Modified pull-through delayed hand-sewn coloanal anastomosis after laparoscopic total mesorectal excision

Introduction

Since its first description by Babcock¹ in 1932, the pull-through procedure has continuously evolved over the decades. Turnbull and Cutait^2,3 adopted it for Hirschsprung’s disease and rectal cancer requiring delayed colorectal anastomosis. In 1999, Baulieux⁴ described the DCA for low rectal cancer. With the arrival of surgical stapling devices, DCA has lost its popularity, and has only survived through redo-surgery. Recently, there has been a resurgence of interest in DCA, largely motivated by the results of published studies.^4–6 Some authors have described a new version of the DCA called “SHiP” Short stump and High anastomosis Pull-through procedure.^7,8 This modified delayed coloanal anastomosis (mDCA) seems to have promising results. In this paper, we describe the mDCA as it is performed in the Department of Oncologic Surgery at the Debussy Clinic (CPMC, Algiers).

Methods

All patients had received a mechanical bowel preparation the day before the surgery using polyethylene glycol (Fortrans^®) and Metronidazole-based antibiotic prophylaxis for 5 days prior to surgery. In Lloyd-Davis position and under general anesthesia; using a Lone Star^® retractor, a Vicryl^® 0 purse-string was placed at least 1 cm from the inferior border of the tumor. After anal mucosectomy started from the dentate line, a circumferential incision was made at the level of the folds generated by the tightening of the purse-string. The posterior plane was dissected first, followed by the lateral and anterior ones. This dissection was pursued as high as possible until reaching the mesorectal plane. The abdominal approach consisted of a conventional high tie low anterior resection with complete splenic flexure mobilization and up to down TME by laparoscopy (Figure 1). The specimen was retrieved transanally, the left colon was cut and pulled through the anus, and the digestive tract was restored by mDCA.

Figure 1. (a) Ports placement. (b) Abdomen without ileostomy at the end of the operation.

Modified delayed coloanal anastomosis

A 3 cm colonic stump is transanally pulled through. Three 000Vicryl^® stitches are used to secure the stump by anchoring the seromuscular layer to the upper part of the anal canal on its anterior hemi-circumference. These sutures were left long and were used as landmarks for the subsequent recutting and delayed anastomosis (Figure 2). Daily, the viability of the colonic stump was checked and a fatty dressing was applied. Also, between the two stages, in bed, the patients lay on their back with legs flexed and spread in order to avoid any compression of the colonic stump. Seven days later, the second stage was conducted under spinal anesthesia. By gentle dissection, the adhesions between the colonic stump and the anal canal were progressively released until reaching the stitches placed during the first stage of the procedure (Figure 3). The stump was then cut 1-2 mm distally, and a hand-sewn end-to-end coloanal anastomosis was achieved as described by Parks.⁹ Eight to twelve sutures using 000Vicryl^® are usually required to secure the pull-through colon to the upper edge of the anal sphincter (Figure 4). Postoperatively, the ERAS protocol was applied to our patients.¹⁰ Thus, on the first postoperative day, the bladder catheter was removed, patients were mobilized and liquid diet was allowed. On the 4th postoperative day, the abdominal drain was removed, and all patients were discharged on the 5th day.

Figure 2. (a) Short colonic stump after securing to the sphincter. (b) Final aspect of the colonic stump after removal of the Lonestar^® retractor.

Figure 3. (a,b) Appearance of the colonic stump on the 7^th postoperative day. (c) Section of the stump and its meso.

Figure 4. Final view of the high anastomosis.

Results

The intra and post-operative data are summarized in Table 1.

Discussion

Current guidelines after sphincter-sparing proctectomy with TME for low rectal cancer suggest hand-sewn coloanal anastomosis protected by a temporary stoma.^11,12 Despite the advances in surgical techniques, increasingly conservative and less invasive, anterior resection for rectal cancer remains a real challenge, particularly in terms of morbidity. Indeed, complications are far from negligible, mainly due to anastomosis failure and its consequences. Drainage or even colostomy with a high likelihood of non-restoration of the digestive tract, have long been the only alternatives. Increasingly, DCA is emerging as a valid option for these complex scenarios.¹³ Several authors have shown that DCA is a safe approach associated with a significant success rate in redo-surgery for chronic pelvic sepsis, rectovaginal or rectourethral fistulas, avoiding a definitive stoma in most patients.^14–16 Based on these results, and in order to avoid the ileostomy-related morbidity,^17,18 the indications for DCA have been continuously extended and are now proposed as an alternative to the classical ICA with diverting stoma. A comparative study in 223 patients with low rectal cancer showed a significantly higher rate of AF after ICA than DCA: 28% vs. 3% (p = 0.0013).¹⁹ In a multicenter clinical trial, Biondo et al.²⁰ randomized 92 patients between ICA with diversion ileostomy vs. DCA. Although the authors did not show significant differences in terms of overall 30-day postoperative morbidity between the two groups (45.7 vs 34.8%; P = 0.40), the rate of AF was lower without reaching significance in the DCA group (13.0% vs 23.9%; P = 0.28). In addition, 15.2% of patients in the ICA group definitely kept their ileostomy, while 2.2% of patients in the DCA group did not have their anastomosis. In conclusion, the authors have shown that DCA is at least as safe and effective as standard ICA, with the advantage of avoiding a diversion ileostomy and its complications. La Raja et al.²¹ in a recent meta-analysis including four studies, comparing the DCA outcomes to the ICA with diverting stoma, showed no significant difference in terms of postoperative Clavien-Dindo complications ≥ 3 between the two groups (13% vs 21%; OR 1.17; 95% CI 0.38-3.62; p = 0.78). In contrast, patients in the DCA group had a significantly lower rate of postoperative pelvic sepsis (7% vs 14%; OR 0.37; 95% CI 0.16-0.85; p = 0.02). Also, the risk of permanent stoma was similar between groups (2% vs. 2% OR 0.77; 95% CI 0.15-3.85; p = 0.75). Recently, Bianco et al.²² have brought some modifications to the original technique described by Jacques Baulieux.⁴ The new variant is characterized by a 2 cm shorter colonic stump for better patient comfort, instead of the 8-10 cm of the old version; on the other hand, the anastomosis is performed at the upper part of the anal canal. Indeed, shortening the pulled-throw colonic stump will preserve the colonic length and thus will avoid an extensive dissection, which often requires a vascular sacrifice that could cause visceral ischemia.²³ According to the authors, a high anastomosis could avoid ischemia of the colonic stump by a “guillotine” like effect, which can lead to fistulas in the early phase and stenosis later. The SHiP technique was associated with excellent short-term results.²²

No AF was reported in the 37 patients of the series, whereas stenosis was observed in three patients (8%). Furthermore, by this technique, the authors were able to avoid an ileostomy in all their patients with a significant decrease in both morbidity and mortality.

Conclusion

Thanks to its favorable results published in the literature, in particular by substantially decreasing the morbidity rate and by avoiding a diverting stoma, the mDCA is gaining a place of choice in the therapeutic armamentarium of the colorectal surgeon. Further prospective trials assessing both short and long-term outcomes are needed to definitely confirm the benefit of this approach.

Ethical considerations

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. Written informed consent for publication of their clinical details and clinical images was obtained from all individual participants included in the study.