Mechanotechnical faults and particular issues of anastomotic complications following robot‐assisted anterior resection in 968 rectal cancer patients

Abstract

Background As most risk factors for anastomotic complications (AC) in rectal cancer patients appear to be noncorrectable, it is needed to find the correctable causes. Additionally, the outcomes of indocyanine‐green fluorescence imaging (IFI) and robot‐stapled anastomosis have yet been undetermined. Methods This study retrospectively analyzed 968 consecutive patients with rectal cancer, who underwent curative robot‐assisted anterior resections between 2010 and 2018. IFI parameters and stapling features in the surgical records were reviewed, and reconfirmed. Results AC occurred in 54 patients (5.6%), 34 (3.5%) with anastomotic leakage (AL) and 24 (2.5%) with anastomotic stenosis (AS). Mechanotechnical faults including defective stapling configurations, including angles lesser than or equal to 150° and outer deviation (more than half from the center of the circle) of linear staples, between the two linear staples were independently associated with AL (P < .001 each). IFI significantly reduced AL rate (2.5% vs 5.3%, P = .029) and AS rate (2% vs 18.8%, P = .006), respectively. Robot linear stapling enabled to maintain the obtuse angle during consecutive staplings and reduced console time. AL and AS were independent risk factors for disease‐free survival (P = .02) and local recurrence (P = .03), respectively. Conclusions AC were associated with some correctable causes, namely, mechanotechnical errors and lack of use of IFI.

Interpretation and clinical utility of indocyanine‐green fluorescence imaging (IFI) in robot‐assisted anorectal‐function saving operations (ASOs): A propensity‐score matched analysis of 872 prospectively enroled patients undergoing IFI

“…These two parameters may explain our findings of non‐reducing anastomotic complication through IFI. Most technical errors are due to multiple linear stapling and uneven depth of stapling, as previously reported 22,23 . Anatomical defects included restrictive pelvis, bowel adhesion, and malrotation/short mesocolon.…”

Definition and grading of anastomotic stricture/stenosis following low anastomosis after total mesorectal excision: A single-center study

“…Furthermore, factors such as the ligation site of IMA have also been studied; studies found that low ligation may result in a reduced rate of AS following colorectal cancer surgeries and then suggest that low ligation should be preferred over high ligation [22,29]. Another factor is blood perfusion evaluated using ICG, which signi cantly reduces AL and AS rates [30]. However, none of these factors thought to in uence AS was identi ed as meaningful in this study.…”

Anastomotic Complications

“…Intraoperative risk factors include the inability to achieve a tension-free anastomosis and poor blood supply to the ends of bowel used for anastomosis, blood loss and blood transfusions, prolonged operating time, and intraoperative contamination [10][11][12][13][14][15][16]. Using multiple stapler firings across the rectum, which is commonly done in laparoscopic and robotic approaches, may also be associated with a higher risk for anastomotic leak [21][22][23]. The operating surgeon is another potential risk factor, although little is known about which surgeon characteristics would increase the risk for a surgical complication [24,25].…”