Page 12 - Laparoscopic Journal - WJOLS

Abdullah Badawi
Natural orifice transluminal endoscopic surgery (NOTES) Vitali-Goriainov and Andrew J Miles showed in their
to colorectal disease has not yet fully transpired, though study the height of anastomosis has been shown to affect
there have been major advances as instrumentation the incidence of anastomotic leak and a life-threatening
improves and transitional techniques allow natural clinical AL occurred in anastomosis lower than (6 cm).
orifice specimen extraction following laparoscopic colo- Lopez-Kostner et al showed the rate of leak was 8.4%
rectal surgeries. 51-54 when it was below 10 cm from the anal verge, 5.4% when it
was 10 to 15 cm from the anal verge and 0.14% when the
AIM anastomoses was above 15 cm, in a study performed on
5
The aim of this paper is to review the published studies 819 patients with rectal or sigmoid cancers. Rullier et al
regarding the risk factors and the prevention of AL have shown that the leak rate was 6.5 times higher in
following MAS for colorectal cancer. anastomoses located < 5 cm from the anal verge, with
overall leak rate of 13% in a study of 272 patients with
6
ConTenT consecutive anterior resections and a leak rate of 7.7%
after low rectal stapling (< 7 cm of the anal verge) com-
Anastomotic fistula after colorectal surgery represents pared with 1% for high stapling, reported by Vignali et al
a major and potentially life-threatening postoperative
complication. The incidence rate has been reported to be in a review of 1014 patients with stapled rectal anasto-
7
moses. A study of laparoscopic anterior resection with
as high as 1 to 19%. 6,36,37,38,55-58 Mortality rate postopera- intracorporeal rectal transection and double-stapling
tively associated with anastomotic complications ranges
from 3 to 20% 6,56,58,59 and accounts for approximately 30% technique (DST) anastomosis for rectal cancer showed
60
of all deaths following colorectal surgery. There is still results suggest that tumor localization and preservation
35
of the left colic artery are predictive factors for clinical AL.
three significant diversity between surgeons in what
they define as AL. In a systematic review of gastrointes- Tumor Size
tinal anastomotic leakage, 49 papers were found with 29
61
different definitions. In 2010, specific guidelines on the Multiple studies suggest that tumor size is risk factor for
definition of an anastomotic leak with a grading system an anastomotic leak (tumor size > 5 cm). 38-63
of severity following rectal surgery were published by
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the International Study Group of Rectal Cancer. Accor- Transanal Tube
ding to that paper, AL should be defined as a defect of Transanal tube placement was effective for prevention
the intestinal wall at the anastomotic site (including of AL following laparoscopic low anterior resection and
suture and staple lines of neo-rectal reservoirs) leading to decreases the risk of reoperation after symptomatic
a communication between the intra- and extra-luminal leakage. In study performed on 96 patients, a transanal
compartments. tube was placed after anastomosis, the frequency of
leakage was 4.2% (4/96) in group with transanal tube
MATeRIALS and was 13.8% (15/109) in group without transanal
Studies Population tube. The rate of leakage was significantly lower in with
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transanal tube.
From the 31 studies published from January 2009 to
September 2015 involving 6,921 patients underwent Mechanical Bowel Preparation
elective laparoscopic colorectal procedures with stapling
technique (ST) anastomosis. There is good evidence supporting the use of mecha-
nical bowel preparation (MBP) in the preoperative
ReSuLT management of patients undergoing elective right-sided
and left-sided colorectal surgical resections. In another
Tumor Location study showed no evidentiary indications for more severe

The selected data showed that the overall AL rate was complications in patients without preoperative bowel
6.21% (430/6921 patients). A total of 6,921 patients, male preparation. 39
patients represented (63.2%) with a median age of
65 (50–74) years at the time of surgery were included. Surgical Technique
Data analysis showed that most common risk factor for Important risk factor for anastomotic leak was precom-
leakage in all papers was distance of the anastomosis pression before stapler firings. Study of 154 rectal cancer
1-4
from the anal verge. The lower the anastomosis (almost patients who underwent laparoscopic LAR with DST
below 6 cm) the higher is the risk of developing fistula. showed precompression before stapler firings and
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