When Patricia Sylla, MD, pioneered transanal total mesorectal excision (taTME) in 2009, she helped usher in a new era of minimally invasive surgical approaches for rectal cancer that has helped reduce the morbidity and recovery time of patients undergoing these procedures, as well as the need for a permanent stoma in patients with low-rectal tumors close to the anal sphincters. Now, she is helping to pioneer the use of the same transanal endoscopic surgical approach to salvage failed pelvic anastomoses, which could spare thousands of patients from living with a stoma.
“Traditionally, when patients presented with complications such as a leak, stricture, or fistula following rectal or pelvic surgery with colorectal anastomosis, the thinking was that it was too difficult and dangerous to reconstruct the anastomosis, so they were offered the option to have it removed via abdominal perineal resection and have a permanent stoma,” says Dr. Sylla, Associate Professor of Surgery at the Icahn School of Medicine at Mount Sinai. “Based on our success with taTME among rectal cancer patients, we realized that we could use the same transanal endoscopic approach to address other pathologies, which means we have the potential to salvage something that was once thought to be unsalvageable and thus spare patients from being consigned to life with a stoma.”
Dr. Sylla says the procedure is suited for cases involving a high-risk reoperative pelvic surgery with take-down of the prior failed anastomosis, correction of anastomotic leak both in the early postoperative period and, even more important, in the chronic setting, and as an alternative to the creation or maintenance of a stoma. Candidates are evaluated based on several factors, including their ability to tolerate another major pelvic operation and their willingness to accept the high—but not yet quantifiable—risk of complications such as infection and leaks. Candidate assessment also necessitates a full workup, including endoscopy, pelvic MRI, and CT scans, to assess the nature of the anastomotic complication and determine whether there is enough healthy colon and rectal tissue above and below the anastomosis to restore gastrointestinal continuity and continence.
“The presence of some residual healthy rectal tissue is the real basis for success in these procedures, and we have been pushing the boundaries quite a bit when it comes to that,” Dr. Sylla says. “Five centimeters of remaining healthy rectal tissue is optimal because there is still sufficient sphincter muscle to maintain fecal continence. However, there are some patients who are willing to take the risk with less than five centimeters of tissue because they would rather live with some degree of fecal incontinence than a permanent stoma.”
Once the patient is determined to be a good candidate, a multidisciplinary team performs the procedure, working from both the top and bottom to mitigate the risk of surgical error or organ injury. The upper colon is dissected laparoscopically via the abdomen, or by open surgery in cases where patient scarring is extensive, and the anastomosis is accessed, mobilized, dissected, and resected transanally by Dr. Sylla using a specialized operative endoscope.
“When you do that from above, all you can see is the fibrosis from the previous procedure, which makes it hard to find the correct anatomy,” she says. “The advantage of doing this transanally is that five centimeters of healthy rectum tissue enables you to start the dissection from a plane that is essentially virgin, which is preferable because it is easier to work from healthy tissue toward the pathology than from the pathology down toward healthy tissue.”
On average, it takes Dr. Sylla four to six hours to complete these procedures due to the difficulties with reoperative pelvic surgery. “The adhesions tend to be brutal, especially in cases where there has been a leak because that means the patient had feces or pus in their pelvis, resulting in a robust inflammatory response,” Dr. Sylla says. “By the time we perform the procedure, months or years have passed and the inflammation has been replaced by thick scarring. That must be removed meticulously and slowly because of the high risk of injury to the patient’s bowel, vagina, bladder, or ureters.”
Length of hospital stay is typically three to five days for patients who have undergone laparoscopic abdominal surgery and five to seven days for those who have undergone open surgery. Dr. Sylla says surgical drains are left in place to address the risk of postoperative abscesses and leaks, and patients who present without a stoma prior to the procedure often also require a temporary diverting ileostomy to facilitate healing of the newly reconstructed colorectal anastomosis. If healing progresses without complication, the stoma can be closed approximately two or three months after the procedure.
To date, Dr. Sylla has performed the procedure on six patients. All have had positive outcomes, but she cautions that those numbers are insufficient to gain any insights as to long-term impacts or risk of complications. “We do not have a large or multicenter cohort, so we do not know if these patients are at risk of developing complications or if they will remain stoma-free,” she says. “My goal is to start a registry for those of us who are performing these procedures to share our experiences and patient outcomes so we can start to answer those questions.”
Patricia Sylla, MD
Associate Professor of Surgery