Validation of a Colonoscopic Grading System for the Intraoperative Evaluation of Rectal Anastomoses

Saif A Ghole, MD, Audrey Nguyen, Raul M Bosio, MD, Mehraneh D Jafari, MD, Steven D Mills, MD, Joseph C Carmichael, MD, Michael J Stamos, MD, Alessio Pigazzi, MD. University of California, Irvine.

Anastomotic leaks remain a source of morbidity following proctectomy. We have developed an intraoperative grading system utilizing flexible endoscopy to identify rectal anastomoses at high risk of anastomotic leak (AL).

Intraoperative flexible endoscopic assessment was performed on a series of 75 patients undergoing proctectomy. A 3-tiered endoscopic anastomosis grading system was developed. Grade1 anastomosis was defined by circumferentially normal mucosa on both sides of the staple line. Grade2 anastomoses had <30% of the mucosa on one side of the staple line with evidence of ischemia. Grade3 were those where 30% or more of the mucosa appeared ischemic on one side of the staple line. All patients were followed longitudinally.

Of 75 patients evaluated: 63 were Grade1, 8 were Grade2, 4 were Grade3. The air leak test was negative for all patients except one. The total anastomotic leak rate for this series was 15%. Seven patients with Grade1 anastomoses developed AL (11%). Three of these represented symptomatic AL requiring minor drainage procedures. The remaining three patients had an incidental finding of AL for which no intervention was necessary. Among Grade2 anastomoses, 4 of 8 patients experienced an AL (50%). All Grade3 anastomoses were reconstructed immediately at time of the index surgery; none subsequently leaked. 13 mid rectal anastomoses were not diverted based upon the healthy endoscopic appearance of the anastomosis. Only 1 of these patients experienced a minor symptomatic leak.

This study demonstrates that endoscopic evaluation of the perianastomotic mucosa is useful in stratifying patients at high risk of anastomotic leak.

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