Features to Prevent Failed Hardware Colorectal Anastomoses in Laparoscopic Rectal Resections

Introduction. Currently, laparoscopic operations abroad and in Russia have become the "gold standard" for the treatment of colon cancer, including rectal cancer [1, 2]. Performing anterior resections of the rectum by laparoscopic means implies the mandatory formation of a colorectal anastomosis by mechanical suture using circular stitching devices. This makes it possible to impose low colorectal anastomoses, shorten the duration of this stage of the operation, and preserve the sensory zones of the lower ampullary rectum and anal canal [3, 4].
One of the main and most severe complications in the formation of any type of anastomosis between the hollow organs of the abdominal cavity is its failure [5, 6]. Unfortunately, this type of complications also occurs with hardware anastomosis. The relevance of this problem is evidenced by the following data: the frequency of failure of colorectal anastomoses formed with the help of crosslinking devices is 1.5-15.2%, and the mortality rate reaches 4.7% [1]. In order to reduce the frequency of failure of hardware colorectal anastomosis, various methods of its protection are proposed: from strengthening the anastomosis suture line with various materials (own tissues, polymer films, adhesive substances, etc.) to applying a preventive discharge transverso - or ileostomy [7-9]. However, there is still no clear algorithm for preventing the failure of colorectal anastomoses in clinical practice. This is mainly due to the fact that a lot of different factors directly or indirectly affect the healing process of the anastomosis, and intraoperative control of the reliability of the performed hardware anastomosis is limited and includes only visual control and performing an air test for tightness. It should be remembered that even a negative result of an intraoperative air sample does not completely guarantee against the development of colorectal anastomosis failure in the near postoperative period.
Clinical manifestations of anastomosis failure can be different, causing one or another therapeutic tactic (from local anti-inflammatory therapy to repeated surgical intervention). The failure of the colorectal anastomosis not only significantly increases the number of postoperative complications, but is also accompanied by an increase in the frequency of local cancer relapses, a decrease in the overall 5-year survival rate [10]. Many authors consider the frequency of the development of anastomosis failure to be an indicator of the quality of work of the coloproctology department in general, and the qualifications of the operating surgeon in particular. This is partly due to the fact that the development of this complication significantly increases (by 1.5-3 times) the cost of treating patients [11, 12].
Thus, the problem of the failure of the hardware mechanical suture after laparoscopic anterior resection of the rectum remains relevant, debatable and requires further solution.
The aim of the study was to study the own results of performing laparoscopic anterior resection of the rectum using intraoperative measures to prevent the failure of hardware colorectal anastomoses in patients with a rectal tumor.
Material and methods of research. The analysis of the results of surgical treatment of 68 patients (37 men and 31 women, average age 58.2±5.7 years, patients older than 60 years - 49 (72%)) who were in the surgery department of the Federal State Budgetary Institution "Federal Scientific and Clinical Center for Specialized Types of Medical Care and Medical Technologies" of the Federal Medical and Biological Agency from January 2013 to March 2020 was carried out. All patients underwent anterior rectal resection by laparoscopic method with the formation of a hardware colorectal anastomosis. Prevention of the failure of the formed anastomosis was as follows: the imposition of a circular anastomosis in a certain position with only 1 corner (right) of the rectum stump left; transabdominal strengthening of the hardware anastomosis with nodular serous-muscular sutures (on 2, 4, 6, 8, 10, 12 on the conventional dial); the formation of a preventive transversostomy.
Histologically, adenocarcinoma of various degrees of differentiation was detected in all patients. The depth of tumor invasion: T1 was found in 4 (5.9%) patients, T2 - in 22 (32.3%), T3-in 39 (57.4%), T4-in 3 (4.4%). Lymphogenic metastases: N0 were diagnosed in 26 (38.2%) patients, N1 - 2-in 42 (61.8%). Hematogenous metastases: M0 - in 57 (83.8%) patients, M1 - in 11 (16.2%). In 4 (5.9%) patients, the distal pole of the tumor was located in the lower ampullary part of the rectum (4-6 cm from the outer edge of the anal canal), in 17 (25%)-in the middle ampullary part (6-9 cm), in 29 (42.6%) - in the upper ampullary part (9-13 cm) and in 18 (26.5%)-in the rectosigmoid part (13-16 cm). In the preoperative period, 14 (20.6%) patients underwent courses of chemoradiotherapy. More than 70% of patients (48) had concomitant diseases in the stage of compensation (cardiovascular, respiratory, digestive, endocrine and urinary system), the body mass index (BMI) of 30 was identified in 49 (72,1%) patients, up to 40 - 12 (17.6%) and more than 40 in 7 (10.3 per cent).
All patients underwent standard preoperative preparation, including: orthograde cleaning of the large intestine, correction of comorbidities, prevention of thromboembolic complications, and antibiotic prophylaxis.
The criteria for inclusion in the study were: age from 18 to 80 years, the presence of resectable rectal adenocarcinoma, the distance from the anastomosis to the outer edge of the anal canal is at least 4 cm (without involving the internal and external anal sphincter). The exclusion criteria were: squamous cell carcinoma, inability to perform R0 resection, recurrence of rectal cancer, chemoradiation complications.
The technique of the operation. Anterior rectal resection with total or subtotal mesorectumectomy was performed in all patients under combined anesthesia with artificial ventilation. When the tumor was localized above the level of the pelvic peritoneum, a high intersection of the lower mesenteric artery was performed (in the area of its mouth), when the tumor was located below the level of the pelvic peritoneum, the lower mesenteric artery was crossed immediately after the departure of the left colon artery, but with the mandatory removal of apical lymph nodes. Mobilization of the left colon was performed in 13 (19.1%) patients. The rectum was crossed with an articulating endoscopic suturing-cutting device. The end-to-end colorectal anastomosis was formed using a circular crosslinking device with a head diameter from 28 to 31 mm. In all cases, we used the following technique of applying a hardware anastomosis (Fig. 1,2,3). After the device was inserted into the stump of the rectum, the trocar was extended through the intestinal wall closer to the left corner of the stump. Thus, after stitching and crossing the intestinal tissue, only one corner (right) of the anastomosed stump of the rectum remained, and not two, as with the standard technique of applying a hardware suture. The remaining corner was immersed into the lumen of the intestine with a single U-shaped seam, thus securely closing the section of the corner staple seam. In all cases, an intraoperative assessment of the tightness of the anastomosis was performed using an air sample. In cases of a positive or doubtful test, additional intracorporeal serous-muscular sutures were applied with an atraumatic needle at 2, 4, 6, 8, 10 and 12 hours according to the conventional dial. With a low location of the colorectal anastomosis (less than 10 cm from the outer edge of the anal canal), as well as with aggravating factors of its formation or the presence of concomitant diseases that increase the risk of its failure, a preventive unloading double-stem transversostomy was additionally applied in the epigastrium or left hypochondrium.
The aggravating preoperative factors that increase the risk of failure of the formed colorectal anastomosis were: low tumor localization (less than 10 cm from the outer edge of the anal canal), diabetes mellitus (glycated hemoglobin level more than 9%), body mass index (BMI) more than 35, hypoalbuminemia (less than 35 g / liter), anemia (less than 90 g/liter), neoadjuvant chemotherapy. The group of intraoperative risk factors for the occurrence of colorectal anastomosis failure included: blood loss (more than 500 ml), inadequate drainage of the pelvis (accumulation of fluid in the pelvic cavity according to ultrasound and the absence of drainage in the immediate postoperative period), undetected ischemia (with visual assessment) of the terminal part of the descending colon, a dubious air sample, the duration of the operation is more than 4 hours, unjustified refusal of preventive ileo- or transversostomy, insufficient experience of the surgeon (independent performance of less than 50 operations).
In all cases, the operation was completed either by transperitoneal drainage of the pelvis or by transperitoneal presacral drainage of the sacral fossa.
In the postoperative period, clinical and laboratory parameters were evaluated, X-ray and ultrasound examinations were performed if necessary. From the laboratory parameters, special attention was paid to the total number of white blood cells in the blood and the level of C reactive protein (1, 3, 5 days after surgery). Body temperature, the nature and amount of discharge through the safety drainage were monitored daily. In the case of clinical detection of colorectal anastomosis failure and its confirmation by proctography, the classification of International Study Group of Rectal Cancer was used to assess its severity (A-failure that does not require active therapy; B - failure that requires active conservative therapy, but without relaparotomy; C - failure that requires relaparotomy) [3]. Further treatment tactics depended on the clinical and laboratory data and the severity of the complication.