Tricks to decrease the suture line dehiscence rate during endoluminal loco-regional resection (ELRR) by transanal endoscopic microsurgery (TEM)

ELRR by TEM is a valid alternative to TME in selected patients with early low rectal cancer, with similar long-term oncological results and better Quality of Life. The authors' policy is to close the residual defect, with possibly a higher risk of dehiscence from tension on the suture line. Aim is to evaluate if a modified technique may reduce the risk of dehiscence.

The latest series of 50 patients undergoing ELRR was analyzed and patients were divided in two consecutive groups. In Group A, 25 patients underwent ELRR by TEM with the authors' standard technique. In Group B, a subsequent series of 25 patients also underwent ELRR, but the perirectal residual cavity was filled with a hemostatic agent prior to rectal wall closure. After suture completion, the rectal ampulla was stuffed with gauzes to avoid the formation of a perirectal fluid collection, by enlarging the volume of the residual rectal ampulla. A transanal Foley catheter was positioned for gas evacuation.

There were no significant differences in mean tumor distance from the anal verge, mean lesion diameter, mean operative time, and pathological staging between the two groups. Neoadjuvant radio-chemotherapy (n-RCT) in Groups A and B was performed in 6 and 2 patients, respectively. Suture line dehiscence in Group A occurred in 3 patients (12%) and in group B it was nil. In patients who experienced a dehiscence, mean lesion diameter was 6.3 cm (range 6-7). None of these patients had undergone n-RCT.

After ELRR by TEM, suture line dehiscence is presumably related to the wider size of the residual cavity. Obliteration of the residual perirectal space with hemostatic agent and by gauzes' introduction in the rectal ampulla may reduce the risk of postoperative perirectal abscess and thus reduce the suture line dehiscence rate.