Functional outcomes with handsewn versus stapled anastomoses in the treatment of ultralow rectal cancer

Abstract

Adequate oncological outcomes have been demonstrated with rectal resection and handsewn coloanal anastomosis (CAA) in tumours in close proximity to the internal anal sphincter. Our aim was to assess functional differences between handsewn CAA and ultralow stapled anastomosis. Participants were identified from a single-surgeon series. Included participants underwent anorectal physiology testing of anal sphincter function, in addition to completion of several questionnaires: Wexner Incontinence Score (WIS); Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ); Low Anterior Resection Syndrome (LARS) Score; SF36. Non-parametric data compared using the Mann–Whitney U test. 20 participants were included; 11 stapled and 9 handsewn. Mean follow-up was 2.95 ± 1.97 years. The mean LARS score was 21.9 ± 1.97 years in the stapled group versus 29.4 ± 9.57 in the handsewn group (p = 0.133). The Wexner incontinence score was significantly higher in the handsewn group (p = 0.0076), with a mean score of 4.6 ± 3.69 versus 10.9 ± 4.76. The incontinence domain of the BBUSQ was also significantly worse in patients with a handsewn anastomosis (p = 0.001). With the exception of general health (p = 0.035) and social functioning (p = 0.035), which were worse in the handsewn groups, the other six domains of the SF-36 showed no statistical difference between groups. Anorectal physiology scores were not significantly different. Handsewn CAA anastomosis is known to be safe and oncologically feasible. Patient selection should be vigorous, with preoperative counseling regarding the likelihood of incontinence to manage patients’ expectations and promote comparable quality of life in the long-term.

Short stump and high anastomosis pull-through (SHiP) procedure for delayed coloanal anastomosis with no protective stoma for low rectal cancer

“…Rullier et al indicated that it is possible to reconstruct pelvic floor muscles with full anatomic integrity if they are free from neoplasia via sphincter-saving coloanal anastomosis [ 5 ]. Thus, it is possible to achieve such reconstruction while abolishing the need for a few centimeters’ of free margin; however, the ideal ultra-low coloanal anastomosis method (hand-made or stapled) remains the subject of debate [ 1 – 3 ].…”

“…Coloanal anastomosis remains the subject of lively clinical debate despite modern advances in the technique, given that outcomes remain unsatisfactory [ 1 – 4 ]. Since Rullier et al published their criteria in 2013, there has been a notable increase in the rate of surgeries that conserve the pelvic floor, thereby promoting the possibility of expanding this type of reconstruction to all patients who have no invasion of the pelvic floor muscles [ 5 ].…”

Handsewn perineal rectosigmoidectomy (Altemeier) for complete full-thickness rectal prolapse: a case study

“…Ramage et al also used in the treatment of ultralow rectal cancer, the handsewn anastomosis reported being safe and feasible. 10 Case 1 and case 3 patients had comorbid uterine prolapse, and the problem was corrected by an obstetrician with trans-perineal hysterectomy, so our procedure of choice was trans-perineal rectal prolapse repair. The second patient had mental retardation comorbidity, so our procedure of choice to correct the rectal prolapse was perineal rectosigmoidectomy because we considered the patient cannot take care of the post-operative wound from infection.…”

The role of colonic motility in low anterior resection syndrome

“…Few small studies have assessed differences in functional outcomes or anorectal physiology between handsewn and stapled anastomoses. Generally, there is similar symptomatology (104) between the groups but one study reported higher incontinence scores in association with handsewn anastomoses despite no difference in anorectal physiology parameters (105,106). Further investigation of differences in colonic or neorectal motility between reconstruction techniques may reveal important factors associated with functional outcomes.…”