Cuesta, M.

Peet, D. van der

Sietses, C.

Veenhof, A.

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LETTER TO THE EDITOR
Pull-through procedure as treatment for coloanal
anastomotic dehiscence following laparoscopic total
mesorectal excision
A. A. F. A. Veenhof & D. L. van der Peet & C. Sietses &
M. A. Cuesta
Accepted: 4 July 2006 / Published online: 5 October 2006
# Springer-Verlag 2006
Dear Editor:
Anastomotic leakage following laparoscopic rectal surgery
remains a frequent and serious complication. Overall leak
rates for laparoscopic anterior resections and coloanal
anastomosis are reported to range from 7.3% to 17%.
Several studies describing risk factors for anastomotic
dehiscence have been published. Neoadjuvant chemoradio-
therapy, old age, male gender and distal anastomosis are
different reported factors. Anastomotic dehiscence, with or
without protective loop ileostomy, can be limited to the
pelvis as a local abscess that has to be drained or followed
by general peritonitis, in which standard intervention is
taking down the anastomosis with creation of a left
colostomy. In the last case, restorative procedures are often
very difficult to perform due to the short remaining rectal
stump, making dissection very hazardous. The authors
present a pull-through procedure in a male patient as
treatment of coloanal anastomotic dehiscence, consequently
preventing a definitive colostomy.
A 60-year-old man with a proven rectal adenocarcinoma
located 8 cm from the anal verge had a laparoscopic total
mesorectal excision (TME) following radiation therapy
(five doses of 5 Gy) 6 weeks earlier. No perioperative
complications occurred, and a stapled anastomosis was
made approximately 3–4 cm from the anal verge at the
level of the pelvic floor. The donuts were intact and the
anastomosis was checked with methylene blue, after which
a protective loop ileostomy was created. On day 6 after
surgery, the patient developed signs of general peritonitis,
most likely based on an anastomotic dehiscence. At
laparotomy, a small posterior leak in the anastomosis was
observed with general purulent peritonitis. Due to the low
anastomosis in this patient and therefore the difficulty of
creating a new anastomosis in the future, a pull-through
procedure was performed in order to prevent a definitive
colostomy, according to the wishes of the patient. The
splenic flexure was mobilized, and the descending colon
was pulled through the anus and fixated with two sutures.
The protective loop ileostomy was preserved. After the
pull-through procedure, no complications occurred and the
patient was discharged from hospital after 10 days. Two
weeks later, the pull-through colon was inspected under
anesthesia. At this time, the entire circumference of the
descending colon had already grafted onto the remaining
rectum and the excess material of the pull-through graft was
removed. Four weeks after the pull-through procedure, the
loop ileostomy was closed under general anesthesia. After
4 months of follow-up, the patient is doing well with good
continence and two to six defecations per day.
Following laparoscopic TME with a low or coloanal
anastomosis, leak rates of up to 17% have been reported. In
the case of local pelvic abscess formation, the treatment
includes an adequate drainage of the abscess, mostly
through the anastomosis. In the case of a general peritonitis,
it is often necessary to take down the anastomosis and
create a colostomy. Frequently, this colostomy will be
permanent due to the difficulty in restorative procedures.
The very short remaining rectal stump, covered with scar
tissue at the pelvic floor, makes re-anastomotic procedures
Int J Colorectal Dis (2007) 22:1413–1414
DOI 10.1007/s00384-006-0191-9
A. A. F. A. Veenhof :D. L. van der Peet : C. Sietses :
M. A. Cuesta
Department of Surgery, VU Medical Center,
de Boelelaan 1117,
1081 HVAmsterdam, The Netherlands
M. A. Cuesta (*)
Department of Surgery, Vrije Universiteit Medical Center,
Post bus 7057, 1007 MB Amsterdam, The Netherlands
e-mail: ma.cuesta@vumc.nl
very difficult. A historical surgical procedure, the pull-
through coloanal operation can help solve this problem
during re-intervention. If the patient is hemodynamically
stable and the peritonitis only purulent, the pull-through
procedure may be considered, subsequently avoiding a
definitive colostomy. A temporary loop ileostomy may be
necessary for protection of the pull-through graft and
prevention of complications. In this case, the pull-through
procedure avoided a permanent colostomy. In our opinion,
a pull-through procedure can be considered in the case of a
low or coloanal anastomotic leak following TME in order
to prevent a definitive colostomy on patient demand.
1414 Int J Colorectal Dis (2007) 22:1413–1414


Pull-through procedure as treatment for coloanal anastomotic dehiscence following laparoscopic total mesorectal excision

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Pull-through procedure as treatment for coloanal anastomotic dehiscence following laparoscopic total mesorectal excision

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