Turnbull procedure – analysis of a cohort in the salvage setting

Turnbull procedure – analysis of a cohort in the salvage setting | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article Turnbull procedure – analysis of a cohort in the salvage setting Gerrit Arlt, Fabian Doyon, Richard Magdeburg, Peter Kienle This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-8899531/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 10 You are reading this latest preprint version Abstract Purpose: The Turnbull procedure (coloanal pull-through with delayed coloanal anastomosis, DCAA) serves as a salvage option for complex, therapy-refractory pelvic floor disorders to avoid permanent colostomy. This study evaluated the perioperative outcomes, stoma avoidance, and functional results of 16 patients treated between 2018 and 2024. Methods: A retrospective analysis of 16 consecutive patients with hostile pelvis (e.g., post-surgical fistulas, chronic pelvic sepsis, and Crohn´s disease). The key outcomes were time to anastomosis, Clavien-Dindo complications, stoma reversal rate, SF-12 quality of life, LARS, and Wexner continence score. Follow-up: 19–80 months Results: Anastomosis occurred after a mean of 11 days (range, 6–19 days). Permanent stoma was avoided in 13/16 (81%) patients. Perioperative morbidity was low, and the SF-12 scores (14/16) ranged from 29% to 86%, correlating with the LARS (p=0.016). In 12 patients, minor LARS was observed in 3/12, major LARS in 7/12, Wexner good continence in 4/12, moderate in 5/12, and severe in 3/12. The fistula subgroup showed the best functional results. Conclusions: The Turnbull/DCAA procedure enables sphincter preservation in complex pelvic disorders, particularly postoperative fistulas. Despite frequent major LARS and incontinence, 81% of the patients avoided permanent stoma. Meticulous selection and informed consent are essential because of the functional limitations. Turnbull procedure delayed coloanal anastomosis hostile pelvis LARS score fistula salvage Figures Figure 1 Figure 2 Introduction Coloanal pull-through with interval anastomosis (delayed coloanal anastomosis, DCAA) is a technique originally conceived for the treatment of Hirschsprung’s disease in childhood [1, 2]. It is frequently referred to as the Turnbull-Cutait procedure after its original describers, Turnbull and Cutait [3]. In rectal carcinoma resection, this procedure has experienced a renaissance in recent years [4, 5] as an alternative to one-stage transanal ultra-low anastomosis. Improved techniques in minimally invasive surgery, such as transanal platforms, 3D technology, robotics, and new anastomosis techniques such as transanal transsecting single stapled (TTSS) anastomosis, appear to be more promising for the treatment of rectal carcinoma at present [6, 7]. Another important indication for the Turnbull procedure is complex, often therapy-refractory pelvic floor disorders requiring surgical intervention. In this specific problem area, the Turnbull procedure represents a 'salvage' option for patients who wish to avoid a permanent colostomy and for whom an ultra-low primary (i.e., one-stage) anastomosis would be problematic: healing disturbances with persistent fistula and abscess cavities following complicated pelvic surgeries such as rectal resections or prostatectomies (“chronic pelvic sepsis”) [8, 9], additionally, in protracted, often multiply pre-operated fistula diseases, [10, 11, 12, 13] which led to the term “hostile pelvis“ [14]. A special collective in this context includes patients with Crohn's disease (MC), chronic fistula disease, and supra-anal stenosis. The procedure consists of two parts: first, the residual rectum or diseased rectal portion and the fistula tissue are removed. This usually involves an intersphincteric (residual) proctectomy with sphincter preservation. In cases of fistulas, closure or reconstruction of the other fistula-bearing organs is also performed. The colon is mobilized abdominally, if possible, minimally invasively, until it can be pulled through the anus externally ('pull-through'). There are relatively few data in the literature regarding how many of the procedures were ultimately successful, that is, to what extent a definitive stoma could be avoided. Data on the functionality and quality of life (QoL) are scarce and almost exclusively refer to procedures performed primarily in the context of rectal carcinomas. Overall, this specific procedure is rarely performed for this indication. Objectives: This was a non-interventional, retrospective study of patients who underwent the Turnbull procedure (DCAA) at our institution between 2018 and 2024. In addition to perioperative parameters and evaluation of success in terms of avoiding a permanent stoma, special emphasis was placed on QoL and functional outcomes in the patients. Methods This is a non-interventional, retrospective cohort study of consecutive patients treated with the Turnbull procedure (DCAA) at our institution between 2018 and 2024 (recruitment of n=16 consecutive patients). The inclusion criteria were as follows: therapy-refractory pelvic floor disorders (“hostile pelvis”) with multiple prior surgeries (ex domo). Patients were recorded in a database, and REDCap [15] was used for data processing. A positive vote was obtained from the Ethics Committee of Heidelberg University (reference no. S-526/2024). The STROBE guidelines were followed for reporting the results of this study. All surgeries were performed at the Brüderklinikum Julia Lanz, Mannheim, Germany. A retrospective analysis was performed between December 2025 and January 2026. Follow-up: The time in days until delayed anastomosis, perioperative complication rate graded by the Clavien-Dindo classification, and rate of patients who were successfully treated, that is, avoidance of a definitive stoma to date, were recorded. A subgroup consisted of patients with defined fistula disease. QoL and functionality follow-up data (secondary outcomes) were collected throughout 2025, when the questionnaires were collected by mail, e-mail (survey function RedCap), or during outpatient visits. Quality of life (QoL) was assessed using the SF-12 questionnaire [16], continence function according to the Cleveland Clinic Incontinence Score (Wexner Score, CCS) [17], and the severity of Low Anterior Resection Syndrome (LARS) [18]. Baseline predictors included underlying diagnoses (e.g., post-surgical, defined fistulas such as recto-urethral/vesical/vaginal, chronic pelvic sepsis after anastomotic leak, and MC), multiple prior surgeries ("hostile pelvis"), and subgroups such as defined fistula disease (without MC). Confounders may include prior surgical history (multiple interventions), underlying disease severity (e.g., MC vs. post-surgical sepsis), follow-up duration (19-80 months), and response rates to questionnaires. Heterogeneity in indications (defined fistulas vs. chronic pelvic sepsis vs. MC) and small sample size (n=16) could confound associations such as the SF-12 correlation with LARS. The consecutive recruitment of all 16 patients undergoing Turnbull/DCAA (2018-2024) at a single center minimized selection bias by avoiding cherry-picking. The STROBE guidelines were followed for the transparent reporting of methods and patient flow (Fig. 1). The manuscript explicitly notes the retrospective design, small sample size (n=16), and patient heterogeneity (diverse diagnoses/prior surgeries) as limitations that complicate comparisons and subgroup analyses. There were no explicit adjustments for confounding (e.g., via multivariable analysis); a simple Spearman correlation was used for the SF-12/LARS/CCS due to the small, non-parametric sample size. Statistical calculations and box plot visualizations were performed using the online data analysis program numiqo [19]. Post-hoc subgroups were created for exploratory comparison: defined fistula (n=7, non-MC; 100% healing, better CCS trends) versus MC (n=4) versus “chronic pelvic sepsis” (n=5). Groupings based on baseline diagnoses (Table 1) were used to explore the effects of etiology. Perplexity, an AI tool, was used for translation. Results The cohort comprised 16 patients. The diagnoses included, alongside complicated courses following interventions on the rectum, prostate, and vagina, four patients with longstanding MC (Table 1 ). Table 1 List of patients with indication/baseline diagnosis Pt. no. Indication Success, Ileostoma reversal 1 Persistent fistula/abscess cavity after anastomotic insufficiency (AI) following low anterior rectal resection (LAR)– „chronic pelvic sepsis“ No 2 MC with supra-anal stenosis, perianal fistula yes 3 MC with supra-anal stenosis, perianal fistula yes 4 Persistent fistula/abscess cavity after LAR, recto-urethral fistula yes 5 Recto-urethral fistula following prostatectomy yes 6 Persistent abscess cavity presacral after AI following LAR - „chronic pelvic sepsis“ yes 7 MC with recto-vaginal fistula no 8 Recto-vesical fistula following iatrogenic perforation of the bladder, Urothel-, bladder carcinoma yes 9 Rectal prolapse re-re-recurrence no 10 Recto-vaginal fistula following multiple gynecological surgerys yes 11 Recto-vesical and recto-urethral fistula following failed restoration of continuity (diverticulitis) yes 12 Persistent abscess cavity, AI following LAR - „chronic pelvic sepsis“ yes 13 Recto-vaginal fistula, AI following LAR (diverticulitis) yes 14 Persistent abscess cavity und transsphincteric anal fistula, AI following LAR with resection of a recurrent dermoid tumor – „chronic pelvic sepsis“ yes 15 MC, supra-anal stenosis yes 16 Persistent abscess cavity after AI following LAR - „chronic pelvic sepsis“ yes All patients had undergone prior surgeries ex domo. A permanent stoma was avoided in 13 of the 16 patients. 14 could be followed up in the sense of completing the QoL questionnaires, and 12 completed the functional questionnaire (patient flow-chart Fig. 1 ). One patient in the no reversal/definitive stoma group did not answer due to a non-related illness, and one patient in the reversal/success group did not answer the questionnaires. Follow-up was performed after a minimum of 19 months and a maximum of 80 months after the procedure. Anastomosis was performed on the median after an interval of 11 days (range, 6–19 days). Perioperative morbidity was low (Clavien-Dindo: 1×IIIa, 1×II, 2×I, and 12×0). SF-12 scores (FU in 14/16) ranged from 29% to 86%, with poor quality of life values predictably correlating with poor LARS scores (Spearman correlation analysis, p = 0.016), but not significantly with CCS (p = 0,333). Functional scores were obtained in 12 patients: Minor LARS was present in 2/12 and major LARS in 7/12. According to the Wexner score, 4/12 patients showed good continence (CCS 10, < 15) and 3/12 from severe incontinence, respectively (Table 2 ). Table 2 Functional results and quality of life Pt. no. SF12 Score LARS Score Wexner Score (CCS) 1 86% AP AP 2 74% 25 14 3 69% 32 13 4 40% 31 9 5 83% 16 9 6 77% 32 16 7 74% AP AP 8 83% 21 4 9 LTFU AP AP 10 29% 41 13 11 71% 9 1 12 LTFU LTFU LTFU 13 86% 31 13 14 37% 37 17 15 51% 34 15 16 86% 20 11 The subgroup of patients with defined fistula disease (excluding patients with MC) included seven patients (Table 3 ): Complete closure was achieved in all cases; however, re do procedures were required in two patients (1x gracilis plasty and 1x direct closure). Table 3 Patients with defined fistulas Pt. no. Diagnosis Fistula healing 4 Recto-urethral fistula Yes 5 Recto-urethral fistula Yes 8 Recto-vesical fistula Yes 10 Recto-vaginal fistula Recurrence, healed with gracilis plasty 11 Recto-urethral and -vesical fistula Yes 13 Recto-vaginal fistula Recurrence, healed after re do (direct closure) 14 Trans-sphincteric anal fistula yes In these patients, QoL and functional scores tended to be better, although no statistical significance was demonstrated in this small differentiated group. The numerical difference was most pronounced in the incontinence score (CCS; Fig. 2 ). All patients in this group completed the questionnaire and were able to avoid permanent stomas. In the three MC patients with defined fistulas, permanent closure could not be achieved. Although the rectovaginal fistula healed, an anal fistula recurrence occurred. Nevertheless, both patients who presented with an anal fistula as the initial finding were able to avoid a permanent stoma to date despite recurrences and ongoing need for therapy, whereas the patient with the healed rectovaginal fistula could not due to the new anal fistula. (Table 4 ). Table 4 MC patients with fistulas Pt. no. Diagnosis Recurrence 2 Anal fistula Yes, 5x re do surgery 3 Anal fistula Yes, re do surgery, therapy with stem cells 7 Recto-vaginal fistula Rekto-vaginal fistula healed, but new perianal fistulas Discussion This retrospective analysis shows as a key result that the Turnbull procedure (DCAA) can be an effective salvage option for patients with highly complex pelvic floor pathologies. In a patient cohort characterized by high morbidity, multiple previous surgeries, and often longstanding disease courses ('hostile pelvis'), a permanent stoma could be successfully avoided in 13 of 16 patients (81%). This rate is remarkable, given the considerably high number of previous surgeries in these cases. In a study by Justiniano and Hull [ 8 ], this rate was only 50% at 5 years postoperatively. However, our success rate is within the range of previously published case series that have described similar indications [ 11 , 20 , 21 ]. Our series included more patients than those of Lavryk et al., although the follow-up periods were not entirely comparable. Perioperative morbidity was low, underscoring that the two-stage technique can be performed safely. In particular, the low rate of severe complications (1× Clavien-Dindo IIIa) demonstrates that DCAA can be performed safely - even in complex situations. The average interval of 11 days until definitive suturing is somewhat longer than the usual timeframe of the originally described Turnbull technique, which may be due to the difficult and chronically damaged tissues compared to DCAA, for example, in primary surgery for rectal carcinoma. Fistula closure The good results of fistula closure, particularly in rectovaginal fistulas, appear reproducible [ 22 , 23 ]. Primarily, DCAA was successful in five of seven patients, and one additional intervention was performed in each patient. Here, satisfaction is comparatively high, and the functional scores are also in the upper range. In contrast, the fistula healing rate in MC’s is predictably poor, although this group in the cohort is very small. Functional results Another result of this study is the functional data, which have rarely been described in the literature, mostly in the context of rectal cancer surgery. Despite the high risk of functional limitations due to prior surgeries, scar formation, and sphincter damage, the patients showed partially good functional results: four of the 12 assessed patients achieved a low Wexner score, and five met the criteria for no or minor LARS. Nevertheless, it must be noted that a significant proportion exhibited relevant functional limitations (major LARS in 7/12, severe incontinence in 3/12). However, these results must be interpreted against the background of the initial situation: in many cases, no sphincter-preserving procedure would have been possible without DCAA involvement. Moreover, the observed limitations correspond in severity to the functional outcomes described for ultra-low anastomoses in carcinoma surgery [ 24 ]. Quality of life Notably, the wide range of SF-12 scores reflects significant interindividual variation in the perceived QoL. The correlation between low SF-12 scores and pronounced LARS confirms that functional limitations after DCAA are major determinants of QoL. Nevertheless, individual patients with acceptable functional outcomes report a good health-related quality of life (QoL). This indicates that satisfactory functional reconstruction is possible, even for complex pathologies. Here, the baseline situation in this specific cohort must be considered, as patients often suffer from this issue for years beforehand. Another portion of patients continues to suffer, or has begun suffering again, from the underlying disease, e.g., in the context of tumor recurrence elsewhere, which naturally influences the current SF-12 value.​ The main limitations of this study are its small sample size and retrospective design. The heterogeneity of the patient cohort regarding underlying diseases and prior surgeries also complicates direct comparisons with other techniques. Whether the small MC subgroup particularly benefits remains unclear, as fistula recurrences occurred in 3 of 4 patients, yet a stoma-free perspective still existed, lending even greater significance to this markedly younger subgroup.​ An interesting aspect would be the baseline value for quality of life to enable a comparison with the follow-up results. However, given the highly complex disease courses before and after pull-through surgery in nearly all patients, establishing such a correlation would be difficult. Moreover, it must be noted that the quality of life with a permanent stoma, particularly a colostomy, is not necessarily poor. A functionally poor coloanal anastomosis certainly impacts daily life more negatively than a well-constructed anus praeter. This is confirmed here too: the two patients with definitive anus praeter who responded have relatively good SF-12 values.​ This study provides one of the most comprehensive insights to date into the functional outcomes of the Turnbull procedure in the salvage setting, outside oncologic rectal surgery. Ideally, prospective studies would examine functional long-term results on a larger scale, however, this is hardly feasible given the specific cohort and the demanding surgical technique. Overall, the results underscore that Turnbull/DCAA represents a valuable tool for sphincter-preserving reconstruction in complex pelvic floor disorder cases. This enables patients for whom a definitive stoma would otherwise be the only option to maintain anatomically correct continence. Above all, complex fistulas arising from intra- or postoperative complications strongly indicate DCAA. Given the functional limitations described, meticulous patient selection and informed consent are essential. Declarations Funding: This research did not receive any external funding. Conflict of interest: The Authors declare no conflicts of interest. Ethics approval: The study was approved by the local ethics committee (University of Heidelberg; reference no. S-526/2024). Consent: Written informed consent was obtained from all answering patients. 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(2022) Surgical outcomes of Turnbull-Cutait delayed coloanal anastomosis with pull-through versus immediate coloanal anastomosis with diverting stoma after total mesorectal excision for low rectal cancer: a systematic review and meta-analysis. TECHNIQUES IN COLOPROCTOLOGY 26:603-613 Foppa C, Carvello M, Maroli A et al. (2023) Single-stapled anastomosis is associated with a lower anastomotic leak rate than double-stapled technique after minimally invasive total mesorectal excision for MRI-defined low rectal cancer. Surgery 173:1367-1373 Spinelli A, Foppa C, Carvello M et al. (2021) Transanal transection and single-stapled anastomosis (TTSS): a comparison of anastomotic leak rates with the double-stapled technique and with transanal total mesorectal excision (TaTME) for rectal cancer. European Journal of Surgical Oncology 47:3123-3129 Justiniano CF, Hull T (2023) The failed colorectal anastomosis: Turnbull-Cutait as a salvage option. In: Seminars in Colon and Rectal Surgery. Elsevier, p 100988 Banchini F, Luzietti E, Conti L et aRe do2022) Redo surgery after low anterior resection for chronic pelvic sinus and anastomotic disruption. Could pull-through procedure with delayed anastomosis be a feasible alternative? Case reports and narrative review. International Journal of Surgery Case Reports 93:106967 Maspero M, Lavryk O, Prien C et al. (2023) Two-Stage Turnbull-Cutait Pull-through Coloanal Anastomosis for Recurrent Rectovaginal Fistula. Diseases of the Colon & Rectum:10.1097 Lavryk OA, Justiniano CF, Bandi B et al. (2023) Turnbull-cutait pull-through procedure is an alternative to permanent ostomy in patients with complex pelvic fistulas. Diseases of the Colon & Rectum 66:1539-1546 Karakayali FY, Tezcaner T, Ozcelik U et al. (2016) The outcomes of ultralow anterior resection or an abdominoperineal pull-through resection and coloanal anastomosis for radiation-induced recto-vaginal fistula patients. Journal of Gastrointestinal Surgery 20:994-1001 Gaertner WB, Burgess PL, Davids JS et al. (2022) The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Diseases of the Colon & Rectum 65:964-985 Patsouras D, Yassin N, Phillips R (2014) Clinical outcomes of colo‐anal pull‐through procedure for complex rectal conditions. Colorectal Disease 16:253-258 Harvey L (2018) REDCap: web-based software for all types of data storage and collection. Spinal cord 56:625-625 Drixler K, Morfeld M, Glaesmer H et al. (2020) Validierung der Messung gesundheitsbezogener Lebensqualität mittels des short-form-health-Survey-12 (SF-12 Version 2.0) in einer deutschen Normstichprobe. Zeitschrift für Psychosomatische Medizin und Psychotherapie 66:272-286 Jorge MJ, Wexner SD (1993) Etiology and management of fecal incontinence. Diseases of the colon & rectum 36:77-97 Ribas Y, Aguilar F, Jovell-Fernández E et al. (2017) Clinical application of the LARS score: results from a pilot study. International journal of colorectal disease 32:409-418 Team N (2025) numiqo: Online Statistics Calculator. In:numiqo e.U., Graz, Austria Hallet J, Bouchard A, Drolet S et al. (2014) Anastomotic salvage after rectal cancer resection using the Turnbull-Cutait delayed anastomosis. Can J Surg 57:405-411 Martín-Pérez B, Dar R, Bislenghi G et al. (2021) Transanal minimally invasive proctectomy with two-stage Turnbull-Cutait pull-through coloanal anastomosis for iatrogenic rectourethral fistulas. Diseases of the Colon & Rectum 64:e26-e29 Maggiori L, Blanche J, Harnoy Y et aRe do2015) Redo-surgery by transanal colonic pull-through for failed anastomosis associated with chronic pelvic sepsis or rectovaginal fistula. International Journal of Colorectal Disease 30:543-548 Blondeau M, Labiad C, Melka D et al. (2022) Postoperative rectovaginal fistula: Can colonic pull‐through delayed coloanal anastomosis avoid the need for definitive stoma? An experience of 28 consecutives cases. Colorectal Disease 24:1000-1006 Biondo S, Barrios O, Trenti L et al. (2024) Long-Term Results of 2-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer: A Randomized Clinical Trial. YESMA Surgery 159:990-996 Additional Declarations No competing interests reported. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-8899531","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":603613503,"identity":"b30ddad1-3777-4a0e-b049-a0696cac6f1e","order_by":0,"name":"Gerrit Arlt","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA4UlEQVRIiWNgGAWjYLCCBww2CQYIbgIRWhIS0hIM2EjUcpgELfIOzM8+JP44n2cu337tM++OO3IM7MkH8GoxPMBmPCMh4XaxZRtP8WzeM8+MGXie4bfGsIHBGOiw24kbjvEkM/O2HU5skMgxIKCF/TNQyzm4lvoGifwP+P3CwAOy5QBQC/thkJYEBokcvDoYDJh5ihkS0pKBfslhZpx75plhG88z/A6Tb2/fzPDBxi7PnPn4Y4a3O+7I87MnP8Bvy2E4k8eAgbHhAAMbHtUQWxrgTPYHYC2jYBSMglEwCtABAOofSCAGoNsIAAAAAElFTkSuQmCC","orcid":"","institution":"Brüderklinikum Julia Lanz","correspondingAuthor":true,"prefix":"","firstName":"Gerrit","middleName":"","lastName":"Arlt","suffix":""},{"id":603613504,"identity":"74e15cda-e692-41f7-b923-0fb42cfbd75a","order_by":1,"name":"Fabian Doyon","email":"","orcid":"","institution":"Brüderklinikum Julia Lanz","correspondingAuthor":false,"prefix":"","firstName":"Fabian","middleName":"","lastName":"Doyon","suffix":""},{"id":603613505,"identity":"085ac886-2376-47a9-a0a1-04767b0eb35c","order_by":2,"name":"Richard Magdeburg","email":"","orcid":"","institution":"Brüderklinikum Julia Lanz","correspondingAuthor":false,"prefix":"","firstName":"Richard","middleName":"","lastName":"Magdeburg","suffix":""},{"id":603613506,"identity":"ebe22e17-ff4a-4ce9-840b-403d1458bde6","order_by":3,"name":"Peter Kienle","email":"","orcid":"","institution":"Heidelberg University","correspondingAuthor":false,"prefix":"","firstName":"Peter","middleName":"","lastName":"Kienle","suffix":""}],"badges":[],"createdAt":"2026-02-17 09:23:58","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-8899531/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-8899531/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":104414019,"identity":"a18870ea-6357-47f8-99a7-3ee905f0b262","added_by":"auto","created_at":"2026-03-11 13:06:18","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":130907,"visible":true,"origin":"","legend":"\u003cp\u003ePatient flow chart.\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-8899531/v1/107b3170c105378932a4d656.png"},{"id":104412321,"identity":"6af4ed29-0a70-4a76-b608-b03a7e6a40f1","added_by":"auto","created_at":"2026-03-11 12:59:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":58719,"visible":true,"origin":"","legend":"\u003cp\u003eBoxplot representation of the distribution of CCS values by initial condition (numiqo.de). MC=Crohn´s disease, CPS=chronic pelvic sepsis.\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-8899531/v1/ce9e37563f38fcc74bb53f46.png"},{"id":104417019,"identity":"584f9a7e-11fe-4fa4-b9c4-1b2ca5e59e19","added_by":"auto","created_at":"2026-03-11 13:17:45","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":629817,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8899531/v1/9e6d2e01-a751-4690-8121-5b923d98ea38.pdf"},{"id":104413895,"identity":"02313c4f-f505-4cf3-86e9-b74e9d8d36ff","added_by":"auto","created_at":"2026-03-11 13:05:44","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":32166,"visible":true,"origin":"","legend":"","description":"","filename":"STROBEchecklistTurnbull.docx","url":"https://assets-eu.researchsquare.com/files/rs-8899531/v1/bddb39ba638fa7c95c71c467.docx"},{"id":104415397,"identity":"99c250f3-d460-47b2-9255-2b5326c7f30a","added_by":"auto","created_at":"2026-03-11 13:10:45","extension":"pdf","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":7217717,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementImagesOPtechnique.pdf","url":"https://assets-eu.researchsquare.com/files/rs-8899531/v1/73cd140555f4837a495b8f12.pdf"}],"financialInterests":"No competing interests reported.","formattedTitle":"Turnbull procedure – analysis of a cohort in the salvage setting","fulltext":[{"header":"Introduction","content":"\u003cp\u003eColoanal pull-through with interval anastomosis (delayed coloanal anastomosis, DCAA) is a technique originally conceived for the treatment of Hirschsprung’s disease in childhood [1, 2]. It is frequently referred to as the Turnbull-Cutait procedure after its original describers, Turnbull and Cutait [3]. In rectal carcinoma resection, this procedure has experienced a renaissance in recent years [4, 5] as an alternative to one-stage transanal ultra-low anastomosis. Improved techniques in minimally invasive surgery, such as transanal platforms, 3D technology, robotics, and new anastomosis techniques such as transanal transsecting single stapled (TTSS) anastomosis, appear to be more promising for the treatment of rectal carcinoma at present [6, 7].\u003c/p\u003e\n\u003cp\u003eAnother important indication for the Turnbull procedure is complex, often therapy-refractory pelvic floor disorders requiring surgical intervention. In this specific problem area, the Turnbull procedure represents a 'salvage' option for patients who wish to avoid a permanent colostomy and for whom an ultra-low primary (i.e., one-stage) anastomosis would be problematic: healing disturbances with persistent fistula and abscess cavities following complicated pelvic surgeries such as rectal resections or prostatectomies (“chronic pelvic sepsis”) [8, 9], additionally, in protracted, often multiply pre-operated fistula diseases, [10, 11, 12, 13] which led to the term “hostile pelvis“ [14]. A special collective in this context includes patients with Crohn's disease (MC), chronic fistula disease, and supra-anal stenosis.\u003c/p\u003e\n\u003cp\u003eThe procedure consists of two parts: first, the residual rectum or diseased rectal portion and the fistula tissue are removed. This usually involves an intersphincteric (residual) proctectomy with sphincter preservation. In cases of fistulas, closure or reconstruction of the other fistula-bearing organs is also performed. The colon is mobilized abdominally, if possible, minimally invasively, until it can be pulled through the anus externally ('pull-through').\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThere are relatively few data in the literature regarding how many of the procedures were ultimately successful, that is, to what extent a definitive stoma could be avoided. Data on the functionality and quality of life (QoL) are scarce and almost exclusively refer to procedures performed primarily in the context of rectal carcinomas. Overall, this specific procedure is rarely performed for this indication.\u003c/p\u003e\n\u003cp\u003e\u003cu\u003eObjectives:\u003c/u\u003e\u003c/p\u003e\n\u003cp\u003eThis was a non-interventional, retrospective study of patients who underwent the Turnbull procedure (DCAA) at our institution between 2018 and 2024. In addition to perioperative parameters and evaluation of success in terms of avoiding a permanent stoma, special emphasis was placed on QoL and functional outcomes in the patients.\u0026nbsp;\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThis is a non-interventional, retrospective cohort study of consecutive patients treated with the Turnbull procedure (DCAA) at our institution between 2018 and 2024 (recruitment of n=16 consecutive patients). The inclusion criteria were as follows: therapy-refractory pelvic floor disorders (“hostile pelvis”) with multiple prior surgeries (ex domo). Patients were recorded in a database, and REDCap [15] was used for data processing. A positive vote was obtained from the Ethics Committee of Heidelberg University (reference no. S-526/2024). The STROBE guidelines were followed for reporting the results of this study.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eAll surgeries were performed at the Brüderklinikum Julia Lanz, Mannheim, Germany. A retrospective analysis was performed between December 2025 and January 2026. Follow-up: The time in days until delayed anastomosis, perioperative complication rate graded by the Clavien-Dindo classification, and rate of patients who were successfully treated, that is, avoidance of a definitive stoma to date, were recorded. A subgroup consisted of patients with defined fistula disease. QoL and functionality follow-up data (secondary outcomes) were collected throughout 2025, when the questionnaires were collected by mail, e-mail (survey function RedCap), or during outpatient visits. Quality of life (QoL) was assessed using the SF-12 questionnaire [16], continence function according to the Cleveland Clinic Incontinence Score (Wexner Score, CCS) [17], and the severity of Low Anterior Resection Syndrome (LARS) [18]. Baseline predictors included underlying diagnoses (e.g., post-surgical, defined fistulas such as recto-urethral/vesical/vaginal, chronic pelvic sepsis after anastomotic leak, and MC), multiple prior surgeries (\"hostile pelvis\"), and subgroups such as defined fistula disease (without MC). Confounders may include prior surgical history (multiple interventions), underlying disease severity (e.g., MC vs. post-surgical sepsis), follow-up duration (19-80 months), and response rates to questionnaires. Heterogeneity in indications (defined fistulas vs. chronic pelvic sepsis vs. MC) and small sample size (n=16) could confound associations such as the SF-12 correlation with LARS. The consecutive recruitment of all 16 patients undergoing Turnbull/DCAA (2018-2024) at a single center minimized selection bias by avoiding cherry-picking. The STROBE guidelines were followed for the transparent reporting of methods and patient flow (Fig. 1).\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe manuscript explicitly notes the retrospective design, small sample size (n=16), and patient heterogeneity (diverse diagnoses/prior surgeries) as limitations that complicate comparisons and subgroup analyses. There were no explicit adjustments for confounding (e.g., via multivariable analysis); a simple Spearman correlation was used for the SF-12/LARS/CCS due to the small, non-parametric sample size. Statistical calculations and box plot visualizations were performed using the online data analysis program numiqo [19]. Post-hoc subgroups were created for exploratory comparison: defined fistula (n=7, non-MC; 100% healing, better CCS trends) versus MC (n=4) versus “chronic pelvic sepsis” (n=5). Groupings based on baseline diagnoses (Table 1) were used to explore the effects of etiology. Perplexity, an AI tool, was used for translation.\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eThe cohort comprised 16 patients. The diagnoses included, alongside complicated courses following interventions on the rectum, prostate, and vagina, four patients with longstanding MC (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eList of patients with indication/baseline diagnosis\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003e Pt. no.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eIndication\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eSuccess, Ileostoma reversal\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersistent fistula/abscess cavity after anastomotic insufficiency (AI) following low anterior rectal resection (LAR)\u0026ndash; \u0026bdquo;chronic pelvic sepsis\u0026ldquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eNo\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMC with supra-anal stenosis, perianal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMC with supra-anal stenosis, perianal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersistent fistula/abscess cavity after LAR, recto-urethral fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-urethral fistula following prostatectomy\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersistent abscess cavity presacral after AI following LAR - \u0026bdquo;chronic pelvic sepsis\u0026ldquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMC with recto-vaginal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-vesical fistula following iatrogenic perforation of the bladder, Urothel-, bladder carcinoma\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRectal prolapse re-re-recurrence\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eno\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-vaginal fistula following multiple gynecological surgerys\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-vesical and recto-urethral fistula following failed restoration of continuity (diverticulitis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersistent abscess cavity, AI following LAR - \u0026bdquo;chronic pelvic sepsis\u0026ldquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-vaginal fistula, AI following LAR (diverticulitis)\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersistent abscess cavity und transsphincteric anal fistula, AI following LAR with resection of a recurrent dermoid tumor \u0026ndash; \u0026bdquo;chronic pelvic sepsis\u0026ldquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eMC, supra-anal stenosis\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003ePersistent abscess cavity after AI following LAR - \u0026bdquo;chronic pelvic sepsis\u0026ldquo;\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eAll patients had undergone prior surgeries ex domo. A permanent stoma was avoided in 13 of the 16 patients. 14 could be followed up in the sense of completing the QoL questionnaires, and 12 completed the functional questionnaire (patient flow-chart Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). One patient in the no reversal/definitive stoma group did not answer due to a non-related illness, and one patient in the reversal/success group did not answer the questionnaires.\u003c/p\u003e \u003cp\u003eFollow-up was performed after a minimum of 19 months and a maximum of 80 months after the procedure. Anastomosis was performed on the median after an interval of 11 days (range, 6\u0026ndash;19 days). Perioperative morbidity was low (Clavien-Dindo: 1\u0026times;IIIa, 1\u0026times;II, 2\u0026times;I, and 12\u0026times;0). SF-12 scores (FU in 14/16) ranged from 29% to 86%, with poor quality of life values predictably correlating with poor LARS scores (Spearman correlation analysis, p\u0026thinsp;=\u0026thinsp;0.016), but not significantly with CCS (p\u0026thinsp;=\u0026thinsp;0,333). Functional scores were obtained in 12 patients: Minor LARS was present in 2/12 and major LARS in 7/12. According to the Wexner score, 4/12 patients showed good continence (CCS\u0026thinsp;\u0026lt;\u0026thinsp;10). 5/12 patients suffered from moderate (\u0026gt;\u0026thinsp;10, \u0026lt;\u0026thinsp;15) and 3/12 from severe incontinence, respectively (Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eFunctional results and quality of life\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"4\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt. no.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eSF12 Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLARS Score\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c4\"\u003e \u003cp\u003eWexner Score (CCS)\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e25\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e69%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e40%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e6\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e77%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e32\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e74%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e83%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e21\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLTFU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eAP\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eAP\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e29%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e41\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e71%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e9\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e1\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e12\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eLTFU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eLTFU\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003eLTFU\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e31\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e37%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e37\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e17\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e51%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e34\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e15\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e16\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003e86%\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003e20\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c4\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eThe subgroup of patients with defined fistula disease (excluding patients with MC) included seven patients (Table\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e): Complete closure was achieved in all cases; however, re do procedures were required in two patients (1x gracilis plasty and 1x direct closure).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003ePatients with defined fistulas\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt. no.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eFistula healing\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e4\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-urethral fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e5\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-urethral fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e8\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-vesical fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e10\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-vaginal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrence, healed with gracilis plasty\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e11\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-urethral and -vesical fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e13\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-vaginal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrence, healed after re do (direct closure)\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e14\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eTrans-sphincteric anal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eyes\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e \u003cp\u003eIn these patients, QoL and functional scores tended to be better, although no statistical significance was demonstrated in this small differentiated group. The numerical difference was most pronounced in the incontinence score (CCS; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). All patients in this group completed the questionnaire and were able to avoid permanent stomas.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eIn the three MC patients with defined fistulas, permanent closure could not be achieved. Although the rectovaginal fistula healed, an anal fistula recurrence occurred. Nevertheless, both patients who presented with an anal fistula as the initial finding were able to avoid a permanent stoma to date despite recurrences and ongoing need for therapy, whereas the patient with the healed rectovaginal fistula could \u003cem\u003enot\u003c/em\u003e due to the new anal fistula. (Table\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e).\u003c/p\u003e \u003cp\u003e \u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e \u003ccaption language=\"En\"\u003e \u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e \u003cdiv class=\"CaptionContent\"\u003e \u003cp\u003eMC patients with fistulas\u003c/p\u003e \u003c/div\u003e \u003c/caption\u003e \u003ccolgroup cols=\"3\"\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e \u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e \u003cthead\u003e \u003ctr\u003e \u003cth align=\"left\" colname=\"c1\"\u003e \u003cp\u003ePt. no.\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c2\"\u003e \u003cp\u003eDiagnosis\u003c/p\u003e \u003c/th\u003e \u003cth align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRecurrence\u003c/p\u003e \u003c/th\u003e \u003c/tr\u003e \u003c/thead\u003e \u003ctbody\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e2\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes, 5x re do surgery\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e3\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eAnal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eYes, re do surgery, therapy with stem cells\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003ctr\u003e \u003ctd align=\"left\" colname=\"c1\"\u003e \u003cp\u003e7\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c2\"\u003e \u003cp\u003eRecto-vaginal fistula\u003c/p\u003e \u003c/td\u003e \u003ctd align=\"left\" colname=\"c3\"\u003e \u003cp\u003eRekto-vaginal fistula healed, but new perianal fistulas\u003c/p\u003e \u003c/td\u003e \u003c/tr\u003e \u003c/tbody\u003e \u003c/colgroup\u003e \u003c/table\u003e\u003c/div\u003e \u003c/p\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis retrospective analysis shows as a key result that the Turnbull procedure (DCAA) can be an effective salvage option for patients with highly complex pelvic floor pathologies. In a patient cohort characterized by high morbidity, multiple previous surgeries, and often longstanding disease courses ('hostile pelvis'), a permanent stoma could be successfully avoided in 13 of 16 patients (81%). This rate is remarkable, given the considerably high number of previous surgeries in these cases. In a study by Justiniano and Hull [\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e], this rate was only 50% at 5 years postoperatively. However, our success rate is within the range of previously published case series that have described similar indications [\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e]. Our series included more patients than those of Lavryk et al., although the follow-up periods were not entirely comparable.\u003c/p\u003e \u003cp\u003ePerioperative morbidity was low, underscoring that the two-stage technique can be performed safely. In particular, the low rate of severe complications (1\u0026times; Clavien-Dindo IIIa) demonstrates that DCAA can be performed safely - even in complex situations. The average interval of 11 days until definitive suturing is somewhat longer than the usual timeframe of the originally described Turnbull technique, which may be due to the difficult and chronically damaged tissues compared to DCAA, for example, in primary surgery for rectal carcinoma.\u003c/p\u003e\n\u003ch3\u003eFistula closure\u003c/h3\u003e\n\u003cp\u003eThe good results of fistula closure, particularly in rectovaginal fistulas, appear reproducible [\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e]. Primarily, DCAA was successful in five of seven patients, and one additional intervention was performed in each patient. Here, satisfaction is comparatively high, and the functional scores are also in the upper range. In contrast, the fistula healing rate in MC\u0026rsquo;s is predictably poor, although this group in the cohort is very small.\u003c/p\u003e\n\u003ch3\u003eFunctional results\u003c/h3\u003e\n\u003cp\u003eAnother result of this study is the functional data, which have rarely been described in the literature, mostly in the context of rectal cancer surgery. Despite the high risk of functional limitations due to prior surgeries, scar formation, and sphincter damage, the patients showed partially good functional results: four of the 12 assessed patients achieved a low Wexner score, and five met the criteria for no or minor LARS. Nevertheless, it must be noted that a significant proportion exhibited relevant functional limitations (major LARS in 7/12, severe incontinence in 3/12). However, these results must be interpreted against the background of the initial situation: in many cases, no sphincter-preserving procedure would have been possible without DCAA involvement. Moreover, the observed limitations correspond in severity to the functional outcomes described for ultra-low anastomoses in carcinoma surgery [\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e].\u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eQuality of life\u003c/h2\u003e \u003cp\u003eNotably, the wide range of SF-12 scores reflects significant interindividual variation in the perceived QoL. The correlation between low SF-12 scores and pronounced LARS confirms that functional limitations after DCAA are major determinants of QoL. Nevertheless, individual patients with acceptable functional outcomes report a good health-related quality of life (QoL). This indicates that satisfactory functional reconstruction is possible, even for complex pathologies. Here, the baseline situation in this specific cohort must be considered, as patients often suffer from this issue for years beforehand. Another portion of patients continues to suffer, or has begun suffering again, from the underlying disease, e.g., in the context of tumor recurrence elsewhere, which naturally influences the current SF-12 value.​\u003c/p\u003e \u003cp\u003eThe main limitations of this study are its small sample size and retrospective design. The heterogeneity of the patient cohort regarding underlying diseases and prior surgeries also complicates direct comparisons with other techniques. Whether the small MC subgroup particularly benefits remains unclear, as fistula recurrences occurred in 3 of 4 patients, yet a stoma-free perspective still existed, lending even greater significance to this markedly younger subgroup.​\u003c/p\u003e \u003cp\u003eAn interesting aspect would be the baseline value for quality of life to enable a comparison with the follow-up results. However, given the highly complex disease courses before and after pull-through surgery in nearly all patients, establishing such a correlation would be difficult. Moreover, it must be noted that the quality of life with a permanent stoma, particularly a colostomy, is not necessarily poor. A functionally poor coloanal anastomosis certainly impacts daily life more negatively than a well-constructed anus praeter. This is confirmed here too: the two patients with definitive anus praeter who responded have relatively good SF-12 values.​\u003c/p\u003e \u003cp\u003eThis study provides one of the most comprehensive insights to date into the functional outcomes of the Turnbull procedure in the salvage setting, outside oncologic rectal surgery. Ideally, prospective studies would examine functional long-term results on a larger scale, however, this is hardly feasible given the specific cohort and the demanding surgical technique. Overall, the results underscore that Turnbull/DCAA represents a valuable tool for sphincter-preserving reconstruction in complex pelvic floor disorder cases. This enables patients for whom a definitive stoma would otherwise be the only option to maintain anatomically correct continence. Above all, complex fistulas arising from intra- or postoperative complications strongly indicate DCAA. Given the functional limitations described, meticulous patient selection and informed consent are essential.\u003c/p\u003e \u003c/div\u003e"},{"header":"Declarations","content":"\u003cul\u003e\n \u003cli\u003eFunding: This research did not receive any external funding.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eConflict of interest: The Authors declare no conflicts of interest.\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eEthics approval: The study was approved by the local ethics committee (University of Heidelberg; reference no. S-526/2024).\u0026nbsp;\u003c/li\u003e\n \u003cli\u003eConsent: Written informed consent was obtained from all answering patients.\u0026nbsp;\u003c/li\u003e\n\u003c/ul\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eTurnbull RB, Cuthbertson A (1961) Abdominorectal pull-through resection for cancer and for Hirschsprung\u0026apos;s disease: delayed posterior colorectal anastomosis. Cleveland Clinic Journal of Medicine 28:109-115\u003c/li\u003e\n\u003cli\u003eCutait DE, Cutait R, Ioshimoto M et al. (1985) Abdominoperineal endoanal pull-through resection. A comparative study between immediate and delayed colorectal anastomosis. Dis Colon Rectum 28:294-299\u003c/li\u003e\n\u003cli\u003eChurch JM (2025) What Is the Turnbull\u0026ndash;Cutait Procedure? What Are the Indications for It? What Are the Pros and Cons. Oh and by the Way, Who Was Turnbull and Who Was Cutait? In: 105 Clinical Questions in Colorectal Surgery. Springer, p 231-237\u003c/li\u003e\n\u003cli\u003eGuillem JG, Cutait R, Remzi F (2020) Turnbull-Cutait Pull-Through\u0026mdash;An Old Procedure With a New Indication? YESMA surgery 155:e201756-e201756\u003c/li\u003e\n\u003cli\u003eLa Rayes C, Foppa C, Maroli A et al. (2022) Surgical outcomes of Turnbull-Cutait delayed coloanal anastomosis with pull-through versus immediate coloanal anastomosis with diverting stoma after total mesorectal excision for low rectal cancer: a systematic review and meta-analysis. TECHNIQUES IN COLOPROCTOLOGY 26:603-613\u003c/li\u003e\n\u003cli\u003eFoppa C, Carvello M, Maroli A et al. (2023) Single-stapled anastomosis is associated with a lower anastomotic leak rate than double-stapled technique after minimally invasive total mesorectal excision for MRI-defined low rectal cancer. Surgery 173:1367-1373\u003c/li\u003e\n\u003cli\u003eSpinelli A, Foppa C, Carvello M et al. (2021) Transanal transection and single-stapled anastomosis (TTSS): a comparison of anastomotic leak rates with the double-stapled technique and with transanal total mesorectal excision (TaTME) for rectal cancer. European Journal of Surgical Oncology 47:3123-3129\u003c/li\u003e\n\u003cli\u003eJustiniano CF, Hull T (2023) The failed colorectal anastomosis: Turnbull-Cutait as a salvage option. In: Seminars in Colon and Rectal Surgery. Elsevier, p 100988\u003c/li\u003e\n\u003cli\u003eBanchini F, Luzietti E, Conti L et aRe do2022) Redo surgery after low anterior resection for chronic pelvic sinus and anastomotic disruption. Could pull-through procedure with delayed anastomosis be a feasible alternative? Case reports and narrative review. International Journal of Surgery Case Reports 93:106967\u003c/li\u003e\n\u003cli\u003eMaspero M, Lavryk O, Prien C et al. (2023) Two-Stage Turnbull-Cutait Pull-through Coloanal Anastomosis for Recurrent Rectovaginal Fistula. Diseases of the Colon \u0026amp; Rectum:10.1097\u003c/li\u003e\n\u003cli\u003eLavryk OA, Justiniano CF, Bandi B et al. (2023) Turnbull-cutait pull-through procedure is an alternative to permanent ostomy in patients with complex pelvic fistulas. Diseases of the Colon \u0026amp; Rectum 66:1539-1546\u003c/li\u003e\n\u003cli\u003eKarakayali FY, Tezcaner T, Ozcelik U et al. (2016) The outcomes of ultralow anterior resection or an abdominoperineal pull-through resection and coloanal anastomosis for radiation-induced recto-vaginal fistula patients. Journal of Gastrointestinal Surgery 20:994-1001\u003c/li\u003e\n\u003cli\u003eGaertner WB, Burgess PL, Davids JS et al. (2022) The American Society of Colon and Rectal Surgeons clinical practice guidelines for the management of anorectal abscess, fistula-in-ano, and rectovaginal fistula. Diseases of the Colon \u0026amp; Rectum 65:964-985\u003c/li\u003e\n\u003cli\u003ePatsouras D, Yassin N, Phillips R (2014) Clinical outcomes of colo‐anal pull‐through procedure for complex rectal conditions. Colorectal Disease 16:253-258\u003c/li\u003e\n\u003cli\u003eHarvey L (2018) REDCap: web-based software for all types of data storage and collection. Spinal cord 56:625-625\u003c/li\u003e\n\u003cli\u003eDrixler K, Morfeld M, Glaesmer H et al. (2020) Validierung der Messung gesundheitsbezogener Lebensqualit\u0026auml;t mittels des short-form-health-Survey-12 (SF-12 Version 2.0) in einer deutschen Normstichprobe. Zeitschrift f\u0026uuml;r Psychosomatische Medizin und Psychotherapie 66:272-286\u003c/li\u003e\n\u003cli\u003eJorge MJ, Wexner SD (1993) Etiology and management of fecal incontinence. Diseases of the colon \u0026amp; rectum 36:77-97\u003c/li\u003e\n\u003cli\u003eRibas Y, Aguilar F, Jovell-Fern\u0026aacute;ndez E et al. (2017) Clinical application of the LARS score: results from a pilot study. International journal of colorectal disease 32:409-418\u003c/li\u003e\n\u003cli\u003eTeam N (2025) numiqo: Online Statistics Calculator. In:numiqo e.U., Graz, Austria\u003c/li\u003e\n\u003cli\u003eHallet J, Bouchard A, Drolet S et al. (2014) Anastomotic salvage after rectal cancer resection using the Turnbull-Cutait delayed anastomosis. Can J Surg 57:405-411\u003c/li\u003e\n\u003cli\u003eMart\u0026iacute;n-P\u0026eacute;rez B, Dar R, Bislenghi G et al. (2021) Transanal minimally invasive proctectomy with two-stage Turnbull-Cutait pull-through coloanal anastomosis for iatrogenic rectourethral fistulas. Diseases of the Colon \u0026amp; Rectum 64:e26-e29\u003c/li\u003e\n\u003cli\u003eMaggiori L, Blanche J, Harnoy Y et aRe do2015) Redo-surgery by transanal colonic pull-through for failed anastomosis associated with chronic pelvic sepsis or rectovaginal fistula. International Journal of Colorectal Disease 30:543-548\u003c/li\u003e\n\u003cli\u003eBlondeau M, Labiad C, Melka D et al. (2022) Postoperative rectovaginal fistula: Can colonic pull‐through delayed coloanal anastomosis avoid the need for definitive stoma? An experience of 28 consecutives cases. Colorectal Disease 24:1000-1006\u003c/li\u003e\n\u003cli\u003eBiondo S, Barrios O, Trenti L et al. (2024) Long-Term Results of 2-Stage Turnbull-Cutait Pull-Through Coloanal Anastomosis for Low Rectal Cancer: A Randomized Clinical Trial. YESMA Surgery 159:990-996\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false},"keywords":"Turnbull procedure, delayed coloanal anastomosis, hostile pelvis, LARS score, fistula salvage","lastPublishedDoi":"10.21203/rs.3.rs-8899531/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-8899531/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003ePurpose: \u003c/strong\u003eThe Turnbull procedure (coloanal pull-through with delayed coloanal anastomosis, DCAA) serves as a salvage option for complex, therapy-refractory pelvic floor disorders to avoid permanent colostomy. This study evaluated the perioperative outcomes, stoma avoidance, and functional results of 16 patients treated between 2018 and 2024.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods: \u003c/strong\u003eA\u003cstrong\u003e \u003c/strong\u003eretrospective analysis of 16 consecutive patients with hostile pelvis (e.g., post-surgical fistulas, chronic pelvic sepsis, and Crohn´s disease). The key outcomes were time to anastomosis, Clavien-Dindo complications, stoma reversal rate, SF-12 quality of life, LARS, and Wexner continence score. Follow-up: 19–80 months\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eAnastomosis occurred after a mean of 11 days (range, 6–19 days). Permanent stoma was avoided in 13/16 (81%) patients. Perioperative morbidity was low, and the SF-12 scores (14/16) ranged from 29% to 86%, correlating with the LARS (p=0.016). In 12 patients, minor LARS was observed in 3/12, major LARS in 7/12, Wexner good continence in 4/12, moderate in 5/12, and severe in 3/12. The fistula subgroup showed the best functional results.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions:\u003c/strong\u003e The Turnbull/DCAA procedure enables sphincter preservation in complex pelvic disorders, particularly postoperative fistulas. Despite frequent major LARS and incontinence, 81% of the patients avoided permanent stoma. Meticulous selection and informed consent are essential because of the functional limitations.\u003c/p\u003e","manuscriptTitle":"Turnbull procedure – analysis of a cohort in the salvage setting","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-03-11 12:03:16","doi":"10.21203/rs.3.rs-8899531/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-04-04T20:02:01+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-04T19:20:38+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-27T23:53:38+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"287092891022256534411084631357936714147","date":"2026-03-22T22:02:27+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"269037886051537342491448562802990212686","date":"2026-03-18T12:22:56+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-03-14T11:58:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"300976705542138247040455966917657920411","date":"2026-03-10T07:24:40+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-03-06T05:51:58+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-03-06T01:25:56+00:00","index":"","fulltext":""},{"type":"submitted","content":"International Journal of Colorectal Disease","date":"2026-03-05T17:42:24+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"international-journal-of-colorectal-disease","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"ijcd","sideBox":"Learn more about [International Journal of Colorectal Disease](http://link.springer.com/journal/384)","snPcode":"384","submissionUrl":"https://submission.nature.com/new-submission/384/3","title":"International Journal of Colorectal Disease","twitterHandle":"","acdcEnabled":true,"dfaEnabled":true,"editorialSystem":"em","reportingPortfolio":"Springer Hybrid","inReviewEnabled":true,"inReviewRevisionsEnabled":false}}],"origin":"","ownerIdentity":"299f8b35-ce70-4dba-a785-d9cbb405a263","owner":[],"postedDate":"March 11th, 2026","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-16T12:08:19+00:00","versionOfRecord":[],"versionCreatedAt":"2026-03-11 12:03:16","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-8899531","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-8899531","identity":"rs-8899531","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}