Avoidance of anastomotic complications in low anterior resection of the rectum

Abstract

PURPOSE: This retrospective study was designed to evaluate the efficacy of suction-irrigation drainage systems in reducing anastomotic complications. The current trend for lesions of the upper and middle rectum emphasizes maintaining an intact anal sphincter mechanism as long as limits of resection are not compromised. Removal of the rectosigmoid colon with an anastomosis below the peritoneal reflection accomplishes this goal but with appreciable morbidity and mortality, which is in great part related to subsequent anastomotic breakdown and resultant pelvic abscess and fecal fistula formation. The presence of collections of blood, serum, and cellular debris contribute significantly to anastomotic disruption by serving as a culture medium in which bacteria may thrive, leading to abscess formation with subsequent deleterious effects on the integrity of the adjacent low lying anastomosis. Many surgeons accepted this risk and routinely performed diverting colostomies to minimize the consequences of anastomotic disruption below the peritoneal reflection. The authors felt that if this risk could be sufficiently reduced, it would obviate the need for a protecting stoma. METHODS: From 1980 to 1988, 60 consecutive patients were subjected to anterior or low anterior resections in which a closed Shirley sump irrigation system was used to facilitate postoperative drainage of the pelvis and thus avoid hematoma formation. Since this original study group of 60 patients, another 100 consecutive patients have been entered into this study. This cohort group again consisted of patients with lesions of the upper, middle, and lower rectum who underwent anterior or low anterior resections of the rectum. RESULTS: Fifty-three of the original 60 patients did not have protecting stomas. Clinical leak rate for this series was 1.67 percent. Clinical leak rate for this updated series of 100 patients was 1 percent, with overall clinical leak rate of 1.25 percent in 160 consecutive patients. There were no deaths in the series, and overall morbidity was 7.5 percent. CONCLUSIONS: The authors felt that removing blood, serum, and cellular debris from the pelvis following resections of all or part of the rectum minimizes the risk of anastomotic disruption. With this routine, covering colostomies are no longer required for most patients undergoing anterior or low anterior resections of all or part of the mesorectum.