Use of the modified double-stapling technique with vertical division of the rectum during a sphincter-preserving operation for the treatment of a rectal tumor

Summary

Background/Objectives

The modified double-stapling technique (DST) with vertical division of the rectum(IO-DST) has been reported as a feasible and safe procedure for performing low anastomosis during rectal cancer surgery. In this procedure, an endostapler was vertically used, instead of using a horizontally orientated linear stapler, when dividing the rectum. A previous study reported that this technique is useful for treating patients with a narrow pelvis and/or performing a very low anastomosis.

Methods

The use of IO-DST anastomosis during anterior resection(AR) and low anterior resection was performed on 80 cases of rectal cancer between April 1998 and June 2004 at our institution. We reviewed those cases and evaluated the leakage rate.

Results

We found that leakage occurred in six cases (7.5%); however, leakage was not found in cases of AR or cases with a preserved left colic artery (LCA).

Conclusions

The IO-DST technique is an adequate procedure for performing AR. The preservation of the LCA could be used to prevent leakage.

Keywords

rectal tumor;double-stapling technique;sphincter preserving operation

1. Introduction

The modified double-stapling technique (DST) with vertical division of the rectum (IO-DST) has been reported as a feasible and safe procedure for performing low anastomosis during rectal cancer surgery.¹ During this procedure, an endostapler is vertically applied, instead of a horizontally oriented linear stapler, when dividing the rectum. Maeda reported that this technique is useful for treating patients with a narrow pelvis and/or for performing a very low anastomosis.¹ Leakage was reported to occur in 2.9% of patients by Sato.² According to those reports, the use of IO-DST anastomosis during anterior resection and low anterior resection was performed to treat 80 cases of rectal tumors between April 1998 and June 2004 at our institution. We reviewed these cases and evaluated the leakage rate.

2. Patients and methods

The characteristics of the study patients are presented in Table 1. Tumor location was classified according to the Japanese Classification of Colorectal Carcinoma.³ The IO-DST technique was used to perform anastomosis in each case. Fifteen tumors (18.8%) were located below the peritoneal reflection.

Table 1. Characteristics of patients.

Gender
Men	53 patients
Women	27 patients
Location of tumora
Rectosigmoid cancer(Rs)	38 cases
Middle rectal cancer (Ra)	27 cases
Lower rectal cancer (Rb)	15 cases
Age (average and range)	63.7y (35～83)

a. According to the Japanese Classification of Colorectal Carcinoma, location of tumor was defined. Rectosigmoid cancer was defined as the bowel at the level of between the promontrium and the lower margin of the second sacral vertebra. Middle rectal cancer was defined as the bowel at the level of between the lower margin of the second sacral vertebra and the peritoneal reflection. Lower rectal cancer was defined as the bowel at the level of below the peritoneal reflection.

2.1. Operative technique

The patient was placed in the lithotomy position. After identifying the origin of the inferior mesenteric artery (IMA), we dissected the lymph nodes en bloc after ligation of the IMA at its root was completed. For benign tumors, early stage cancer, and patients over 80 years of age, the left colic artery (LCA) was preserved by dissecting the lymph nodes surrounding the IMA. We preserved the superior hypogastric nerves, hypogastric nerves, and pelvic plexus by mobilizing the sigmoid colon, the rectum, and mesorectum. We divided the sigmoid colon and an appropriately sized (usually 31 mm) circular stapler was fitted in the proximal bowel using a purse-string suture (Purstring, Covidien, Mansfield, MA, USA). An occlusion clamp was placed vertically across the rectum distal to the tumor in order to perform IO-DST anastomosis, followed by perianal wash out.

The Powered Multifire Endo GIA 60 stapler (Covidien) was applied vertically across the rectum distal to the bowel clamp and fired at an appropriate surgical margin one or two times. Finally, a circular stapler (PCEEA; Covidien) was perianally introduced and double-stapling anastomosis was performed. A diverting ileostomy was created when the anastomotic site was < 5 cm from the anal verge. Mobilization of the colon at the splenic flexure was not performed in each case.

Pelvic lymph node dissection was indicated for cancers in which the lowest margin of the tumor was located below the peritoneal reflection or for lower rectal cancer with over T3 and/or lymph node metastasis that was preoperatively or intraoperatively diagnosed. This procedure was performed after resection of the tumor. All operations were performed by one surgeon, with an operator or a first assistant, who had > 10 years experience as a colorectal surgeon.

Anastomotic leakage was clinically evaluated and/or by a gastrografin enema after surgery. Differences were considered statistically significant when the p value was < 0.05 according to the t test.

3. Results

The IO-DST technique was used to perform the anastomosis in each case. Low anterior resection was performed on 67.5% of patients. Pelvic lymph node dissection with a sphincter-preserving operation was performed on 16 cases in this study, and a covering ileostomy was performed in 10 cases for LAR. Ligation at the root of the IMA was performed in 59 cases (73.8%; Table 2). The Dukes' classification of each case is shown in Table 3.

Table 2. The type of operation.

Anterior Resection (AR)	26 cases
Low Anterior Resection (LAR)	54 cases
Pelvic Lymph node Dissection (PL)	16 cases
Without PL	64 cases
With covering ileostomy	10 cases
Preservation of Left Colic Artery (LCA)	21 cases
Ligation of Inferior Mesenteric Artery (IMA)	59 cases

Table 3. Pathological findings and Dukes' classification of cancers.

Dukes' Classification
A	24 cases
B	16 cases
C	29 cases
D	10 cases
Adenoma	1 case

Over 70% of the cases were classified as advanced cancers. Leakage was found in six cases (7.5%). However, leakage was not found in the AR cases or cases with a preserved LCA (Table 4).

Table 4. Number of patients who has been found the leakage.

Total number	6 cases (7.5%)
AR (26 cases)	none
LAR (54 cases)	6 cases (11.1%)*
Cases of preservation of LCA (21cases)	none
Cases of ligation of IMA (59 cases)	6 cases (10.2%)**

• p = 0.07.

• • p = 0.13.

4. Discussion

DST with horizontal clamping of the rectum for low anterior resection was first reported by Knight and Griffen in 1980 and was presented as a method with great facility and safety.⁴ Cohen et al also described the safety and functional benefits of this method.⁵ They reported only one case of postoperative anastomotic leakage among 26 cases (3.8%) treated using TA55 (Ethicon) and EEA (Covidien) staplers. Varma et al reported their experience of using DST to treat 28 patients, reporting two cases of clinical anastomotic leakage (7.1%).⁶ The DST technique with horizontal clamping can be difficult to perform on patients with a narrow pelvis because the space in the pelvis is occupied by the linear stapler.

The IO-DST technique with vertical division of the rectum was described by Maeda et al as an easy and safe procedure for clamping the rectum in patients with a narrow pelvis and for performing very low anastomosis.¹ Sato et al compared the clinical outcomes of using the single-stapling technique (SST) in on patients and IO-DST on 34 patients. Leakage occurred in six patients (12.8%) in the SST group and in one patient (2.9%) in the IO-DST group. In our study, six cases of leakage (7.5%) developed. Regarding the type of operation, leakage did not occur in any of the 26 cases of AR or any of the 21 cases with preserved LCA. On the other hand, six patients who underwent LAR developed leakage; however, this difference was not statistically significant. These rates are higher than those reported by Sato. Inadequate preparation and the length of the colon reconstruction are believed to have resulted in leakage. In our study, mobilization of the splenic flexure was not performed during LAR or in the cases with a ligated IMA. The length of the colon reconstruction would not have been enough to prevent complications. Preservation of the LCA could be an important procedure that maintains the blood supply necessary for colon reconstruction.

We conclude that preservation of the LCA could be a useful procedure that prevents leakage when performing the IO-DST technique.

References

1. 1 K. Maeda, M. Maruta, T. Utsumi, Y. Okamura; Vertical division of the rectum by endostapler in very low colorectal anastomosis with a double-stapling technique; Min Invas Ther & Allied Technol, 8 (1999), pp. 3–4
2. 2 H. Sato, K. Maeda, T. Hanai, et al.; Modified double-stapling technique in low anterior resection for lower rectal carcinoma; Surg Today, 36 (2006), pp. 30–36
3. 3 Japanese Society for Cancer of the Colon and Rectum; Japanese Classification of Colorectal Carcinoma; (1st English ed.)Kanehara & Co., Ltd., Tokyo (1997)
4. 4 C.D. Knight, F.D. Griffen; An improved technique for low anterior resection of the rectum using the EEA stapler; Surgery, 88 (1980), pp. 710–714
5. 5 Z. Cohen, E. Myers, B. Langer, et al.; Double stapling technique for low anterior resection; Dis Col & Rec, 26 (1983), pp. 231–235
6. 6 J.S. Varma, A.C.W. Chan, M.C.K. Li, A.K.C. Li; Low anterior resection of the rectum using a double stapling technique; Br J Surg, 77 (1990), pp. 888–890