Can a Local Drainage Salvage a Failed Colorectal or Coloanal Anastomosis? A Prospective Cohort of 54 Patients
Alexandre Challine, M.D.1 • Jeremie H. Lefèvre, M.D., Ph.D.1 • Ben Creavin, M.D.2 Olivier Benoit, M.D.1 • Najim Chafai, M.D1 • Clotilde Debove, M.D.1
Thibault Voron, M.D.1 • Yann Parc, M.D., Ph.D.1
- Sorbonne Université, Department of Digestive Surgery, Assistance Publique–Hôpitaux de Paris, Hôpital Saint Antoine, Paris, France
- Department of Surgery, Vincent’s University Hospital, Dublin, Ireland
BACKGROUND: Local drainages can be used to manage leakage in select patients without peritonitis.
OBJECTIVE: The aim of this study was to evaluate the efficacy of drainage procedures in maintaining a primary low anastomosis after anastomotic leakage.
DESIGN: A retrospective observational study was performed on a prospectively maintained database.
SETTINGS: The study was performed between 2014 and 2017 in a tertiary referral center.
PATIENTS: Patients undergoing rectal resections with either a colorectal or coloanal anastomosis with diverting stoma were identified. Anastomotic leakages requiring
a radiological or transanal drainage without peritonitis were included.
MAIN OUTCOME MEASURES: The primary outcome was the maintenance of the primary anastomosis after local drainage of an anastomotic leakage and stoma reversal.
Funding/Support: None reported.
Financial Disclosure: None reported.
Poster presentation at the meeting of the European Society of Colo- proctology, Nice, France, September 26 to 28, 2018, and at the National French Congress of Digestive Surgery in 2018, Marne-La-Vallée, France.
Correspondence: Jérémie H. Lefèvre, M.D., Ph.D., Department of Di- gestive Surgery, Hôpital Saint-Antoine, Assistance Publique Hôpitaux de Paris, Sorbonne Université, Paris VI, 184 rue du Faubourg Saint-An- toine, 75012 Paris, France. E-mail: [email protected] Structured tweet: Drainage of failed low anastomosis by @jeremielefevre @BenC- reavin from Hopital Saint-Antoine @HUEstParisien @Sorbonne_Univ_ #ColorectalResearch @DCRjournal
Dis Colon Rectum 2020; 63: 93–100 DOI: 10.1097/DCR.0000000000001516
© The ASCRS 2019
DISEASES OF THE COLON & RECTUM VOLUME 63: 1 (2020)
RESULTS: A low anastomosis for rectal cancer with diverting stoma was performed in 326 patients. A total of 77 anastomotic leakages (24%) occurred, of which, 6
(8%) required abdominal surgery, 17 (22%) were treated conservatively (medical management), and 54 (70%) were managed by drainage. Surgical transanal drainage was performed in 21 patients (39%), with radiologic drainage procedures performed in 33 patients (61%). The median interval between surgery and drainage was 13 days
(range, 9–21 d). Five patients (9%) required emergency abdominal surgery. Twenty-seven patients (50%) did not require any additional intervention after drainage procedure, whereas 21 patients (39%) underwent redo anastomotic surgery. Forty-three patients (80%) had no stoma at the end of follow-up. Failure to maintain the primary anastomosis after local drainage was associated with increased age (p = 0.04), a pelvic per-operative drainage (p = 0.05), a drainage duration >10 days
(p = 0.002), the time between surgery and drainage >15 days (p = 0.03), a side-to-end or J-pouch anastomosis (p = 0.04), and surgical transanal drainage (p = 0.03).
LIMITATIONS: The small sample size of the study was the main limitation.
¿PUEDE UN DRENAJE LOCAL SALVAR UNA ANASTOMOSIS COLORRECTAL O COLOANAL FALLIDA? UNA COHORTE PROSPECTIVO DE 54 PACIENTES
ANTECEDENTES: Los drenajes locales se pueden utilizar para controlar las fugas en pacientes seleccionados sin peritonitis.
OBJETIVO: El objetivo de este estudio fue evaluar la eficacia de los procedimientos de drenaje, para mantener una anastomosis primaria baja, después de una fuga anastomótica.
DISEÑO: Se realizó un estudio observacional retrospectivo en una base de datos mantenida prospectivamente.
CONFIGURACIÓN: El estudio se realizó entre 2014-2017, en un centro de referencia terciaria.
PACIENTES: Se identificaron pacientes sometidos a resecciones rectales con anastomosis colorrectal o coloanal y estoma de derivación. Se incluyeron fugas anastomóticas sin peritonitis, que requirieron drenaje radiológico o transanal.
PRINCIPALES MEDIDAS DE RESULTADO: El resultado
primario fue el mantenimiento de la anastomosis primaria, después del drenaje local de una fuga anastomótica y la reversión del estoma.
RESULTADOS: Se realizó una anastomosis baja para cáncer rectal con estoma derivativo en 326 pacientes. Se produjeron 77 (24%) fugas anastomóticas, de las cuales 6 (8%) requirieron cirugía abdominal, 17 (22%) fueron tratadas de forma conservadora (tratamiento médico) y 54 (70%) fueron manejadas por drenaje.
Se realizó drenaje transanal en 21 pacientes (39%) y procedimientos de drenaje radiológico en 33 pacientes (61%). La mediana del intervalo entre la cirugía y
el drenaje fue de 13 días [9-21]. 5 (9%) pacientes requirieron cirugía abdominal de emergencia.
Veintisiete (50%) pacientes no requirieron ninguna intervención adicional después del procedimiento de drenaje, mientras que 21 pacientes (39%) se
sometieron a una reparación quirúrgica anastomótica. 43 pacientes (80%) no tuvieron estoma al final del seguimiento. El fracaso para mantener la anastomosis primaria después del drenaje local, se asoció con un aumento de la edad (p = 0.04), un drenaje pélvico preoperatorio (p = 0.05), una duración del drenaje
>10 días (p = 0.002), el tiempo entre la cirugía y el drenaje >15 días (p = 0.03), anastomosis termino lateral o bolsa en J (p = 0.04) y drenaje quirúrgico transanal (p = 0.03).
LIMITACIONES: El pequeño tamaño de la muestra del estudio fue la principal limitación.
CONCLUSIÓNES: Después de la fuga anastomótica, los procedimientos del drenaje local conservaron la anastomosis primaria en el 50% de los casos. Vea el
Resumen del Video en http://links.lww.com/DCR/B57.
KEY WORDS: Anastomotic drainage; Anastomotic leakage; Coloanal anastomosis; Outcome.
CHALLINE ET AL: DRAINAGE OF FAILED LOW ANASTOMOSIS
he ability to perform sphincter-sparing rectal can- cer resections has increased over the years, mainly because of the reduction in the distance to the dis-
tal margin and the downstaging effects of neoadjuvant therapy.1–3 However, the rate of anastomotic leakage still remains ≈20%.4–6 Consequences of leakage are severe and can lead to septic shock or death.7 The use of a diverting ileostomy does not prevent an anastomotic leakage; how- ever, the severity of the sepsis-related morbidity can be re- duced.8,9 Leakages can be graded by the clinical outcomes of patients.10 The most severe leakages (grade C) are in those who need a relaparotomy for peritonitis. In such cas- es, the anastomosis is often taken down and an end stoma created. For grade B leakage, medical treatments including antibiotics and/or local treatments (drainage) are needed to treat a pelvic abscess. Finally, asymptomatic leakage can occur (grade A) up to 6 months after bowel continuity.11
Recently, the endo-SPONGE has been used to treat leakage; however, there are few studies with small sample sizes describing this procedure currently.12–20 Stoma rever- sal rates after this procedure vary between 37% and 90%. This technique requires several procedures to change the endo-SPONGE but can be performed in an outpatient set- ting without sedation in some cases. The majority of grade B leakages are drained either by a surgical transanal ap- proach or a radiologic approach.
Radiologic transgluteal drainage is safe, although rare complications including hemorrhage or fistula formation have been reported.21 Radiologic drainage is an effective approach, with successful management of abscess with- out recurrence being reported at ≈96%.11,21 However, the functional outcomes of the anastomosis after radiologic drainage are unknown. This too is true with regard to the transanal approach, with a lack of data currently in the lit- erature.22,23 The need for an additional drainage with this approach is reported to be 38% without abdominal sur- gery; however, stoma reversal rates are >90%.23
Definitive stoma rates after failed sphincter-sparing surgery is close to 20% for all patients with rectal cancer.24 Maggiori et al25 found that the rate of definitive stoma increases after a nonconservative approach for grade C leakage. Redo surgery to create a new anastomosis is chal- lenging, with a high morbidity and risk of injury to the genitourinary system.26,27
The aim of this study was to evaluate the efficacy of drainage procedures in maintaining a primary low anas- tomosis after anastomotic leakage.
PATIENTS AND METHODS
A retrospective observational study was performed on a prospectively maintained database of patients undergoing rectal resections with either a colorectal or coloanal anas-
DISEASES OF THE COLON & RECTUM VOLUME 63: 1 (2020) 95
tomosis (CR-CAA) with diverting stoma between 2014 and 2017. Patient medical charts were reviewed for patient characteristics, comorbidities, surgical and histologic char- acteristics, date of drainage, duration of drainage, the need for redo coloanal anastomosis, and stoma closure rates.
Population and Follow-up
Patients who had an anastomotic leakage diagnosed by imaging (CT scan) or local examination under general an- esthesia and requiring a radiologic or transanal surgical drainage during their postoperative courses were analyzed. Patients were excluded if they presented with peritonitis requiring emergency surgery by an abdominal approach before a local drainage.
Follow-up included clinical examination and C-re- active protein (CRP) levels at 1, 3, and 5 postoperative days.28 In cases of any deviation in the postoperative clini- cal course, a CT scan was performed. When a pelvic abscess occurred, 2 types of pelvic drainage were used: a radiologic drain (usually performed under CT guidance) by a trans- gluteal approach or by a transanal approach under a ge- neral anesthetic. Drains were flushed with 10 mL of sterile saline 3 times per day by a specialized nurse. Drains were removed when outputs remained low (<20 mL per day) or when a repeat CT scan showed good resolution of the col- lection. When patients were discharged from the hospital with a drain, outpatient consultations occurred weekly. A consultation 1 month after discharge was performed to re- peat a CT scan to assess resolution of the leakage and plan the stoma closure. Before stoma closure, integrity of anas-
tomosis was tested with radiologic assessment and clinical local examination. After 6 months, in cases of persistent leakage with chronic sepsis or stricture, a redo surgery and new CAA were performed. Otherwise, a stoma reversal was performed when an anastomosis was healed or a chronic leakage without sepsis occurred. The follow-up of patients in the present study was stopped on the October 1, 2018.
Outcome and Variables
The primary outcome was maintenance of the primary CR-CAA after a local drainage and the closure of the di- verting stoma. The secondary outcome was the rate of de- finitive stoma.
The R software was used (R Foundation for Statisti- cal Computing, Vienna, Austria, www.R-project.org). Descriptive analysis was performed using percentages, means, medians, and proportion, with SD and interquar- tile ranges reported. Univariate analysis was performed on the primary binary outcomes with general linear models with the univariateTable function of the R-Package Pub- lish. A p value <0.05 was considered as significant.
Participants and Incidence of Leakage
The flow chart of the study is presented in Figure 1. A total of 326 patients underwent a low anastomosis with divert-
Hartmann procedures (n = 3) Abdominal drainages (n = 1) Others (n = 2)
54 Local drainages (76%)
17 Medical treatments (24%)
Stoma reversal (n = 2) End stoma (n = 4)
5 Abdominal surgeries (9%)
Stoma reversal (n = 3) End stoma (n = 2)
49 Successful drainages (91%)
Stoma reversal (n = 39) End stoma (n = 10)
Stoma reversal (n = 10) End stoma (n = 6) Missing data (n = 1)
FIGURE 1. Flow chart of the study.
ing stoma for rectal cancer, of which 77 (24%) anastomotic leakages occurred. Six anastomotic leakages (8%) needed emergency abdominal surgery (grade C). Among the re- maining 71 grade B leakages (92%), 17 (22.1%) were treat- ed medically with antibiotics alone, and 54 (70.1%) were primarily managed by drainage. The change in our practice over time is illustrated in Figure 2. There was no difference in the rate of leakage (p = 0.41) or numbers requiring drain- age (p = 0.30) per year; however, abdominal reintervention with a new coloanal anastomosis was lower (p < 0.001).
Characteristics of Drained Patients
Fifty-four patients underwent pelvic drainage, with the majority diagnosed by fever in the postoperative course. Forty three (96%) of 45 patients had a CRP >100 on post- operative day 3 or 5. Patient characteristics are detailed in Table 1. The mean age was 62 ± 13 years, of which 31 (57.4%) were men. A total of 37 patients (69%) under- went neoadjuvant therapy.
Fifty patients (93%) had resections for low-rectal or midrectal tumors. All of the patients had a divert- ing ileostomy. A laparoscopic approach was the most frequent approach used (n = 45 (83%)). The majority of patients had a J-pouch or side-to-end anastomosis (n = 43 (80%)).
CHALLINE ET AL: DRAINAGE OF FAILED LOW ANASTOMOSIS
approach. Surgical transanal drainage was more likely used for purulent discharge, whereas a radiologic drain- age was used for fever (p = 0.01). The median interval between surgery and drainage was 13 days (range, 9–21). Escherichia coli was found in 19 available cases (73%), whereas 2 (10%) had extended spectrum β−lactamase. Drainage duration >10 days was more frequent for sur- gical drainage (p < 0.001). Eighteen patients (33.3%) needed a second drainage procedure to treat a recurrent abscess (median time interval between drainages of 25.5 d (range, 2.8–54.2 d)). Secondary drainage was needed for 7 patients (33%) after primary transanal drainage and 11 (33%) after radiologic drainage (p = 1.00). Five patients (9%) needed emergency abdominal surgery after primary drainage: 1 was treated by Hartmann procedure, and 4 were managed with preservation of the anastomosis. The length of stay (LOS) for surgery and drain management was 24 ± 10 days. LOS was lower for radiologic drainage (22 ± 10 vs 28 ± 10 d; p = 0.02). Twelve patients (26%) were discharged with a drain.
Maintenance of the anastomosis was achieved in 27 pa- tients (50%), with stoma reversals performed after a mean interval of 5.1 ± 2.5 months. Twenty-one patients (38%)
Evolution of practice
2014 2015 2016 2017
FIGURE 2. Representation of the evolution of the rates of conservation, leakage, drainage, and new anastomosis by years.
Characteristics of drain management are described in Table 2. A surgical transanal approach under general an- esthetic was performed for 21 patients (39%), whereas 33 patients (61%) underwent a radiologic transgluteal
needed an additional procedure to treat a chronic leakage (n = 19 (90%)) or stenosis (n = 2 (10%)). Among those, 15 patients (71%) required a new coloanal or ileoanal anas- tomosis, 4 (20%) required a new delayed coloanal anasto- mosis, and 2 (10%) had an end stoma performed.
DISEASES OF THE COLON & RECTUM VOLUME 63: 1 (2020) 97
TABLE 1. Characteristics of patients treated by local drainage
Type Data (N = 54)
Age, mean ± SD, y 61.7 ± 13.1
BMI, mean ± SD, kg/m2 24.9 ± 4
Men, n (%) 31 (57.4)
ASA score, n (%)
1 23 (42.6)
2 29 (53.7)
3 2 (3.7)
Use of anticoagulant, n (%) 4 (7.4)
TABLE 2. Characteristics of drainage
Characteristics Total (N = 54)
Clinical diagnosis, n (%)
Fever 29 (55.8)
Purulent discharge 7 (13.5)
Pelvic pain 5 (9.6)
Clinical assessment 7 (13.5)
Others 6 (11.1)
C-reactive protein, mean ± SD
POD 3 237.5 ± 130.7
POD 5 212.3 ± 128.2
|Diabetes mellitus, n (%)
Cardiovascular disease, n (%)
Type of drainage, n (%)
|188.5 ± 115.2|
|Tumor characteristics, n (%)||Radiologic||33 (61.1)|
|Local excision before surgery||5 (9.3)||Surgical||21 (38.9)|
|Neoadjuvant treatment||37 (68.5)||Time between surgery and drainage >15 d, n (%)||25 (46.3)|
|Location of tumor||Duration of drainage >10 d, n (%)||22 (40.7)|
|High||4 (7.4)||Output per day, mean ± SD||90.8 ± 72.3|
|Mid||24 (44.4)||Need for second drainage, n (%)||18 (33.3)|
|Low||26 (48.1)||Type of second drainage, n (%)|
|Surgical characteristics, n (%)||Radiologic||6 (33.3)|
|Laparoscopy||45 (83.3)||Surgical||12 (66.6)|
|Mechanical anastomosis||27 (50.0)||Need for abdominal surgery, n (%)||5 (9.3)|
|Type of anastomosis||Time between first and second drainage, median||25.5 (2.8–54.2)|
|J-pouch||20 (37.0)||(range), d|
|Side-to-end||23 (42.6)||LOS, mean ± SD, d||24.1 ± 10.1|
|End-to-end||11 (20.4)||Imaging before drain removal, n (%)||26 (53.1)|
|Pelvic drainage||34 (65.4)||Discharged with drain, n (%)||12 (25.5)|
Histologic characteristics, n (%)
|11 (20.4)||LOS = length of stay; POD = postoperative day.|
interval between surgery and drainage >15 days (p = 0.03), side-to-end or J-pouch anastomosis (p = 0.04), and year of surgery were associated with failure to maintain the CR-CAA.
M stage 1 4 (7.4)
R1 resection 7 (13.0)
Forty three (80%) of the 54 patients had no stoma at the end of follow-up (22 ± 14 mo). Stoma closure was performed after an interval of 7 ± 4 months. Median fol- low-up after stoma reversal was 15 ± 12 months. Of the 11 patients who had a definitive stoma (20%), 6 had a redo procedure, of which 2 patients had an end stoma during the redo surgery, whereas 4 presented with a recurrence of leakage after their redo coloanal anastomosis. Five patients did not require redo surgery but did not have a stoma re- versal (1 lost to follow-up, 2 for chronic leakages, and 2 for patient preference).
Risk Factor for Failure to Maintain the Anastomosis
In univariate analysis (Table 3), increased age (p = 0.04), a per-operative pelvic drainage (p = 0.05), a surgical drain- age (p = 0.03), a drainage duration >10 days (p = 0.002), the
This study reports the experience of a single center re- garding drainage procedures after anastomotic leakage for low colorectal/coloanal anastomosis for rectal cancer. Maintenance of the anastomosis was achieved in 50% of the cohort undergoing local drainage; however, the rate of definitive end stoma was 20%. The present study found that a short drainage duration was associated with main- tenance of the primary anastomosis in univariate analysis. Furthermore, the implementation of a more conserva- tive approach to leakage management (drainage) over the years decreased the rate of redo surgery and increased the likelihood of maintaining the anastomosis.
Only 5 patients needed an emergency abdominal surgery af- ter local drainage for peritonitis. The choice of the drainage procedure for anastomotic leakage is not clear in the litera- ture. In the present study, radiologic drainage was associated with maintenance of the anastomosis in univariate analysis. A recent review reported definitive stoma rates of 25% af- ter vacuum-assisted therapy, similar to the present study.19
98 CHALLINE ET AL: DRAINAGE OF FAILED LOW ANASTOMOSIS
Neoadjuvant treatment, n (%) 15 (55.6) 22 (81.5) 0.08
Height of tumor from anal
|sphincter, n (%), cm|
|1–3||15 (55.6)||11 (40.7)|
|3–8||9 (33.3)||15 (55.6)||0.2|
|8–13||3 (11.1)||1 (3.7)|
|Laparoscopy, n (%)||23 (85.2)||22 (81.5)||1|
|Mechanical anastomosis,||15 (55.6)||12 (44.4)||0.59|
Type of anastomosis, n (%)
present study are based on grade B leakages with long fol- low-up. Overall symptomatic leakage rate was 24%, with 2% classified as grade C leakage and 22% as grade B. These rates are in accordance with previously reported studies, with rates varying between 8% and 28%.4,5,29 Our rate of leakage is high, but the inclusion of patients is highly selective, because 93% of patients had a low-rectal or midrectal tumor with subse- quent total mesorectal excision.30 Nearly 70% of patients had neoadjuvant therapy. The literature is not clear on the impact of radiotherapy on anastomotic leakage; however, it can in- crease the definitive stoma rate.31,32 Furthermore, there is no consensus on the definition of an anastomotic leakage, which may account for the variation in rates seen in the literature. The present study included all pelvic collections and perito- nitis, which may account for a higher leakage rate.33
The present study reported that an early and short-duration drainage was associated with maintenance of the anastomo- sis. However, this should be interpreted with caution and could be influenced by leakage and drainage characteristics. For example, a leakage with high output is associated with worse outcomes and may require a longer drainage period,
|0–2||12 (44.4)||8 (29.6)||0.4 especially if there is a longer interval between surgery and|
|3–4||15 (55.6)||19 (70.4)||drainage. Previous studies report similar result with im-|
|N, n (%)||proved stoma reversal rates after an early drainage.13,15 As|
|0||18 (66.7)||12 (44.4)||0.17 shown in several studies on vacuum therapy, leakages with|
|+||9 (33.3)||15 (55.6)|
|M, n (%)||an early drainage have a better prognosis than others.13,17|
|1||1 (3.7)||3 (11.1)||0.6 This may be explained by the fibrosis found at redo surgery,|
|R, n (%)||which is more frequent after a chronic leakage. Influenced|
|1||1 (3.7)||6 (22.2)||0.11 by previous reports in the literature, the management of|
|Adjuvant treatment, n (%)||6 (25.0)||13 (54.2)||0.08 anastomotic leakage in our center has evolved, which has|
|Septic leakage, n (%)||17 (68.0)||12 (44.4)||0.15
resulted in a reduction in the number of redo surgeries.6,25,34
|Type of drain, n (%)|
|Surgical 6 (22.2)||15 (55.6) 0.03 This evolution was significantly associated with maintain-|
|Radiologic 21 (77.8)||12 (44.4) ing the anastomosis on univariate analysis.|
|Time between surgery and 8 (29.6)||17 (63.0) 0.03 Routine pelvic drain placement at index surgery was|
|drainage >15 d, n (%)
Duration of drainage >10 5 (18.5)
|17 (63.0) 0.002 associated with a higher risk of failure. This practice has|
|d, n (%)||changed in our center after the findings of Denost et al4|
intervention, n (%) Year of surgery, n (%)
2014–2015 7 (25.9) 19 (70.4) 0.003
2016–2017 20 (74.1) 8 (29.6)
LAR = low anterior resection.
Furthermore, Borstlap et al17 showed previously that >50% of patients treated with local drainage techniques have a healed anastomosis at 6 months. Using a local drainage as a first approach in the management of grade B leakages is fea- sible in select patients, as seen in the present study.
Definitive Stoma Rate and Leakage Rate
The end-stoma rate in this study is in line with previous reported literature (>20%),4,24 although the results in the
Furthermore, an end-to-end anastomosis was asso- ciated with maintenance of the anastomosis compared with a side-to-end or J-pouch anastomosis. We did not have the details of the leakage location in patients with a side-to-end or J-pouch anastomosis. Interestingly, Hain et al36 found no difference in terms of definitive stoma rates based on the location of leakage in side-to-end or J-pouch anastomosis. Finally, after comparing the types of local drainage, radiologic drainage was more successful at maintaining the anastomosis.
First, the retrospective design of the present study does not allow the authors to standardize the indication for
DISEASES OF THE COLON & RECTUM VOLUME 63: 1 (2020) 99
drainage. The majority of drainages in this study were performed for sepsis; however, some drainages were per- formed for asymptomatic leakage, elevated CRP levels, and after radiologic assessment. Surgical transanal drain- age was commonly used for purulent discharge. There was no significant difference regarding the maintenance of a- nastomosis, but all 6 of the patients drained for purulent discharge did not keep their initial anastomosis. Charac- teristics of each drainage influenced the LOS and the fea- sibility of outpatient management for the drain. The use of CT scans to diagnose anastomotic leakage has increased over the years, mainly because of improved access to scan- ners and imaging quality. However, data collection on drain output, microbiology, and length of drainage was limited because of the retrospective nature of the study.
Furthermore, the sample size of patients undergoing
drainage was small, limiting the results of the study. How- ever, to our knowledge, this is the first and largest study to assess risk factors for failing to maintain a colorectal anastomosis.
Local drainage avoided redo anastomosis in 50% of pa- tients who had a grade B leakage for low colorectal/ coloanal anastomosis for rectal cancer. An end-to-end a- nastomosis, a shorter length of drainage, and radiologic drainage were associated with maintenance of the primary anastomosis.
- Moore HG, Riedel E, Minsky BD, et Adequacy of 1-cm distal margin after restorative rectal cancer resection with sharp me- sorectal excision and preoperative combined-modality therapy. Ann Surg Oncol. 2003;10:80–85.
- Pahlman L, Bujko K, Rutkowski A, Michalski Altering the therapeutic paradigm towards a distal bowel margin of < 1 cm in patients with low-lying rectal cancer: a systematic review and commentary. Colorectal Dis. 2013;15:e166–e174.
- Appelt AL, Pløen J, Vogelius IR, Bentzen SM, Jakobsen Ra- diation dose-response model for locally advanced rectal cancer after preoperative chemoradiation therapy. Int J Radiat Oncol Biol Phys. 2013;85:74–80.
- Denost Q, Rouanet P, Faucheron JL, et al.; French Research Group of Rectal Cancer Surgery (GRECCAR). To drain or not to drain infraperitoneal anastomosis after rectal exci- sion for cancer: the GRECCAR 5 randomized trial. Ann 2017;265:474–480.
- Lefevre JH, Mineur L, Kotti S, et al. Effect of interval (7 or 11 weeks) between neoadjuvant radiochemotherapy and surgery on complete pathologic response in rectal cancer: a multicenter, randomized, controlled trial (GRECCAR-6). J Clin Oncol. 2016;34:3773–3780.
- Hain E, Maggiori L, Manceau G, Zappa M, Prost à la Denise J, Panis Persistent asymptomatic anastomotic leakage after
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- Peeters KC, Tollenaar RA, Marijnen CA, et ; Dutch Colorectal Cancer Group. Risk factors for anastomotic failure after total mesorectal excision of rectal cancer. Br J Surg. 2005;92:211–216.
- Matthiessen P, Hallböök O, Rutegård J, Simert G, Sjödahl De- functioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a random- ized multicenter trial. Ann Surg. 2007;246:207–214.
- Wong NY, Eu A defunctioning ileostomy does not pre- vent clinical anastomotic leak after a low anterior resec- tion: a prospective, comparative study. Dis Colon Rectum. 2005;48:2076–2079.
- Rahbari NN, Weitz J, Hohenberger W, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Surgery. 2010;147:339–351.
- Robert B, Chivot C, Rebibo L, Sabbagh C, Regimbeau JM, Yzet
- Percutaneous transgluteal drainage of pelvic abscesses in in- terventional radiology: a safe alternative to surgery. J Visc Surg. 2016;153:3–7.
- Mussetto A, Arena R, Buzzi A, et Long-term efficacy of vac- uum-assisted therapy (Endo-SPONGE®) in large anastomotic leakages following anterior rectal resection. Ann Gastroenterol. 2017;30:649–653.
- van Koperen PJ, van Berge Henegouwen MI, Rosman C, et al. The Dutch multicenter experience of the endo-sponge treat- ment for anastomotic leakage after colorectal Surg En- dosc. 2009;23:1379–1383.
- Arezzo A, Verra M, Passera R, Bullano A, Rapetti L, Morino
- Long-term efficacy of endoscopic vacuum therapy for the treatment of colorectal anastomotic leaks. Dig Liver Dis. 2015;47:342–345.
- Jimenez-Rodriguez RM, Araujo-Miguez A, Sobrino-Rodriguez S, et al. A new perspective on vacuum-assisted closure for the treatment of anastomotic leak following low anterior resection for rectal cancer, is it worthy? Surg 2018;25:350–356.
- Strangio G, Zullo A, Ferrara EC, et al. Endo-sponge ther- apy for management of anastomotic leakages after colorectal surgery: a case series and review of literature. Dig Liver Dis. 2015;47:465–469.
- Borstlap WAA, Musters GD, Stassen LPS, et Vacuum-assisted early transanal closure of leaking low colorectal anastomoses: the CLEAN study. Surg Endosc. 2018;32:315–327.
- Gardenbroek TJ, Musters GD, Buskens CJ, et al. Early recon- struction of the leaking ileal pouch-anal anastomosis: a novel solution to an old Colorectal Dis. 2015;17:426–432.
- Shalaby M, Emile S, Elfeki H, Sakr A, Wexner SD, Sileri Sys- tematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage. BJS Open. 2019;3:153–160.
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