Int J Colorect Dis (1992) 7:227 229
Colb eclal Disease 9 Springer-Verlag 1992
A simple technique for sutureless very low colorectal anastomosis Marcello Bezzi, Michele Casella, Mariano Batori and Licinio Angelini Fourth Department of Surgery, University of Rome, Medical School "La Sapienza", Rome, Italy Accepted: 6 July 1992
An accurate distal purse-string suture can be difficult to place and close on the rectum when performing low anterior resection. The double stapling technique after closure of the rectal stump with linear stapler avoids these difficulties [1]. Nevertheless, in some cases with a narrow pelvis and a lower third rectal cancer, it is particularly difficult to insert the linear stapler without direct vision to assure a satisfactory distal margin below the level of the tumor. F o r these reasons we found it useful to perform the anastomosis after stapled closure of the everted anorectal stump [2]. Some limitations of the double stapling procedure have, however, been reported. The incidence of anastomotic leakage is no less than with other techniques, while the risk of stricture is higher [3]. There is now evidence that a sutureless anastomosis using a biofragrnentable ring can be performed in the large bowel more easily with more reliable healing than with other anastomotic techniques [4]. The BAR device has been used in anterior resection for cancer of the upper third of the rectum but so far no transanal insertion technique has been described. In patients requiring a low colorectal or coloanal anastomosis we have used the BAR with eversion of the anorectal stump after endorectal pull-through of the left colon.
The tumor is resected and the proximal colonic stump with the proximal purse-string suture already inserted is brought down through the anorectal stump. The BAR (VALTRAC| mm with the introducer is inserted into the proximal colon and the purse string is tied. The rectal purse-string suture is then tied onto the central portion of the ring (Fig. 2). The BAR is closed by even pressure on both edges to result in sutureless low colorectal anastomosis that is then pushed back through the anal canal into the pelvis (Fig. 3). The peritoneum covering the pelvis is replaced by mobilized omentum. A diverting colostomy is not performed. We used this technique in two female patients with BAR anastomosis respectively at 3.5 and 4 cm
Technique The rectum and mesorectal tissue are fully mobilized down to the levator ani muscle and the bowel is divided a few centimetres above the level of the tumor. The upper rectum with the dissected perirectal fat (including that removed from the distal remnant) and the sigmoid colon are removed as for a standard low anterior resection. The anorectal stump is closed with a simple running suture and evaginated through the anus. A safe distal clearance from the tumor of no less than 2 cm is determined and a purse-string suture is placed at this level using the Autosuture instrument (Fig. 1).
Fig. 1. The automatic purse-string suture is placed on the everted anorectal stump
228
Fig. 2. After endorectal pullthrough the BAR (VALTRAC) is inserted and the purse-string sutures are tightened extra-anally
Fig. 3. The BAR (VALTRAC) is closed resulting in an ex9ternal sutureless anastomosis that is pushed back into the pelvis f r o m anal verge. N o operative mortality or general complications were observed. Local complications were observed in one patient, with a radiological fistulax healed in one week and a troublesome tenesmus until the B A R expulsion (15 p.o. day).
Comments There is no d o u b t that the double stapling technique increased low sphincter-saving operations providing a greater closeness to the anus and shorter operative time.
Unfortunately this technique does not reduce the risk of leakage and anastomotic stricture and does not eliminate technical difficulties and problems o f safety related to the distal clearance when dealing with a very low rectal cancer within a narrow pelvis. Eversion o f the t u m o r pulling the stump through the anus does not alter subsequent anal function or entail a higher local recurrence rate [5]. The biofragmentable ring for sutureless large bowel anastomosis provides certain advantages which m a y permit an extension of safe colorectal or coloanal anastomosis.
229 T h e e x t r a - a n a l low c o l o r e c t a l a n a s t o m o s i s using B A R is a suitable o p t i o n w h e n e v e r a s p h i n c t e r - s a v i n g o p e r a tion is i n d i c a t e d a n d an a b d o m i n a l a n a s t o m o s i s is difficult o r n o t feasible.
References 1. Knight CD, Griffen FD (1988) An improved technique for low anterior resection of the rectum using the EEA stapler. Surgery 88:710-714
2. Illuminati G, Bezzi M, Martinelli V (1990) Stapled coloanal anastomosis after linear closure of everted anorectal stump. Acta Chir Scand 156:641 642 3. Dyess DL, Curreri PW, Ferrara JJ (1990) A new technique for sutureless intestinal anastomosis. A prospective, randomized, clinical trial. Am Sur 56:71-75 4. Cahill CJ, Betzler M, Gruwez JA, Jeekel J, Patel JC, Zederfeldt B (1989) Sutureless large bowel anastomosis: European experience with the biofragmentable anastomosis ring. Br J Surg 76: 344- 347 5. Hautefeuille P, Valleur P, Perniceni T, Martin B, Galian A, Cherqui D, Hoang C (1988) Functional and oncologic results after coloanal anastomosis for low rectal carcinoma. Ann Surg 207:61-64
Colb eclal Disease 9 Springer-Verlag 1992
A simple technique for sutureless very low colorectal anastomosis Marcello Bezzi, Michele Casella, Mariano Batori and Licinio Angelini Fourth Department of Surgery, University of Rome, Medical School "La Sapienza", Rome, Italy Accepted: 6 July 1992
An accurate distal purse-string suture can be difficult to place and close on the rectum when performing low anterior resection. The double stapling technique after closure of the rectal stump with linear stapler avoids these difficulties [1]. Nevertheless, in some cases with a narrow pelvis and a lower third rectal cancer, it is particularly difficult to insert the linear stapler without direct vision to assure a satisfactory distal margin below the level of the tumor. F o r these reasons we found it useful to perform the anastomosis after stapled closure of the everted anorectal stump [2]. Some limitations of the double stapling procedure have, however, been reported. The incidence of anastomotic leakage is no less than with other techniques, while the risk of stricture is higher [3]. There is now evidence that a sutureless anastomosis using a biofragrnentable ring can be performed in the large bowel more easily with more reliable healing than with other anastomotic techniques [4]. The BAR device has been used in anterior resection for cancer of the upper third of the rectum but so far no transanal insertion technique has been described. In patients requiring a low colorectal or coloanal anastomosis we have used the BAR with eversion of the anorectal stump after endorectal pull-through of the left colon.
The tumor is resected and the proximal colonic stump with the proximal purse-string suture already inserted is brought down through the anorectal stump. The BAR (VALTRAC| mm with the introducer is inserted into the proximal colon and the purse string is tied. The rectal purse-string suture is then tied onto the central portion of the ring (Fig. 2). The BAR is closed by even pressure on both edges to result in sutureless low colorectal anastomosis that is then pushed back through the anal canal into the pelvis (Fig. 3). The peritoneum covering the pelvis is replaced by mobilized omentum. A diverting colostomy is not performed. We used this technique in two female patients with BAR anastomosis respectively at 3.5 and 4 cm
Technique The rectum and mesorectal tissue are fully mobilized down to the levator ani muscle and the bowel is divided a few centimetres above the level of the tumor. The upper rectum with the dissected perirectal fat (including that removed from the distal remnant) and the sigmoid colon are removed as for a standard low anterior resection. The anorectal stump is closed with a simple running suture and evaginated through the anus. A safe distal clearance from the tumor of no less than 2 cm is determined and a purse-string suture is placed at this level using the Autosuture instrument (Fig. 1).
Fig. 1. The automatic purse-string suture is placed on the everted anorectal stump
228
Fig. 2. After endorectal pullthrough the BAR (VALTRAC) is inserted and the purse-string sutures are tightened extra-anally
Fig. 3. The BAR (VALTRAC) is closed resulting in an ex9ternal sutureless anastomosis that is pushed back into the pelvis f r o m anal verge. N o operative mortality or general complications were observed. Local complications were observed in one patient, with a radiological fistulax healed in one week and a troublesome tenesmus until the B A R expulsion (15 p.o. day).
Comments There is no d o u b t that the double stapling technique increased low sphincter-saving operations providing a greater closeness to the anus and shorter operative time.
Unfortunately this technique does not reduce the risk of leakage and anastomotic stricture and does not eliminate technical difficulties and problems o f safety related to the distal clearance when dealing with a very low rectal cancer within a narrow pelvis. Eversion o f the t u m o r pulling the stump through the anus does not alter subsequent anal function or entail a higher local recurrence rate [5]. The biofragmentable ring for sutureless large bowel anastomosis provides certain advantages which m a y permit an extension of safe colorectal or coloanal anastomosis.
229 T h e e x t r a - a n a l low c o l o r e c t a l a n a s t o m o s i s using B A R is a suitable o p t i o n w h e n e v e r a s p h i n c t e r - s a v i n g o p e r a tion is i n d i c a t e d a n d an a b d o m i n a l a n a s t o m o s i s is difficult o r n o t feasible.
References 1. Knight CD, Griffen FD (1988) An improved technique for low anterior resection of the rectum using the EEA stapler. Surgery 88:710-714
2. Illuminati G, Bezzi M, Martinelli V (1990) Stapled coloanal anastomosis after linear closure of everted anorectal stump. Acta Chir Scand 156:641 642 3. Dyess DL, Curreri PW, Ferrara JJ (1990) A new technique for sutureless intestinal anastomosis. A prospective, randomized, clinical trial. Am Sur 56:71-75 4. Cahill CJ, Betzler M, Gruwez JA, Jeekel J, Patel JC, Zederfeldt B (1989) Sutureless large bowel anastomosis: European experience with the biofragmentable anastomosis ring. Br J Surg 76: 344- 347 5. Hautefeuille P, Valleur P, Perniceni T, Martin B, Galian A, Cherqui D, Hoang C (1988) Functional and oncologic results after coloanal anastomosis for low rectal carcinoma. Ann Surg 207:61-64
