Annals of Coloproctology

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Optimal anastomotic technique in rectal surgery to prevent anastomotic leakage: Daichi Kitaguchi, Masaaki Ito; Ann Coloproctol. 2023;39(2):97-105. Published online January 3, 2023; DOI: https://doi.org/10.3393/ac.2022.00787.0112

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Complications after colorectal surgery remain inevitable, and anastomotic leakage is one of the most severe and potentially fatal complications. Generally, anastomotic leakage is associated with severe peritonitis, the need for emergency reoperation, and an increased mortality rate. Additionally, particularly after rectal cancer surgery, it has a negative impact on long-term outcomes, including postoperative anorectal function, local recurrence, and survival. To prevent anastomotic leakage, understanding the characteristics of each anastomotic technique and establishing a stable anastomotic procedure are important. Transanal total mesorectal excision (TaTME) is a relatively new advanced surgical access technique for pelvic dissection and facilitates different anastomotic techniques without the need for transabdominal rectal transection. Especially, stapled anastomosis in TaTME, also known as double purse-string circular stapled anastomosis or the single stapling technique (SST), has gained much attention as an alternative to the conventional double stapling technique (DST). In this article, we describe the DST, SST, and hand-sewn anastomosis as anastomotic techniques after rectal surgery, focusing mainly on the differences between conventional anastomotic techniques and SST in TaTME. Furthermore, the blood flow evaluation method for the reconstructive colon before anastomosis, which is extremely important in anastomotic leakage prevention regardless of the anastomotic type, is also described.

Citations

Citations to this article as recorded by

Neutrophil-to-lymphocyte ratio as an early predictor of anastomotic leakage after rectal cancer surgery
Yingjun Liu, Bing Han, Weifeng Xu, Youcai Wang, Mingke Huo, Jianwei Wang, Hongli Wang, Zhi Li
Surgery.2026; 190: 109829. CrossRef
Optimizing outcomes in anastomotic recurrence of rectal cancer: Efficacy of transanal total mesorectal excision
Mengqin Yu, Ximo Xu, Hao Zhong, Duohuo Shu, Naijipu Abuduaini, Jingyi Liu, Zhenfeng Huang, Haiqin Song, Sen Zhang, Xiao Yang, Zhenghao Cai, Gaojian Cao, Jianwen Li, Bo Feng
Current Problems in Surgery.2025; 66: 101748. CrossRef
Sphincter-preserving surgical techniques in low rectal cancer management: A systematic review of contemporary evidence
Song Wang, A-Jian Li, Hui-Hong Jiang, Yin Lin, Hai-Bo Ding
World Journal of Gastrointestinal Surgery.2025;[Epub] CrossRef
The robotic intracorporeal single-stapled anastomosis (RiSSA) technique in robotic left-sided colorectal resection: a technical note
Chih-Chien Wu, Yung-Lin Tan, Chao-Wen Hsu, Hsin-Ping Tseng, Danilo Miskovic, Shih-Feng Huang
Annals of Coloproctology.2025; 41(4): 357. CrossRef
Achieving the perfect end-to-end single-stapled anastomosis in low anterior resection for rectal cancer: technical aspects
Cherylin Wan Pei Fu
Annals of Coloproctology.2025; 41(4): 361. CrossRef
Comparative perioperative outcomes of articulated versus conventional straight devices in laparoscopic low anterior resection: a propensity score–matched analysis
Hayoung Lee, Yong Sik Yoon, Young Il Kim, Min Hyun Kim, Jong Lyul Lee, Chan Wook Kim, In Ja Park, Seok-Byung Lim
Annals of Coloproctology.2025; 41(5): 434. CrossRef
Dissection layer selection based on an understanding of pelvic fascial anatomy in transanal total mesorectal excision
Daichi Kitaguchi, Masaaki Ito
Annals of Coloproctology.2024; 40(4): 375. CrossRef
Successful Clinical Avoidance of Colorectal Anastomotic Leakage through Local Decontamination
Gerhard Ernst Steyer, Markus Puchinger, Johann Pfeifer
Antibiotics.2024; 13(1): 79. CrossRef
Combined Robotic Transanal Transection Single-Stapled Technique in Ultralow Rectal Endometriosis Involvement Associated With Parametrial and Vaginal Infiltration
Gianmarco D'Ancona, Benjamin Merlot, Quentin Denost, Stefano Angioni, Thomas Dennis, Horace Roman
Journal of Minimally Invasive Gynecology.2024; 31(4): 267. CrossRef
Risk factors for the failure of endoscopic balloon dilation to manage anastomotic stricture from colorectal surgery: retrospective cohort study
Young Il Kim, Seung Wook Hong, Seok-Byung Lim, Dong-Hoon Yang, Eon Bin Kim, Min Hyun Kim, Chan Wook Kim, Jong Lyul Lee, Yong Sik Yoon, In Ja Park, Chang Sik Yu
Surgical Endoscopy.2024; 38(4): 1775. CrossRef
The impact of powered circular staplers on anastomotic leak in left-sided colorectal cancer surgeries
Hayoung Lee, Yong Sik Yoon, Young Il Kim, Eun Jung Park, Min Hyun Kim, Jong Lyul Lee, Chan Wook Kim, In Ja Park, Seok-Byung Lim
Surgical Endoscopy.2024; 38(10): 6111. CrossRef
Effect of powered circular stapler in colorectal anastomosis after left-sided colic resection: systematic review and meta-analysis
Andrea Scardino, Carlo Galdino Riva, Luca Sorrentino, Sara Lauricella, Alberto Aiolfi, Matteo Rottoli, Gianluca Bonitta, Marco Vitellaro, Luigi Bonavina, Davide Bona, Michael Kelly, Emanuele Rausa
International Journal of Colorectal Disease.2024;[Epub] CrossRef
Early detection of anastomotic leakage in colon cancer surgery: the role of early warning score and C-reactive protein
Gyung Mo Son
Annals of Coloproctology.2024; 40(5): 415. CrossRef
Optimal Indocyanine Green Dosage for Repetitive Angiography for Laparoscopic Colorectal Surgery
Gyung Mo Son, Sang-Ho Park, Nam Su Kim, Mi Sook Yun, In Young Lee, Myeong-Sook Kwon, Tae Kyun Kim, Eun Hwa Lee, Eun Jung Hwang, Kwang-Ryul Baek
Medicina.2024; 60(12): 1966. CrossRef
The Safe Values of Quantitative Perfusion Parameters of ICG Angiography Based on Tissue Oxygenation of Hyperspectral Imaging for Laparoscopic Colorectal Surgery: A Prospective Observational Study
Gyung Son, Armaan Nazir, Mi Yun, In Lee, Sun Im, Jae Kwak, Sang-Ho Park, Kwang-Ryul Baek, Ines Gockel
Biomedicines.2023; 11(7): 2029. CrossRef
Impact of Postoperative Naples Prognostic Score to Predict Survival in Patients with Stage II–III Colorectal Cancer
Su Hyeong Park, Hye Seung Woo, In Kyung Hong, Eun Jung Park
Cancers.2023; 15(20): 5098. CrossRef

Case Report

Benign proctology,Complication,Surgical technique

Rectal perforation and perirectal abscess following stapled hemorrhoidectomy for prolapsed hemorrhoids successfully managed with Endo-SPONGE endoluminal vacuum-assisted wound closure system: Emanuele Rosati, Manuel Valeri, Luigina Graziosi, Lavinia Amato, Stefano Avenia, Annibale Donini; Ann Coloproctol. 2022;38(5):387-390. Published online June 9, 2021; DOI: https://doi.org/10.3393/ac.2021.02.07

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1 Web of Science
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Abstract PDF

Active drains, which work by negative pressure, are commonly used to drain closed airtight wounds. Higher negative pressure is used in vacuum-assisted wound closure dressings. Gastrointestinal leaks may be difficult to treat by surgical approach because of their association with high morbidity and mortality. Recently, endoscopic approaches have been applied with several degrees of success. Most recently, endoluminal vacuum-assisted wound closure (EVAC) has been employed with high success rates in decreasing both morbidity and mortality. In the present paper, the authors describe the successful use of Endo-SPONGE (B. Braun Medical B.V.) EVAC system therapy to drain an open rectal wound, following a perforation occurred during stapled hemorrhoidectomy.

Citations

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Innovative Treatment of Combat-Related Extraperitoneal Penetrating Rectal Injury with Intraluminal Vacuum Therapy: A Case Report
Yafa Shani Parnasa, Oded Cohen-Arazi, Gad Marom, Mahmoud Abu-Gazala, Noam Shussman, Miklosh Bala
Trauma Care.2025; 5(2): 12. CrossRef
Endoluminal Vacuum Therapy (EVT) for the Treatment of Rectal Perforation Following Cleansing Enema Application
Alper Sozutek, Ekin Y Tas, Kemal Yener, Julia Ozcomert
Cureus.2023;[Epub] CrossRef

Original Articles

Benign GI diease,Benign diesease & IBD,Complication,Surgical technique

Triple-Staple Technique Effectively Reduces Operating Time for Rectal Anastomosis: Marie Shella De Robles, Christopher John Young; Ann Coloproctol. 2021;37(1):16-20. Published online February 5, 2020; DOI: https://doi.org/10.3393/ac.2019.06.30

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10 Web of Science
10 Citations

Abstract PDF

Purpose
Stapled anastomotic techniques to the distal rectum have gained widespread acceptance due to their procedural advantages. Various modifications in the stapling techniques have evolved since their inception. The triple-staple technique utilizing stapled closure of both the proximal colon and distal rectal stump provides a rapid and secure colorectal anastomosis. The aims of this study were to determine the safety and efficacy of the triple-staple technique and to compare the clinical outcomes with a historical control group for which the conventional double-staple technique had been performed.
Methods
One hundred consecutive patients operated on by a single surgeon were included in the study; 50 patients who underwent a double-staple (DSA) procedure and 50 patients undergoing triple-staple anastomosis (TSA).
Results
The most common indication for surgery in both groups was rectal cancer followed by diverticular disease and distal sigmoid cancer. There was no significant difference in number of patients requiring loop ileostomy formation in the groups (TSA, 56.0% vs. DSA, 68.0%; P = 0.621). The mean operating time for the TSA group was significantly shorter compared to that of the DSA group (TSA, 242.8 minutes vs. DSA, 306.1 minutes; P = 0.001). There was no significant difference in complication rate (TSA, 40% vs. DSA, 50%; P = 0.315) or length of hospital stay between the two groups (TSA, 11.3 days vs. DSA, 13.0 days; P = 0.246). Postoperative complications included anastomotic leak, prolonged ileus, bleeding, wound infection, and pelvic collection.
Conclusion
The triple-staple technique is a safe alternative to double-staple anastomosis after anterior resection and effectively shortens operating time.

Citations

Citations to this article as recorded by

Single versus double stapled anastomosis in natural orifice specimen extraction (NOSE) laparoscopic anterior resection
Abdus Salam Raju, Seyed Mohammad Javad Taghavi, Andrew James Gilmore
ANZ Journal of Surgery.2025; 95(6): 1198. CrossRef
Sphincter-preserving surgical techniques in low rectal cancer management: A systematic review of contemporary evidence
Song Wang, A-Jian Li, Hui-Hong Jiang, Yin Lin, Hai-Bo Ding
World Journal of Gastrointestinal Surgery.2025;[Epub] CrossRef
Sex Disparities in Rectal Cancer Surgery: An In-Depth Analysis of Surgical Approaches and Outcomes
Chungyeop Lee, In Ja Park
The World Journal of Men's Health.2024; 42(2): 304. CrossRef
Double-row staple technology versus triple-row staple technology for colorectal surgery: A systematic review and meta-analysis
Tyler McKechnie, Victoria Shi, Elena Huang, Bright Huo, Aristithes Doumouras, Nalin Amin, Cagla Eskicioglu, Dennis Hong
Surgery.2024; 176(3): 633. CrossRef
The Colorectal Anastomosis: A Timeless Challenge
Alexander A. Gaidarski III, Marco Ferrara
Clinics in Colon and Rectal Surgery.2023; 36(01): 011. CrossRef
Fluorescence-guided colorectal surgery: applications, clinical results, and protocols
Jin-Min Jung, In Ja Park, Eun Jung Park, Gyung Mo Son
Annals of Surgical Treatment and Research.2023; 105(5): 252. CrossRef
Preventing Anastomotic Leakage, a Devastating Complication of Colorectal Surgery
Hyun Gu Lee
The Ewha Medical Journal.2023;[Epub] CrossRef
Robotic surgery for colorectal cancer
Sung Uk Bae
Journal of the Korean Medical Association.2022; 65(9): 577. CrossRef
Current Status and Future of Robotic Surgery for Colorectal Cancer-An English Version
Sung Uk Bae
Journal of the Anus, Rectum and Colon.2022; 6(4): 221. CrossRef
Effort to Improve Rectal Anastomosis: the Triple-Stapled Technique for Rectal Anastomosis
Sung Il Kang
Annals of Coloproctology.2021; 37(1): 1. CrossRef

Step-by-step Management and Treatment Outcome of Bleeding Control for Anastomosis Site after Low Anterior Resection with Double Stapling Technique.: Kim, Hyuk Mun , Shin, Eung Jin , Song, Ok Pyung , Kim, Jae Joon , Jang, Yong Seok , Park, Rae Kyung , Baek, Moo Joon; J Korean Soc Coloproctol. 2005;21(6):390-395.

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Abstract PDF: PURPOSE
This study reviews our experience with a step- by-step management approach of increasing aggressiveness and evaluates the treatment outcome for intraluminal hemorrhage.
METHODS
The study group was comprised of patients who had experienced intraluminal hemorrhage after a low anterior resection with the double stapling technique from 1999 to 2003. The choice of management was selected according to our step-by-step management protocol, and the outcomes were evaluated for each step, lincluding mortality and complications.
RESULTS
Nine patients (6 males and 3 females, mean age 55 years) were identified, the mean volume of packed RBC transfusion was 2 pints, and the mean distance of the anastomotic site from the anal verge was 6 cm. The median stapler size was 31 mm. The first step was cold saline irrigation and drainage; four of 9 patients were controlled. The second step was retention enema with topical hemostatics; one of remaining 5 patients stopped bleeding. The third step was colonoscopic hypertonic saline injection around the bleeding site with direct colonoscopic electrocauterization, two of remaining 4 patients were controlled. The last step was suturing the bleeding site through the anus, the remaining 2 patients stopped bleeding. One of the 9 patients developed leakage from the anastomotic site after the last step management, three of the 9 patients had long standing ileus, and one of the 9 patients developed acute renal failure after a massive transfusion. There were no postoperative deaths.
CONCLUSIONS
It is safer and easier to control bleeding with step-by-step management system of increasing aggressiveness.

Efficacy of Stump Irrigation in Removing Tumor Cells During Low Anterior Resection Using the Double Stapling Technique.: Park, Sang Jun , Kim, Hee Cheol , Yu, Yuen Sik , Yu, Jang Hak , Yu, Chang Sik , Kim, Jin Cheon; J Korean Soc Coloproctol. 2004;20(1):52-56.

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Abstract PDF: BACKGROUND
In low rectal cancer, creating a permanent stoma can be avoided by applying a low anterior resection using the double stapling technique. However, the problem of local recurrence is still a major pattern of tumor recurrence in rectal cancer. We aimed to verify the clinicopathologic variables related to exfoliation of tumor cells and searched for an efficient method to remove the tumor cells from the rectal stump during a low anterior resection.
METHODS
Forty-four patients who underwent a low anterior resection using the double stapling technique were enrolled prospectively. For patient, we irrigated each rectal stump twice with 500 cc of normal saline through the anus. Two specimens from each irrigation were obtained and examined for any malignant tumor cells. Cases in which no tumor cells were found from the two specimens were defined as Group I, cases in which tumor cells were found in only the first specimen were defined as Group II, and cases in which tumor cells were found in both the first and the second specimens were defined as Group III. Clinicopathologic variables were analyzed with regard to the presence of exfoliated tumor cells in irrigated saline.
RESULTS
There were sixteen (36%), fourteen (32%), and fourteen cases (32%) in Groups I, II, and III, respectively, according to the examination results. Age classification (P=0.05) and metastatic lymph nodes (P=0.013) were associated with the presence of tumor cells in irrigated saline (I vs. II, II).
CONCLUSIONS
Stump irrigation during a low anterior resection using the double stapling technique is recommended as an easy and simple method to remove exfoliated tumor cells from anastomosis sites, although further study is necessary to elucidate the association between exfoliated tumor cells and local recurrence.

Low Anterior Resection for Rectal Cancer Using Double Stapling Technique.: Cho, Cheon Chun , Baek, Moo Jun , Kim, Sung Yong , Lee, Moon Soo , Kim, Hyung Chul , Kim, Chang Ho , Song, Ok Pyung , Park, Hee Ju; J Korean Soc Coloproctol. 2000;16(5):323-327.

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Abstract PDF: PURPOSE
Since its introduction by Knight and Griffen in 1980, the double stapling technique has gained widespread popularity in performing the low anterior resection for the rectal cancer. But their effectiveness is not clear. The purpose of this study is to evaluate the usefulness of the low anterior resection using the double stapling technique for rectal cancer in an oncological, technical standpoints.
METHODS
Perioperative and follow up data were retrospectively reviewed in all patients undergoing the low anterior resection using the double stapling technique by same surgeons for rectal cancer over a 2.5 year period.
RESULTS
Thirty two rectal cancer patients had double stapling technique anastomoses. There was no postoperative mortality. Intraoperative complications including rectal wall tearing, incomplete doughnuts, misfiring and extraction related problems occurred in 9 of 32 patients (28.2%). Early and late postoperative complications occurred in 9 (28.8%) and 8 (24.9%) of 32 patients. Early anastomotic leak developed in 1 patient (3.1%) and anastomotic site bleeding developed in 2 patient (6.3%). Lately, the local recurrence occurred in 3 patients (9.3%) and anastomotic site stricture occurred in 3 patients (9.3%).
CONCLUSIONS
The low anterior resection using the double stapling technique has relatively low rate of leakage, stricture, local recurrence. The double stapling technique can be performed for mid or low rectal cancer with greater safety and facility.

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