Tricks to Decrease the Suture Line Dehiscence Rate During Endoluminal Locoregional Resection (ELRR) by Transanal Endoscopic Microsurgery (TEM)

Emanuele Lezoche, MD, FACS, Silvia Quaresima, MD, Andrea Balla, MD, Giancarlo D’Ambrosio, MD, Alessandro M Paganini, MD, PhD, FACS. Department of General Surgery, Surgical Specialties and Organ Transplantation “Paride Stefanini”, Sapienza University of Rome, Italy.

INTRODUCTION – ELRR by TEM is a valid alternative to TME in selected patients with early low rectal cancer, with similar long term oncological results and better Quality of Life. ELRR has a possible higher risk of dehiscence due to a larger defect, as compared to local excision by TEM. Aim was to evaluate if the introduction of a new technique during the ELRR procedure may reduce the risk of dehiscence.

METHODS AND PROCEDURES – The latest series of 50 patients undergoing ELRR was analyzed and patients were divided in two consecutive groups. In Group A, 25 patients (12 males, 13 females, mean age 72.1 years, range 47-88) underwent ELRR by TEM with the authors’ standard technique, as previously described. In Group B, a subsequent series of 25 patients (16 males, 9 females, mean age 69.2 years, range 35-87) also underwent ELRR, but the perirectal residual cavity was filled with a hemostatic agent (Floseal, Baxter Healthcare Corporation, Deerfield, Illinois, USA) prior to rectal wall closure, and after suture completion the rectal ampulla was stuffed with sponges to avoid the formation of a perirectal fluid collection, by enlarging the volume of the residual rectal ampulla, together with a transanal Foley catheter for gas evacuation. All patients were closely followed up.

RESULTS – There were no significant differences in mean distance of the tumor from the anal verge, mean lesion diameter, mean operative time and pathological staging between the two groups. Neoadjuvant Radiochemotherapy (nRCT) in Groups A and B was performed in 6 and 2 patients, respectively. Suture line dehiscence in Group A occurred in 3 (12%) patients and in group B it was nil. In patients who experienced a dehiscence, mean lesion diameter was 6.3 cm (range 6 – 7 cm) and final staging was pT0 (1), pTis (1), pT1 (1). None of these patients underwent nRCT.

CONCLUSION – After ELRR by TEM, suture line dehiscence is presumably related to the size of the residual cavity and to the formation of a postoperative perirectal abscess after rectal wall closure. In the literature, suture line dehiscence rate after local excision by TEM is 13% and after ELRR it is 11,5%. In the present series the suture line dehiscence rate decreased from 12% to 0%. Obliteration of the residual perirectal space with a hemostatic agent and enlargement of the residual rectal ampulla volume may avoid formation of a postoperative perirectal abscess and may reduce the suture line dehiscence rate.

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