A new composite program to eliminate anastomotic leakage in laparoscopic colorectal surgery

Hitoshi Idani, MD, FACS, Hiroyuki Araki, MD, Soichiro Miyake, MD, Hisanobu Miyoshi, MD, Kazutaka Takahashi, MD, Toshihiko Fujita, MD, Naoki Mimura, MD, Toshihiro Ogawa, MD, Yasuhiro Komatsu, MD, Hiroaki Inoue, MD, Kenji Yamaguchi, MD, Hijiri Matsumoto, MD, Yasuo Nagai, MD, Masao Harano, MD, Yasutomo Ojima, MD, Noriaki Tokumoto, MD, Hiroyoshi Matsukawa, MD, Takashi Kanazawa, MD, Yasuhiro Choda, MD, Daisuke Sato, MD, Michihiro Ishida, MD, Shigehiro Shiozaki, MD, Masazumi Okajima, MD, FACS, Motoki Ninomiya, MD. Department of Surgery Hiroshima City Hospital

Background: Anastomotic leakage (AL) is still a crucial matter in colorectal surgery. We have introduced a new program to eliminate AL in laparoscopic colorectal surgery and evaluated the outcome.

Methods: Our program consisted of basic care and surgical protocol. The former included smoking cessation, control of blood sugar and nutrition, lactobacillus preparation, disuse of NSAIDS and continuous use of aspirin. The latter included surgery with meticulous hemostasis, anastomosis by linear stapler in colectomy and double stapling technique in anterior resection (AR) with reinforcement sutures at all staple on staple site. Especially in AR, the left colic artery was reserved as long as possible, the rectum was resected  with one stapler or two (planned) in which staple on staple site was resected by circular stapler and anastomosis was confirmed by intraoperative colonoscopy. Pelvic drain was used and trans-rectal decompression tube was used if needed. From January 2014 to August 2015, 91 out of 226 patients who underwent laparoscopic colorectal surgery were enrolled in this program. The occurrence of AL in every grade of Clavien Dindo classification (CDC) was evaluated separately in colon surgery and in AR.

Results: There was no leakage in every grade of CDC in 61 colon surgery. Patients underwent AR consisted of 21 men and 10 women with a mean age of 64.3 years. Body mass index was 23.3.  Location of the tumor was Rs: 5/Ra: 14/Rb: 12. Comorbidities were as follows; diabetes mellitus: 4, aspirin use for coronary stent: 4, warfarin use: 2, chronic renal failure with hemodialysis: 1. High AR, low AR and super low AR were performed on 5, 24 and 2 patients, respectively. Operation time and blood loss were 223 min and 32.8g, respectively. The number of stapler used for rectal resection was one: 24, two: 6, three: 1. Bilateral reinforcement sutures were achieved laparoscopically in 28 (90.3%) patients. Diverting ileostomy was added on 4 patients. Pelvic drain was used in all patients, however, trans-anal tube was never used. The distance from anal verge to the anastomosis was 5.9±1.8 cm. Mean postoperative stay was 10.4 days and there was no leakage in every grade of CDC, whereas there were 6 leakages (grade 2/3: 4/2) in patients who have not enrolled in this program.

Conclusion: Our new composite program can minimize the risk of anastomotic leakage in laparoscopic colorectal surgery. Reinforcement sutures may play an important role to improve resistant pressure at the anastomosis.