Retrospective Analysis Of Rectal Stenosis After Anterior Resections With Or Without Stapling: Rectal Stapling Is Not A “Thornless Rosary”

Abstract

Purpose: Recently, stapler anastomosis is the method of choice in low- or ultra low resection for rectal carcinoma. In this study, risk of rectal stricture formation after double stapling colorectal anastomosis was evaluated. Methods: We herewith presented an invitro investigation and a retrospective analysis of 91 cases of rectal carcinoma treated by low or ultra low anterior resection with hand-sewn or double-stapled colorectal anastomosis between the years 2002-2006 regarding the late complication of postoperative stenosis. In in vitro investigation external and internal diameters of staplers were measured. Also diameters of anastomotic lines were investigated on stapled sheep intestine and low anterior resection specimen of human, in vitro. Results: External and internal diameters of 29 and 33 mm staplers were found 19.5-24 mm respectively. Also diameters of anastomosis with 29 mm stapler at sheep intestine and 33 mm stapler at low anterior specimen were found 15 mm, 20 mm respectively.Rectal stricture was not seen in any of the patients with hand-sewn anastomoses. We found postoperative stricture of the rectal anastomosis in 11 (17.2 %) of the patients treated by double-stapled group (p=0.022). The risk factors that we have investigated were age and gender of the patient, location and stage of the tumour, diameter of EEA staplers, and presence of neoadjuvant or adjuvant chemoradiotherapy. Conclusions: Although double-stapling anastomosis in rectal cancers has clear technical advantages over hand-sewn technique, the late complication of stenosis occurred at a significantly higher rate after this technique.

Keywords

• rectal stenosis
• stapler
• anterior resection

References

1. Ambrosetti, P., Francis, K., De Peyer, R., Frossard, J.L., 2008. Colorectal anastomotic stenosis after elective laparoscopic sigmoidectomy for diverticular disease: a prospective evaluation of 68 patients. Dis. Colon. Rectum. 51, 1345-1349.
2. Araki, Y., Kishimoto, Y., Sato, Y., Torigoe, S., Kido, K., Matono, K., Shirouzu, K., 2002. Transanal dilation using circular stapling for benign rectal stenosis: report of a case. Kurume Med. J. 49, 149-151.
3. Bannura, G.C., Cumsille, M.A., Barrera, A.E., Contreras, J.P., Melo, C.L., Soto, D.C., 2004. Predictive factors of stenosis after stapled colorectal anastomosis: prospective analysis of 179 consecutive patients. World J. Surg. 28, 921-925.
4. Brigand, C., Rohr, S., Meyer, C. 2004. Colorectal stapled anastomosis: results after anterior resection of the rectum for cancer. Ann. Chir. 129, 427-432.
5. De Salvo, L., Razzetta, F., Cagnazzo, A., Tassone, U., Arezzo, A., Mattioli, F.P. 1997. Comparison of colorectal mechanical suture techniques. Ann. Ital. Chir. 68, 381-384. Fain, S.N., Patin, C.S., Morgenstern, L., 1975. Use of a mechanical suturing apparatus in low colorectal anastomosis. Arch. Surg. 110, 1079-1082.
6. Fingerhut, A., Elhadad, A., Hay, J.M., Lacaine, F., Flamant, Y. 1994. Infraperitoneal colorectal anastomosis: hand-sewn versus circular staples. A controlled clinical trial. Fr. Associations Surg. Res. Surgery. 116, 484-490.
7. Graf, W., Glimelius, B., Bergström Påhlman, L., 1991. Complications after double and single stapling in rectal surgery. Eur. J. Surg. 157, 543-547.
8. Kato, K., Saito, T., Matsuda, M., Imai, M., Kasai, S., Mito, M., 1997. Successful treatment of a rectal anastomotic stenosis by transanal endoscopic microsurgery (TEM) using the contact Nd:YAG laser. Surg. Endosc. 11, 485-487.

9. Knight, C.D., Griffen, F.D., 1980. An improved technique for low anterior resection of the rectum using the EEA stapler. Surguery 88, 710-714.
10. Lustosa, S.A., Matos, D., Atallah, A.N., Castro, A.A., 2002. Stapled versus handsewn methods for colorectal anastomosis surgery: a systematic review of randomized controlled trials. Sao Paulo Med. J. 120, 132-136.
11. McKee, R., Pricolo, V.E. 2008. Stapled revision of complete colorectal anastomotic obstruction. Am J. Surg. 195, 526-527. Pan, Z.Z., Wan, D.S., Ding, P.R., Li, L.R., Chen, G., Wu, X.J., Zhou, Z.W., Lu, Z.H., Wan, X.B., Li, C.M. 2004. Long-term result of low anterior resection with stapling devices for rectal cancer. Ai. Zheng. 23, 1508-1511.
12. Petrassi, A., Roncone, A., Formisani, P., Iannello, A., 1994. Results of the multicenter study (A.C.O.I. Stapler Study Group) on 420 cases of esophagojejunal and 544 cases of colorectal anastomoses. Ann. Ital. Chir. 65, 49-58.
13. Sciumè, C., Geraci, G., Pisello, F., Arnone, E., Romeo, M., Modica, G., 2008. Mechanical versus manual anastomoses in colorectal surgery. Personal experience. G. Chir. 29, 505-510.
14. Shimada, S., Matsuda, M., Uno, K., Matsuzaki, H., Murakami, S., Ogawa, M., 1996. A new device for the treatment of coloproctostomic stricture after double stapling anastomoses. Ann. Surg. 224, 603-608
15. Smith, L.E. 1981. Anastomosis with EEA stapler after anterior colonic resection. Dis. Colon Rectum. 24, 236-242. Stahle, E., Pahlman, L., Enblad, P., 1986. Double stapling technique in the management of rectal tumours. Acta. Chir. Scand. 152,743-747.
16. Thiede, A., Jostarndt, L., Troidl, H., Poser, H.L., Bertz, U., Hamelmann, H., 1981.Value of circular mechanical colon and rectum anastomosis. Prospective study of 91 patients. Chirurg. 52, 30-35. Ti, T.K., Rauff, A., Goh, H.S. 1986. Anterior resection using the circular stapling instrument: a Singapore experience. Aust. N. Z. J. Surg. 56, 919-922.
17. Yagyu, T., Yamamoto, T., Mochizuki, H., 2002. Regular finger dilation for preventing anastomotic stenosis after low anterior resection. Surg. Today. 32, 220 - 223.
18. Yu, B., Li, D., Zheng, M., Shen, Y., Wang, H., 2000. Total meso-rectal excision in low anterior resection with double stapling technique. Zhonghua Wai Ke Za Zhi. 38, 496-498