Impact of Transanal Tube on Anastomotic Leakage in Rectal Cancer Surgery with ICG Perfusion

Overview

This retrospective study evaluated the effect of transanal tube (TA) placement on reducing anastomotic leakage (AL) in rectal cancer patients with confirmed adequate anastomotic perfusion via indocyanine green (ICG) fluorescence imaging. Among 211 patients undergoing low anterior resection, TA placement was associated with a lower incidence of AL despite all patients having confirmed good perfusion.

Background

Rectal cancer surgery has been improved by total mesorectal excision (TME), which enhances oncological outcomes and reduces local recurrence. Anastomotic leakage remains a significant postoperative complication, influenced by factors such as anastomotic tension, vascular perfusion, and intraluminal pressure. ICG fluorescence imaging allows intraoperative assessment of bowel perfusion to reduce AL risk, but leakage still occurs despite adequate perfusion. Transanal tube placement has been proposed to reduce intraluminal pressure and potentially decrease AL incidence, though its efficacy in patients with confirmed adequate perfusion remains unclear.

Data Highlights

Key Findings

• All patients included had adequate anastomotic perfusion confirmed intraoperatively by ICG fluorescence imaging.
• Transanal tube placement was performed in 56 patients, with 155 patients not receiving TA.
• TA placement was associated with a reduced incidence of clinically evident anastomotic leakage within 90 days postoperatively.
• Severe anastomotic leakage was defined as Clavien–Dindo grade III or higher, though specific rates were not detailed.
• The decision to place a TA and its length was individualized based on patient anatomy and surgeon discretion.
• Despite adequate perfusion, factors such as intraluminal pressure may contribute to AL, which TA placement aims to mitigate.

Clinical Implications

In patients undergoing rectal cancer surgery with confirmed adequate anastomotic perfusion via ICG imaging, transanal tube placement may serve as an effective adjunct to reduce the risk of anastomotic leakage. Surgeons should consider TA insertion to lower intraluminal pressure and facilitate intestinal content passage, potentially improving postoperative outcomes. Individualized selection of tube length and placement depth is important based on patient anatomy.

Conclusion

Transanal tube placement appears to reduce anastomotic leakage rates in rectal cancer surgery patients with confirmed adequate perfusion by ICG fluorescence imaging. This suggests that addressing factors beyond vascular supply, such as intraluminal pressure, is critical in preventing AL.

References

1. Chiba University Hospital Study 2014-2024 -- Impact of Transanal Tube Insertion on Reducing Anastomotic Leakage