Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastrointest Surg. May 27, 2019; 11(5): 271-278
Published online May 27, 2019. doi: 10.4240/wjgs.v11.i5.271
Novel technique for anastomotic salvage using transanal minimally invasive surgery: A case report
Oscar A Olavarria, Robert L Kress, Shinil K Shah, Amit K Agarwal
Oscar A Olavarria, Center for Surgical Trials and Evidence-Based Practice, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX 77033, United States
Oscar A Olavarria, Robert L Kress, Shinil K Shah, Amit K Agarwal, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, Houston, TX 77033, United States
Author contributions: Olavarria OA, Kress RL, Shah SK and Agarwal AK contributed to study conception and design; Olavarria OA, Kress RL and Agarwal AK contributed to acquisition of data; Olavarria OA, Kress RL, Shah SK and Agarwal AK contributed to analysis and interpretation of data; Olavarria OA, Kress RL and Agarwal AK contributed to drafting of manuscript; Olavarria OA, Kress RL, Shah SK and Agarwal AK contributed to critical revision.
Informed consent statement: Informed written consent was obtained from the patient for the surgical intervention and publication of this report and any accompanying images.
Conflict-of-interest statement: Olavarria OA, Kress RL and Agarwal AK declare that they have no conflict of interest. Shah receives grants from Neosurgical, Medigus and Intuitive Surgical. Also receives educational honoraria from Gore and C-SATS. None of these conflicts of interests are relevant to the current case report
CARE Checklist (2016) statement: Guidelines of the CARE Checklist (2016) have been adopted.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Oscar A Olavarria, MD, Doctor, Postdoctoral Fellow, Senior Research Fellow, Department of Surgery, McGovern Medical School at the University of Texas Health Science Center Houston, 5656 Kelley St., General Surgery Office, Houston, TX 77033, United States. oscarolavarria@hotmail.com
Telephone: +1-713-5664640 Fax: +1-713-5664583
Received: April 4, 2019
Peer-review started: April 4, 2019
First decision: May 8, 2019
Revised: May 18, 2019
Accepted: May 23, 2019
Article in press: May 23, 2019
Published online: May 27, 2019
Processing time: 53 Days and 10.1 Hours
Abstract
BACKGROUND

Anastomotic leak (AL) after low anterior resection (LAR) can be a highly morbid complication. The incidence of AL ranges from 5% to 20% depending on patient characteristics and the distance of the anastomosis from the anal verge. Low anastomoses and leaks pose technical challenges for endoscopic treatment. The aim of this report was to describe the use of a commercially available laparoscopic energy device through a transanal minimally invasive surgery (TAMIS) port for the management of a symptomatic leak not requiring relaparotomy (grade B) after a LAR with diverting loop ileostomy.

CASE SUMMARY

A TAMIS GelPOINT Path port was inserted into the anus to access the distal rectum. Pneumorectum was achieved with AirSeal insufflation and a 30 degree laparoscope was introduced through a trocar. A LigaSureTM Retractable L-Hook device was then used to perform a septotomy of the chronic sinus tract identified posterior to the coloproctostomy. The procedure was then repeated twice in three weeks intervals with ultimate resolution of the chronic leak cavity. Several months after serial TAMIS septotomies, barium enema demonstrated a patent anastomosis with no evidence of persistent leak or stricture. The patient subsequently underwent ileostomy reversal and has had no significant post-operative issues.

CONCLUSION

TAMIS septotomy with the LigaSureTM Retractable L-Hook is a feasible and effective, minimally invasive salvage technique for the treatment of grade B ALs. Larger studies are needed to assess the generalizability and long-term results of this technique.

Keywords: Transanal minimally invasive surgery; Ligasure hook; Anastomotic leak; Low anterior resection; Septotomy; Case report

Core tip: Anastomotic leaks (ALs) after low anterior resection for the treatment of rectal cancer are highly morbid complications and often pose a technical challenge for its treatment. We report a case of a transanal minimally invasive septotomy of a chronic sinus secondary to an AL, with the use of the Ligasure retractable L-Hook device. This safe and effective technique may help avoid re-operations which are associated with higher mortality and higher permanent stoma rates.