The Effect of Multifaceted Anastomotic Leakage Prevention via ICG and SST for Lower Rectal Anastomosis.

Background/aim: In rectal cancer surgery, anastomotic leakage (AL) is the most important complication and has a reported frequency of 11-15%. The causes of AL leakage are complex, and AL prevention should be performed in multiple directions. Thus, this study examined the usefulness of the comprehensive and multifaceted AL preventive measures.

Patients and methods: In total, 164 rectal surgery patients who had low rectal staple anastomosis below the peritoneal reflection were enrolled. The patients were divided into two groups: (i) the multifaceted AL prevention group (MP group, n=34) and (ii) the insufficient AL prevention group (IP group, n=130). Multifaceted AL prevention was defined as intestinal blood flow evaluated via indocyanine green (ICG)-fluorescence imaging (FI), the use of a single-staple technique (SST) without intersecting stapling lines or "dog ears", the use of transanal suture reinforcement according to the air leakage test, and the use of a transanal tube for anatomical decompression and a diverting stoma for diverting the fecal stream. The AL rates were retrospectively compared between the two groups. The data are expressed as the median and interquartile range.

Results: The rate of AL was significantly lower in the MP group (0%) than in the IP group (11.54%) (p=0.0423).

Conclusion: Multifaceted AL prevention, including ICG-FI and SST, achieved a zero incidence of AL. Multifaceted prevention significantly lessened AL more than inadequate prevention did. Therefore, if the weight of each preventive measure cannot be clearly identified, to avoid AL, it is important to take all preventive measures from multiple aspects.