rectal cancer.

CONCLUSION

The CST is a safe and useful procedure in laparoscopic anterior resection. This technique can prevent AL, especially in patients with upper rectal cancer.

[Reinforcement of staple line of colorectal anastomosis for leakage prevention: a systematic review and metaanalysis]

OBJECTIVE

To evaluate the influence of reinforcement of staple line of colorectal anastomosis on the incidence of leakage.

MATERIAL AND METHODS

A systematic review was performed in accordance with the PRISMA recommendations. Statistical analysis was carried out in the Review Manager 5.3 software.

RESULTS

This trial included four original articles published in 2011-2018. There were 493 patients. Reinforcement of anastomosis was made in 232 (47%) cases, colorectal anastomosis was not reinforced in 261 (53%) patients. Anastomotic leakage rate was 5.6 and 11.1% in both groups, respectively (OR 0.55, CI 0.13-2.33; p=0.42). Transabdominal reinforcement reduced leakage rate by 10.2% (OR 0.18, CI 0.06-0.55; p=0.002) while transanal reinforcement was ineffective (OR 1.66, CI 0.38-7.19; p=0,5). Incidence of preventive stoma was similar (OR 0.3, CI 0.07-1.22; p=0.09), but it was possible to abandon preventive stoma in 18% of cases after anastomotic reinforcement.

CONCLUSION

A small number of studies dedicated to anastomosis reinforcement resulted controversial data.

[Prevention of colorectal anastomotic leakage in patients with rectal cancer]

OBJECTIVE

To develop a technique of anastomosis sutures protection using the Foley catheter in rectal cancer surgery.

MATERIAL AND METHODS

There were 42 patients with rectal cancer T1-3N0-2M0 (the 7^th TNM edition) who underwent radical sphincter-sparing surgery with neoadjuvant chemoradiotherapy for the period from November 2016 to June 2018. All procedures were performed at the Regional Clinical Oncology Center. All operations were completed with formation of colorectal anastomosis in 'end-to-side' fashion. Patients were divided into 2 groups (main and control) depending on used technique. In the main group (n=20), Foley catheter #30 in accordance with original method was used to protect the anastomosis. Preventive colostomy was applied in 15 patients. The control group consisted of 22 patients. None of these patients underwent prevention of anastomosis leakage. Preventive colostomy was performed in 14 patients.

RESULTS

There were no early postoperative complications in the main group. The catheter was removed after 7-9 days. In the control group, 5 patients had symptoms of anastomotic leakage (22.5%; p<0.05). Medication was effective in 4 cases. Re-laparotomy were required in 1 patient.

CONCLUSION

Thus, anastomosis sutures protection using the Foley catheter is quite reliable and technically simple procedure with favorable outcomes.

Reduced-port laparoscopic restorative proctocolectomy without diverting ileostomy

INTRODUCTION

We introduced a reduced-port procedure for laparoscopic restorative proctocolectomy without diverting ileostomy for patients with familial adenomatous polyposis and ulcerative colitis.

MATERIALS AND SURGICAL TECHNIQUE

A multichannel port was inserted through a 2.5-cm umbilical incision. A 12-mm port in the right lower abdomen and a 3- or 5-mm port were also employed. A proctocolectomy was performed intracorporeally, and the entire colon and rectum were delivered through the umbilical incision. An ileal J-pouch was made extracorporeally following division of the mesenteric vessels. Ileal j-pouch-anal anastomosis was performed intracorporeally or transanally after rectal mucosectomy. A drain was inserted through the 12-mm port incision, and a transanal decompression tube was placed in the pouch. Two women and one man underwent this surgery, and their postoperative recovery was uneventful.

DISCUSSION

Laparoscopic restorative proctocolectomy without a diverting stoma by a reduced-port technique is feasible and provides excellent cosmetic outcomes in selected patients.

Efficacy of intracorporeal reinforcing sutures for anastomotic leakage after laparoscopic surgery for rectal cancer

BACKGROUND

The aim of the present study was to investigate the efficacy of intracorporeal reinforcing sutures for preventing anastomotic leakage (AL) after laparoscopic surgery for rectal cancer.

METHODS

This was a retrospective single-institution study consisting of 201 consecutive patients who underwent laparoscopic proctectomy with double-stapling anastomosis for primary rectal cancer between August 2007 and December 2013. The data for patients who received intracorporeal reinforcing sutures were compared with those of patients who did not receive reinforcing sutures. Patient-, tumor- and surgery-related variables were collected and examined using univariate and multivariate analyses.

RESULTS

The overall incidence of AL was 9.0% (18/201). No significant correlations were observed between the various clinicopathological factors and the use of reinforcing sutures. The multivariate analyses revealed the distance of the tumor from the anal verge, tumor size and presence of reinforcing sutures to be independent risk factors for AL. We classified the patients into two risk groups using a combination of the tumor site and tumor size: a low-risk group (patients without any risk factors, n = 134) and a high-risk group (patients with one or two risk factors, n = 67). The frequency of AL was significantly lower (p < 0.02) in the patients treated with reinforcing sutures than in those treated without reinforcing sutures in the high-risk group. However, no significant differences were observed in the low-risk group.

CONCLUSIONS

The use of intracorporeal reinforcing sutures may reduce the incidence of AL. A prospective randomized trial is required to evaluate the effects of reinforcing sutures in preventing AL.

The Use of a Circular Side Stapling Technique in Laparoscopic Low Anterior Resection for Rectal Cancer: Experience of 30 Serial Cases

The double-stapling technique using a circular stapler (CS) to create an end-to-end anastomosis is currently used widely in laparoscopic-assisted rectal surgery. However, a high rate of anastomotic failure has been reported. We report new side-to-side anastomosis creation using a CS, the so-called circular side stapling technique (CST). After excising the rectum at the oral and anal sides of the tumor with a linear stapler, a side-to-side colorectal anastomosis was made on the anterior wall of the rectosigmoid colon and the anterior or posterior wall of the rectum with a CS. Between 2012 and 2013, we recorded 30 serial cases of rectal-sigmoid or rectal cancer that were treated with laparoscopic-assisted surgeries using this method. In the 30 cases, the mean age was 68 ± 12 years, operating time was 288 ± 80 minutes, and blood loss was 66 ± 67 mL. None of the patients suffered from anastomosis leakage or postoperative anastomotic bleeding, and none complained of their stool habits. Three months after the last surgery in this cohort, no anastomosis strictures were reported. Based on these results, we propose an alternative method of side-to-side anastomosis for low anterior resection by using a CS to prevent staple overlap. Our experience indicates that the CST is easy and safe. Therefore, this method is a useful alternative to the current method used in laparoscopic surgery.

Prevention of anastomotic fistula formation after low-position Dixon Operation

Objective: This study aimed to investigate the main points of preventing anastomotic fistula formation after low-position Dixon operation.

Methods: From September 2004 to October 2007, our department continuously conducted 146 cases of low-position Dixon operations. The operation mode involved transabdominal radical resection based on total mesorectal excision for all cases. Except for tumor infiltration, one side of the pelvic vegetative nerve was maintained and ligations were conducted at the superior rectal artery root. Mesorectum at the anastomosis site was removed up to the tunica muscularis recti. The anastomotic stoma blood supply was good and had no tension. An anal tube was inserted when the anastomotic stoma was within 3 cm away from the anal margin. For all cases, a presacral drainage tube was placed via the perineal position.

Results: For all 146 cases, no anastomotic leakage occurred and the post-operative complications included two cases of anastomotic bleeding, three cases of anastomotic stenoses, 48 cases of increased defecation (4-6 times of defecation daily), 34 cases of anal irritation symptoms, and 6 cases of poor loose stool control capacities.

Conclusion: Ensuring enough blood supply for the anastomotic bowel on the two sides, eliminating tension and accurate anastomosis at the anastomosis site could be effective measures to prevent anastomotic fistula in the low position anus preserving surgery of colorectal cancer.

Can trans-anal reinforcing sutures after double stapling in lower anterior resection reduce the need for a temporary diverting ostomy?

AIM: To evaluate trans-anal reinforcing sutures in low anterior resection using the double-stapled anastomosis technique for primary rectal cancers performed at a single institution.

METHODS: The data of patients who received trans-anal reinforcing sutures were compared with those of patients who did not receive them after low anterior resection. Patients who underwent laparoscopic low anterior resection and the double-stapled anastomosis technique for primary rectal cancer between January 2008 and December 2011 were included in this study. Patients with no anastomosis, a hand-sewn anastomosis, high anterior resection, or preoperative chemoradiation were excluded. The primary outcomes measured were the incidence of postoperative anastomotic complications and placement of a diverting ileostomy.

RESULTS: Among 110 patients, the rate of placement of a diverting ileostomy was significantly lower in the suture group (SG) compared with the non-suture control group (CG) [SG, n = 6 (12.8%); CG, n = 19 (30.2%), P = 0.031]. No significant difference was observed in the rate of anastomotic leakage [SG, n = 3 (6.4%); CG, n = 5 (7.9%)].

CONCLUSION: Trans-anal reinforcing sutures may reduce the need for diverting ileostomy. A randomized prospective study with a larger population should be performed in the future to demonstrate the efficacy of trans-anal reinforcing sutures.

Reducing anastomotic leakage by reinforcement of colorectal anastomosis with cyanoacrylate glue

INTRODUCTION

Technical failure of sutured or stapled anastomoses may lead to anastomotic leakage, which is one of the most important complications after colorectal surgery. Cyanoacrylate glue (CA) provides strong mechanical attachment, making it a good candidate for suture reinforcement. This study aimed to demonstrate that CA is the most important factor in the strength of a sealed colorectal anastomosis, in both normal and insufficient anastomoses.

METHODS

Ex vivo porcine colorectal segments were resected. A 1-layer continuous anastomosis or an insufficient 6-interrupted-suture anastomosis was created, and the baseline anastomotic bursting pressure (ABP) was measured. The primary anastomosis was then reinforced either by CA or with 4 additional interrupted sutures, further inverting the anastomosis. After reinforcement a second ABP test was performed.

RESULTS

Thirty-two segments were used. Reinforcing the anastomosis by CA significantly increased ABP in both normal and insufficient anastomoses when compared to the primary anastomosis (p < 0.05 for all groups); no significant difference in ABP was found between normal and insufficient anastomosis groups after CA reinforcement. Anastomotic reinforcement with CA was not inferior to the reinforcement with sutures in both normal and insufficient anastomoses, and had significantly fewer ABP variances in normal anastomosis groups (p = 0.042).

CONCLUSION

Reinforcing a colorectal anastomosis with CA increases its mechanical strength in both normal and technically insufficient situations, which may contribute to the reduction of anastomotic leakage. CA is promising for anastomotic reinforcement based on mechanical improvement of the anastomosis, and in vivo studies are needed to evaluate its biological effects.