title: Hand-sewn coloanal anastomosis for low rectal cancer: technique and long-term outcome.
abstract: OBJECTIVE
  This study compared the operative outcome and long-term survival of three types of hand-sewn coloanal anastomosis (CAA) for low rectal cancer.
  
  
  METHODS
  Patients presenting with low rectal cancer at a single centre between 2006 and 2014 were classified into three types of hand-sewn CAA: type 1 (supra-anal tumours undergoing transabdominal division of the rectum with transanal mucosectomy); type 2 (juxta-anal tumours, undergoing partial intersphincteric resection); and type 3 (intra-anal tumours, undergoing near-total intersphincteric resection with transanal mesorectal excision).
  
  
  RESULTS
  Seventy-one patients with low rectal cancer underwent CAA: 17 type 1; 39 type 2; and 15 type 3. The median age of patients was 61.6 years, with a male/female ratio of 2:1. Neoadjuvant therapy was given to 56 (79%) patients. R0 resection was achieved in 69 (97.2%) patients. Adverse events occurred in 25 (35.2%) of the 71 patients with a higher complication rate in type 1 vs type 2 vs type 3 (47.1% vs 38.5% vs 13.3%, respectively; P = 0.035). Anastomotic separation was identified in six (8.5%) patients and pelvic haematoma/seroma in five (7%); two (8.3%) female patients developed a recto-vaginal fistula. Ten (14.1%) patients were indefinitely diverted, with a trend towards higher long-term anastomotic failure in type 1 vs type 2 vs type 3 (17.6% vs 15.5% vs 6.7%). The type of anastomosis did not influence the overall or disease-free survival.
  
  
  CONCLUSIONS
  CAA is a safe technique in which anorectal continuity can be preserved either as a primary restorative option in elective cases of low rectal cancer or as a salvage procedure following a failed stapled anastomosis with a less successful outcome in the latter. CAA has acceptable morbidity with good long-term survival in carefully selected patients.
authors.affiliation: Department of Surgery and Cancer, Imperial College, London, UK.
authors.forename: P
authors.initials: P
authors.lastname: Tekkis
authors.affiliation: Department of Surgery and Cancer, Imperial College, London, UK.
authors.forename: E
authors.initials: E
authors.lastname: Tan
authors.affiliation: Colorectal, The Royal Marsden Hospital, London, UK.
authors.forename: C
authors.initials: C
authors.lastname: Kontovounisios
authors.affiliation: Colorectal, The Royal Marsden Hospital, London, UK.
authors.forename: J
authors.initials: J
authors.lastname: Kinross
authors.affiliation: Colorectal, The Royal Marsden Hospital, London, UK.
authors.forename: C
authors.initials: C
authors.lastname: Georgiou
authors.affiliation: Department of Surgery and Cancer, Imperial College, London, UK.
authors.forename: R J
authors.initials: RJ
authors.lastname: Nicholls
authors.affiliation: Colorectal, The Royal Marsden Hospital, London, UK.
authors.forename: S
authors.initials: S
authors.lastname: Rasheed
authors.affiliation: Colorectal, The Royal Marsden Hospital, London, UK.
authors.forename: G
authors.initials: G
authors.lastname: Brown
mesh_terms: D001003:Anal Canal / Q000601:surgery*; D000714:Anastomosis, Surgical / Q000379:methods; D003106:Colon / Q000601:surgery*; D003125:Colostomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D006801:Humans; D008297:Male; D008488:Medical Illustration; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology; D011446:Prospective Studies; D012004:Rectal Neoplasms / Q000473:pathology / Q000601:surgery*; D012006:Rectovaginal Fistula / Q000209:etiology; D013536:Suture Techniques / Q000009:adverse effects*; D016896:Treatment Outcome
keywords: Low rectal cancer; coloanal anastomosis; intersphincteric; sphincter-saving