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.

Introduction:
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).

Methods:
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.
 

Results:
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.
 

Conclusions:
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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