IDEAL Stage 2a/b prospective cohort study of transanal transection and single‐stapled anastomosis for rectal cancer

Abstract

AimThere are several anastomotic techniques available to facilitate restorative rectal cancer surgery after total mesorectal excision (TME), including double‐stapled anastomosis (DST) and handsewn coloanal anastomosis (CAA). However, to date no one technique is superior with regard to anastomotic leakage (AL) or functional outcomes. Transanal transection single‐stapled anastomosis (TTSS) aims to overcome some of the technical challenges and offer comparable clinical and functional outcomes to traditional anastomotic techniques. The aim of this study was to explore the role of TTSS in modern rectal cancer surgery and to provide comparative clinical and functional outcome data with DST and CAA.MethodA prospective cohort study was undertaken to assess the safety and clinical and patient‐reported outcomes associated with the TTSS procedure. All patients undergoing sphincter‐preserving surgery for rectal cancer with an anastomosis performed within 6 cm of the anal verge between January 2016 and April 2021 were prospectively enrolled into this study. Clinical and patient‐reported outcome data, including low anterior resection syndrome (LARS) assessment, were collected. The primary endpoint was anastomotic leakage within 30 days.ResultsA total of 275 patients participated in this study, with 70 (25%) patients undergoing a TTSS, 110 (40%) undergoing a DST and 95 (35%) undergoing a CAA. Patients undergoing a CAA had more distal tumours than those having a TTSS or DST, with a median tumour height of 5, 7 and 9 cm (p < 0.001), respectively. We observed a statistically significant reduction in AL in the TTSS group compared with the DST group, with rates of 8.6% versus 20.9% (p = 0.028). There was no difference in LARS scores between patients undergoing TTSS and DST (p = 0.228), while patients with a CAA had worse LARS scores than TTSS patients (p = 0.002).ConclusionTTSS is a technically safe and feasible anastomotic technique in rectal cancer surgery as an alternative to DST and CAA. Its advantages over DST are a reduced AL rate and, over CAA, improved function. It should therefore be considered as an alternative technique to improve clinical and patient‐reported outcomes in restorative rectal cancer surgery.

Low anterior resection with transanal transection and single-stapled anastomosis: technical aspects and initial results

“…This trend was recently confirmed by the results of the prospective IDEAL cohort study (stage 2 a/b) [ 16 ], in which of 275 patients with medium and lower rectal tumours were compared and divided into three groups: 70 patients who underwent surgery via the TTSS technique, 110 patients who underwent surgery via the DG technique, and 95 patients who underwent coloanal anastomosis. When comparing the data of patients who underwent TTSS with those of patients in the DS group, the AL rates were 8.6 and 20.9%, respectively ( p = 0.028), with a similar incidence of low anterior resection syndrome (LARS) in both groups.…”