Abdominoperineal pull-through with delayed coloanal anastomosis for pelvic anastomotic failure-a systematic review.

The PRISMA diagram is provided in Fig.  1 . Initial literature search identified 417 articles, of which 22 abstracts were identified for full-text review. Seventeen were excluded: nine studies did not report DCAA-specific outcomes in redo surgery [ 10 – 18 ], six investigated DCAA for indications other than redo surgery with insufficient relevant data for analysis [ 19 – 24 ], one had too few patients ( n  = 2) [ 25 ], and one studied a duplicate patient population [ 26 ]. The remaining five studies [ 27 – 31 ] were included in this systematic review. All were retrospective, single-armed cohort studies. Due to study heterogeneity, meta-analysis was not performed. Fig. 1 PRISMA diagram. Source: Page MJ et al. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71 . This work is licensed under CC BY 4.0. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ PRISMA diagram. Source: Page MJ et al. BMJ 2021;372:n71. https://doi.org/10.1136/bmj.n71 . This work is licensed under CC BY 4.0. To view a copy of this license, visit https://creativecommons.org/licenses/by/4.0/ The risk of bias assessment is shown in Table  1 . Study outcomes were well defined throughout all studies and involved either stoma-free survival or recurrence-free survival. Table 1 Risk of bias assessment for studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery Author Study design Newcastle-Ottawa scale components Final score Population Exposure Outcomes Follow-up Confounding domains listed in study protocol Hallet 2014 [ 29 ] Retrospective cohort S: 3 C: 0 O: 2 5 Single centre Identification described Clear description of surgical procedure Clear description of other associated interventions rendered Standardised Complete Mean follow up time < 12 months Not considered Baseline description Noncomparative Maggiori 2015 [ 30 ] Retrospective cohort S: 3 C: 0 O: 3 6 Single centre Identification described Clear description of surgical procedure Clear description of other associated interventions rendered Standardised Complete Not considered Baseline description Noncomparative Barugola 2018 [ 27 ] Retrospective cohort S: 3 C: 0 O: 3 6 Single centre Identification described Clear description of surgical procedure Clear description of other associated interventions rendered Standardised One patient followed up for < 6 months, reason for loss to follow up not given Not considered Baseline description noncomparative Boullenois 2019 [ 31 ] Retrospective cohort S: 3 C: 0 O: 3 6 Single centre Identification described Clear description of surgical procedure Clear description of other associated interventions rendered Standardised Complete Not considered Baseline description Noncomparative Blondeau 2022 [ 28 ] Retrospective cohort S: 3 C: 0 O: 3 6 Single centre Identification described Clear description of surgical procedure Clear description of other associated interventions rendered Standardised Complete Not considered Baseline description Noncomparative Risk of bias assessment for studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery S: 3 C: 0 O: 2 Complete Mean follow up time < 12 months Not considered Baseline description Noncomparative S: 3 C: 0 O: 3 Not considered Baseline description Noncomparative S: 3 C: 0 O: 3 Not considered Baseline description noncomparative S: 3 C: 0 O: 3 Not considered Baseline description Noncomparative S: 3 C: 0 O: 3 Not considered Baseline description Noncomparative Table 2 shows overall patient and clinical characteristics. Across the five studies, a total of 97 patients (32.0% male, n  = 31) with mean age of 55 (range 26 – 77) years, underwent redo surgery with DCAA between 2007 and 2020. Patients were predominantly treated for complications following surgery for rectal cancer ( n  = 74, 76.3%) or pelvic endometriosis ( n  = 14, 14.4%). The most common index procedure was proctectomy or anterior resection ( n  = 84, 86.6%). The most frequent complication necessitating redo surgery was chronic fistula (rectovaginal, colovaginal, or rectovesical) ( n  = 62, 63.9%) followed by chronic pelvic sepsis ( n  = 28, 28.9%) and anastomotic leak ( n  = 6, 6.2%). Pooled mean follow-up duration was 24.2 months, with mean follow-up duration ranging from 11.3 [ 29 ] to 32.3 months [ 27 ]. Three studies [ 27 , 28 , 31 ] reported the mean interval between index surgery and redo DCAA, ranging from 10 [ 27 ] to 37 [ 28 ] months. Table 2 Baseline characteristics among studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery Author N Mean age/years (range) Male n(%) Mean BMI (range) Study period Study design Primary diagnosis, n (%) Other interim procedures, n(%) Nature of index surgery, n (%) Indication of DCAA Mean follow-up time/months (SD) Hallet 2014 [ 29 ] 7 60.3 (49–74) 3 (42.9) NR 2010 to 2011 Retrospective cohort, single centre Distal rectal cancer 4 (57.1); mid rectal cancer 3 (42.9) Transrectal drainage for RVF 1 (14.3); transrectal drainage 2 (28.6); rectal advancement flap 1 (14.3); faecal diversion 2 (28.6) Laparoscopic AR 4 (57.1); open AR 3 (42.9) Subtotal anastomotic disruption and anal stricture 1 (14.3); early distal colonic ischaemia POD9 with sepsis 1 (14.3); anastomotic leak POD6 2 (28.6); fistula 2 (28.6)—one colovesical one RVF; misfired stapler with failed handsewn CAA 1 (14.3) 11.3 (4.1) Maggiori 2015 [ 30 ] 24 58 (25–77) 13 (54) 24 (14–32) 2007 to 2013 Retrospective cohort Rectal cancer 20(83); pelvic endometriosis 2 (8); Crohn's disease 1 (4); trauma 1 (4) NR Proctectomy with stapled CRA 13 (54); proctectomy with manual CAA 11 (46) Chronic pelvic sepsis 15 (62.5); RVF 9 (37.5) 29 (19) Barugola 2018 [ 27 ] 9 41.6 (26–63) 1 (11.1) 24.7 (17–26) 2011 to 2016 Retrospective cohort Pelvic endometriosis 4 (44.4), distal rectal cancer 5 (55.6) NR AR 8 (88.9), Hartmann's procedure 1 (11.1) RVF 7 (77.8), anastomotic leak ( n  = 2) Anastomotic dehiscence ( n  = 1), hostile pelvis ( n  = 1) 32.3 (7.7) Boullenois 2019 [ 31 ] 29 55.9 (13.8–73.3) 14 (48.3) 23.7 (16.2–36.2) 2014 to 2017 Retrospective cohort Rectal cancer 21 (72.4); prostatectomy for cancer 3 (10.3); Hirschsprung disease 2 (6.8); pelvic endometriosis 1 (3.4); vascular malformation 1 (3.4); rectal ischaemic stenosis 1 (3.4) NR Proctectomy 21 (72.4) [CRA 6 (20.7), side-to-end anastomosis 6 (20.7), colonic J pouch 9 (31.0)]; prostatectomy 3 (10.3); Duhamel 1 (3.4); Soave 1 (3.4); CRA 2 (6.8); dilatation for rectal ischaemic stenosis 1 (3.4) Chronic pelvic sepsis 13 (44.8); colovaginal fistula 11 (37.9); RVF 5 (17.2) 22 (IQR 13–30) Blondeau 2022 [ 28 ] 28 55 (26–71) 0 24 (18–33) 2010 to 2020 Retrospective cohort Rectal cancer 21 (75), pelvic endometriosis 7 (25) Ovesco clip 1 (3.6); fibrin glue 2 (7.2); vaginal advancement flap 5 (18); rectal advancement flap 1 (3.6); Martius labial flap 1 (3.6); gracilis muscle transposition 2 (7); porcine dermal collagen mesh interposition 2 (7); previous DCAA 1 (3.6) Proctectomy with CRA 14 (50); proctectomy with CAA 10(36); Hartmann's procedure 1 (3); transanal local excision 1 (3), segmental resection for endometriosis 2 (7) Postoperative rectovaginal fistula 23 (23) CAA coloanal anastomosis, CRA    colorectal anastomosis, DCAA delayed coloanal anastomosis, NR not reported, POD postoperative day, RVF    rectovaginal fistula, SD standard deviation, IQR interquartile range Baseline characteristics among studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery CAA coloanal anastomosis, CRA    colorectal anastomosis, DCAA delayed coloanal anastomosis, NR not reported, POD postoperative day, RVF    rectovaginal fistula, SD standard deviation, IQR interquartile range All studies described a similar two-stage technique detailed below. No study reported using preoperative bowel preparation. This stage incorporated a combined abdominal and perineal approach. The abdominal phase was mostly performed open, although two studies selectively adopted a laparoscopic approach [ 27 ]. All studies reported challenges mobilising sufficient bowel length for abdominoperineal pull-through, attributable to intraperitoneal adhesions, disrupted tissue planes, and ongoing inflammatory processes. Two studies [ 28 , 30 ] mandated splenic flexure mobilisation if not previously performed, while Barugola et al. [ 27 ] routinely mobilised the proximal colon up to the middle colic pedicle. Three studies [ 28 , 30 , 31 ] described selectively employing the Deloyers procedure to gain sufficient length for pull-through of the colonic conduit. During the perineal phase, a circumferential rectotomy was performed transanally starting at the dentate line or just distal to the previous anastomosis, preserving the anal sphincter. The dissection then progressed cranially to meet the intraabdominal dissection plane. No study reported using transanal access platforms to facilitate this phase. Four studies [ 27 – 30 ] described their pull-through technique. The exteriorised colonic conduit was secured at different levels across the studies. In three studies [ 28 – 30 ], the stump was anchored at the dentate line as originally reported by Turnbull and Cutait, while in one study [ 27 ], the conduit was sutured to the upper internal anal sphincter according to the “high coloanal anastomosis” technique described by Bianco et al. [ 32 ]. To anchor the stump, Barugola et al. [ 27 ] placed three absorbable sutures at the 4, 8 and 12 o’clock positions of the conduit, Blondeau et al. [ 28 ] applied five to six anteriorly based sutures, Hallet et al. [ 29 ] used two sutures at the 9 o’clock position, and Maggiori et al. [ 30 ] placed four sutures without specifying their positions. Two studies [ 27 , 29 ] described routinely performing a venting colotomy at one edge of the staple line on the exteriorised conduit to allow bowel decompression. While length of the exteriorised segment was not explicitly mentioned across the studies, leaving a short stump approximately 3–5 cm from the anocutaneous junction can facilitate nursing care, reduce the incidence of stump ischaemia, and improve patient comfort [ 32 ]. All five studies had patients who underwent stoma creation during salvage surgery. In four studies [ 27 – 30 ], a diverting stoma was justified as an added measure to mitigate the consequences of potential anastomotic leak given the high-risk nature of redo anastomoses. Two studies reported a lower rate of end stoma formation from anastomotic failure following DCAA in bowel-diverted patients compared to those without diversion: 9.1 vs. 33.3% in Blondeau et al. [ 28 ] and 12.5% vs. 37.5% in Maggiori et al. [ 30 ]. However, these differences did not achieve statistical significance in either study. In one instance [ 28 ], bowel diversion allowed second-stage surgery to be deferred for 2 months in a patient with postoperative pelvic sepsis. One study [ 31 ] did not report details on stoma management during salvage surgery, although 23 (79.3%) patients had a pre-existing stoma, while 26 (89.7%) had a stoma following DCAA, implying new stoma creation for at least three patients in this study during salvage surgery. All authors performed daily inpatient inspections of the colonic stump. All wrapped the stump with wet gauze, with Barugola et al. [ 27 ] specifying the use of  hyaluronic acid soaked gauze. The frequency of gauze change was not reported in any study. The dietary and ambulatory regime with the pull-through stump in situ was only described by Hallet et al., where patients were permitted full ambulation and escalated to a low-residue diet per orally when deemed clinically appropriate [ 29 ]. The interval between abdominoperineal pull-through and subsequent DCAA varied between 7 [ 27 , 29 ] and 8–10 days [ 28 , 30 ]. In two studies [ 28 , 30 ], the second stage was delayed until complete resolution of any ongoing recurrent pelvic sepsis after antibiotics or percutaneous drainage. In one study, the mean interval from pull-through to DCAA was 14 days [ 31 ], although no specific rationale was provided for the longer interval. The colonic stump was amputated with the patient in lithotomy position, and a handsewn coloanal anastomosis was performed with interrupted absorbable sutures. The level of transection of the exteriorised stump was described in four studies: at the dentate line in two studies [ 28 , 30 ], anal verge in one study [ 29 ], and distal to the previously placed stay sutures in one study [ 27 ]. Following amputation of the stump, a handsewn coloanal anastomosis was fashioned, most often using Vicryl 4–0 [ 27 , 28 , 30 ]. Overall, 80 (82.5%) patients had stomas after salvage DCAA. Time to stoma closure was documented in three studies [ 27 , 29 , 31 ], ranging from 2.2 to 19.9 months following DCAA. Two studies described their criteria for stoma closure [ 27 , 31 ]. Barugola et al. assessed for clinical or radiological features of anastomotic failure, although the postoperative interval at which radiological assessment was performed and the imaging modality used were not reported [ 27 ]. Boullenois et al. routinely performed abdominal computed tomography with antegrade administration of water-soluble contrast to confirm anastomotic integrity, after which stoma closure was undertaken 3 months post-DCAA [ 31 ]. Study-specific procedural details are further described in Table  3 . Table 3 Description of surgical procedures performed among studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery Author N MIS approach n (%) Mean operative time for coloanal pull-through/min (SD) Mean delay to perineal time/days (SD) Additional procedures at time of DCAA Intraoperative blood loss Stoma at time of DCAA, n (%) Stoma closed at end of DCAA, n (%) Stoma created during DCAA, n (%) Stoma at end of DCAA, n (%) Interval between index surgery and DCAA/months (SD) Mean time to stoma reversal/months (range) Hallet 2014 [ 29 ] 7 0 145 (IQR 120–280) 10 None Median 685 ml (IQR 563-2400 ml) 6 (85.7) 0^ 1 (14.3) 7 (100) NR 9.7 (5.1–19.9) Maggiori 2015 [ 30 ] 24 0 239 (48) Range 8–10 in 21 (88%) patients; delayed in 3 patients to POD37, 46, 96 due to pelvic sepsis recurrence 3 Deloyers Volume not reported; 2 (8) had severe bleeding requiring transfusion 11 (45.8) 0 5 (20.8) 16 (66.7) NR NR Barugola 2018 [ 27 ] 9 9 (100) 233.7 (49) Range 7–10 (mean not specified) None  < 150 ml for all cases 8 (88.9) 0 1 (11.1) 9 (100) 10.3 (5.2) 3.5 (2.2–5.2) Boullenois 2019 [ 31 ] 29 NR 226 (66) 14 (3) 3 Deloyers; 8 Trans-mesenteric pull-through Volume not reported; 6 (20.7) required blood transfusion 23 (79.3) NR NR 26 (89.7) 18.4 (IQR 9.1–71.3) Median 2.6 (IQR 2.0–3.3) Blondeau 2022 [ 28 ] 28 5 (18) 243 (78) 12 (14) 1 Deloyers NR 24 (85.7) 6 (21.4) 4 (14.3) 22 (78.6) 37 (75) NR ^One patient had stoma closure reported during DCAA but likely resited—all had stoma at end of DCAA APR abdominoperineal resection, DCAA delayed coloanal anastomosis, MIS minimally invasive surgery, NR not reported, POD postoperative day, SD standard deviation, IQR interquartile range Description of surgical procedures performed among studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery ^One patient had stoma closure reported during DCAA but likely resited—all had stoma at end of DCAA APR abdominoperineal resection, DCAA delayed coloanal anastomosis, MIS minimally invasive surgery, NR not reported, POD postoperative day, SD standard deviation, IQR interquartile range Postoperative outcomes are summarised in Table  4 . Table 4 Outcomes of studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery Author N Stoma free survival, n (%) Overall high-grade postoperative complications, n (%) Length of stay in days, mean (SD) 30-day postoperative mortality Repeat surgery, n (%) Details of repeat surgery Mean LARS score at 12 months [ n (%)] Hallet 2014 [ 29 ] 7 4 (57.1) 3 (42.9) 13.9 (2.3) 0 0 Nil NR Maggiori 2015 [ 30 ] 24 19 (79.2) 10 (41.7) NR 0 6 (25.0) 3 new stoma formed for bad function, anastomotic stricture, recurrent sepsis) 1 redo DCAA for recurrent pelvic sepsis 1 definitive stoma after closure due to poor functional results 1 incarcerated parastomal hernia, underwent laparotomy 22 [7 (41.2) no LARS, 7 (41.2) minor LARS, 3 (17.6) major LARS] Barugola 2018 [ 27 ] 9 8 (88.9) 8 (88.9) 16.1 (4.1) 0 2 (22.2) 2 anastomotic retraction requiring revision 30.1 [1 (12.5) no LARS. 2 (25) minor LARS. 5 (62.5) major LARS] Boullenois 2019 [ 31 ] 29 23 (79.3) 7 (24.1) 18 (3) 0 0 Nil 28.8 [5 (27.8) no LARS, 2 (11.1) minor LARS, 11 (61.1) major LARS] Blondeau 2022 [ 28 ] 28 25 (89.3) 9 (32.1) NR 0 NR NR—3 definitive stoma at end of follow-up for poor functional results, anastomotic leak, did not specify whether these were newly created or preexisting NR DCAA delayed coloanal anastomosis, LARS low anterior resection syndrome, NR not reported Outcomes of studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery 3 new stoma formed for bad function, anastomotic stricture, recurrent sepsis) 1 redo DCAA for recurrent pelvic sepsis 1 definitive stoma after closure due to poor functional results 1 incarcerated parastomal hernia, underwent laparotomy DCAA delayed coloanal anastomosis, LARS low anterior resection syndrome, NR not reported Overall stoma-free survival rate was 81.4% over a mean 24-month postoperative follow-up duration. Stoma-free survival rates ranged from 57.1% (over 11.3 months) [ 29 ] to 89.2% (over 23 months) [ 28 ]. Eighteen patients (18.6%) had a stoma at end of follow-up. Of these, at least three were created after failed DCAA [ 30 ]. Hallet et al. [ 29 ] reported one patient who developed colonic ischaemia after the pull-through procedure, necessitating abdominoperineal resection with end colostomy while precluding DCAA. This complication was attributed to vascular injury during exteriorisation of the colonic conduit, technical challenges associated with obesity (body mass index 37 kg/m 2 ) and a narrow pelvis. Details of high-grade postoperative complications are provided in Table  5 . Table 5 Details of high-grade postoperative complications among studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery Author N Total events recorded Early postoperative complications (Clavien-Dindo score ≥ 3) Late postoperative complications (Clavien-Dindo score ≥ 3) Hallet 2014 [ 29 ] 7 3 1 Colonic stump necrosis with proximal extension, had APR and end colostomy 1 paralytic ileus 1 pelvic abscess NR Maggiori 2015 [ 30 ] 24 10 3 pelvic abscess requiring drainage 1 parastomal hernia with bowel ischaemia 1 recurrent pelvic sepsis resulting in redo DCAA 2 recurrent pelvic sepsis resulting in end stoma 2 bad function resulting in end stoma 1 anastomotic stricture then end stoma Barugola 2018 [ 27 ] 9 8 2 postoperative pelvic abscesses drained at second stage surgery 2 rectal prolapse requiring laparoscopic colopexy 2 recurrence fistulas from anastomotic retraction requiring coloanal anastomosis revision 2 anastomotic strictures underwent dilatation Boullenois 2019 [ 31 ] 29 7 2 early recurrences of RVF with no stoma reversal 2 necrosis of colonic stump 1 anastomotic leak 1 pelvic abscess 1 Late recurrence of RVF after stoma reversal and no stoma required Blondeau 2022 [ 28 ] 28 9 3 pelvic abscess requiring drainage 3 ischemia of colonic conduit 1 RVF recurrence 1 anastomotic leak with pelvic sepsis 1 poor functional results APR abdominoperineal resection, DCAA delayed coloanal anastomosis, NR not reported, RVF rectovaginal fistula Details of high-grade postoperative complications among studies evaluating the use of delayed coloanal anastomosis for salvage pelvic surgery 1 Colonic stump necrosis with proximal extension, had APR and end colostomy 1 paralytic ileus 1 pelvic abscess 3 pelvic abscess requiring drainage 1 parastomal hernia with bowel ischaemia 1 recurrent pelvic sepsis resulting in redo DCAA 2 recurrent pelvic sepsis resulting in end stoma 2 bad function resulting in end stoma 1 anastomotic stricture then end stoma 2 rectal prolapse requiring laparoscopic colopexy 2 recurrence fistulas from anastomotic retraction requiring coloanal anastomosis revision 2 anastomotic strictures underwent dilatation 2 early recurrences of RVF with no stoma reversal 2 necrosis of colonic stump 1 anastomotic leak 1 pelvic abscess 3 pelvic abscess requiring drainage 3 ischemia of colonic conduit 1 RVF recurrence 1 anastomotic leak with pelvic sepsis 1 poor functional results APR abdominoperineal resection, DCAA delayed coloanal anastomosis, NR not reported, RVF rectovaginal fistula All five studies reported postoperative morbidity, with an overall incidence of 37 (38.1%) high-grade (Clavien-Dindo grade ≥ 3) complications. Of these, 21 (21.6%) occurred within 30 postoperative days, with recurrent pelvic sepsis being most common ( n  = 11). Treatment details for these complications were often not specified. Maggiori et al. reported recurrent or persistent pelvic sepsis after abdominoperineal pull-through in three patients, which further delayed fashioning of the coloanal anastomosis to postoperative day 37, 46, and 96 [ 30 ]. Colonic conduit ischaemia was reported in six (6.2%) patients across three studies [ 28 , 29 , 31 ]. In three of these patients, ischaemia affected only the exteriorised stump, which was partially excised in two cases [ 28 ], with undocumented impact on subsequent outcomes. Boullenois et al. [ 31 ] reported two patients with stump necrosis: one who underwent revision colonic pull-through and the other who underwent a total colectomy with ileal pouch anal anastomosis. Possible contributory factors, preceding events and postoperative course were not discussed. As previously stated, Hallet et al. reported one case of long-segment colonic necrosis occurring one week after abdominoperineal pull-through. The ischaemia extended proximally, resulting in insufficient remnant viable colon length to allow a more proximal colonic pull-through, necessitating end colostomy creation [ 29 ]. Late morbidity beyond 30 days was reported by 4 studies [ 27 , 28 , 30 , 31 ], with 16 (16.5%) patients experiencing complications, most frequently pelvic fistula recurrence ( n  = 4) and delayed pelvic sepsis ( n  = 3). The remaining study [ 29 ] did not report any long-term complications among seven patients with a median follow-up duration of 79.1 months. Hospital length of stay was reported in three studies [ 27 , 29 , 31 ], with a pooled mean length of stay of 17 days among 45 patients. No cases of early postoperative death were documented. Four studies [ 27 , 29 – 31 ] reported rates of repeat surgery after salvage DCAA. Pooled incidence was 11.6% ( n  = 8) across 69 patients, ranging from 0 [ 29 , 31 ] to 25% [ 30 ]. The remaining study [ 28 ] did not explicitly document any repeat surgery following DCAA. While the authors described three patients who required definitive stoma for poor functional results and anastomotic leak, whether these stomas were pre-existing or newly created as a consequence of morbidity following DCAA was not specified. Maggiori et al. [ 30 ] reported three instances of bowel diversion for poor function, anastomotic stricture and recurrent sepsis, one redo DCAA for recurrent sepsis, one repeat stoma creation post-stoma closure for poor function and one laparotomy for incarcerated parastomal herniation. Barugola et al. [ 27 ] documented coloanal anastomotic revision in two patients who suffered anastomotic retraction causing recurrent fistulation. Two studies [ 28 , 29 ] did not report functional outcomes. Three studies [ 27 , 30 , 31 ] reported functional outcomes using the low anterior resection syndrome (LARS) score [ 33 ] for 43 patients over a mean follow-up duration of 26.2 months: 19 (44.2%) had major LARS, 11 (25.6%) minor LARS and 13 (30.2%) no LARS. Pooled mean LARS score was 26.4, indicative of minor LARS. Breaking down score components, Boullenois et al. [ 31 ] reported 16 (89%) patients with accidental leakage of liquid stool, 17 (94%) with stool fragmentation and 12 (66.7%) with urgency. Boullenois et al. [ 31 ] also documented the Gastrointestinal Quality of Life Index (GIQLI) score, incorporating 36 patient-reported outcomes across five domains [ 34 ]. Total GIQLI score ranges from 0–144 and higher scores reflect better gastrointestinal health-related quality of life. The mean (SD) score obtained from 16 out of 23 stoma-free patients by end of follow-up was 79.2 (14.3). Barugola et al. [ 27 ] also reported Wexner scores [ 35 ] at postoperative 6, 12 and 24 months. At 12 months, the mean (SD) Wexner score was 12.8 (30.1), indicating severe incontinence. However, at 24 months mean score improved to 7 (16.6), indicating moderate incontinence. No patients had persistent major incontinence by 24 months.

Our study design adhered to recommendations of the Cochrane Effective Practice and Organization of Care Review Group (EPOC) [ 9 ]. Search strategy was developed for MEDLINE in consultation with a medical librarian and adapted for each database. A systematic analysis of existing literature was conducted in August 2024 using MEDLINE (1951 to August 2024) and Embase (1974 to August 2024). No restriction was applied regarding language and type of publication. A search of grey literature was conducted via Google Scholar and relevant studies in the first 10 pages of results were considered for inclusion (Appendix 1 ). This review protocol was registered with the International Prospective Register of Systematic Reviews (PROSPERO) under ID CRD42024566274. All meta-analyses, randomised controlled trials, systematic reviews and observational studies describing DCAA for salvage or redo anastomosis to treat complications from previous pelvic surgery were considered for inclusion. Letters to the editor, case reports, conference abstracts and studies on non-human subjects were excluded. Studies describing other techniques besides DCAA for anastomotic salvage, or those evaluating DCAA for indications other than salvage surgery, were also included if the study reported DCAA-specific outcomes after redo surgery. Bibliographies of articles included into qualitative synthesis were appraised for further relevant studies for inclusion. For duplicate publications, the most relevant study as determined by independent assessment of the authors was included. Primary outcome was overall stoma-free survival rate. Secondary outcomes included hospital length of stay, rates of high-grade postoperative complications (Clavien-Dindo grade III and above), 30-day postoperative mortality rates, incidence of redo surgical intervention after DCAA and postoperative anorectal function. In accordance with the Cochrane Group checklist [ 9 ], the following parameters were collected using a standardised extraction form: age, gender, sample size and type of intervention. Data on surgical technique, intraoperative complications, perioperative care, postoperative morbidity and functional outcomes were also analysed. Articles included for systematic review were independently assessed for risk of bias using the Newcastle-Ottawa Scale (NOS), including key elements of methodological assessment as described by the Cochrane group [ 9 ]. Assessment was independently performed by two authors (TJK, NSM). Disagreements were resolved by consensus or by a third author (ISE). Inter-rater agreement on study selection was calculated using a weighted kappa statistic and reported with 95% confidence intervals. Measures of effect were presented as mean with standard deviation for continuous variables.

Abdominoperineal pull-through with delayed coloanal anastomosis is a viable option for salvage surgery following pelvic anastomotic failure, with low rates of permanent stoma and acceptable long-term anorectal function. Further prospective trials are warranted to draw definitive conclusions.

The Turnbull-Cutait abdominoperineal pull-through with DCAA has experienced a resurgence of interest in recent years. A 2022 review by Lin et al. showed similar complication rates and functional outcomes between delayed and immediate coloanal anastomoses following rectal resection but with a lower rate of bowel diversion using DCAA [ 36 ]. Another 2022 review by La Raja et al. demonstrated a significantly lower risk of pelvic sepsis with DCAA compared with an upfront coloanal anastomosis with a diverting stoma [ 37 ]. DCAA was similarly found to have a lower anastomotic leak rate compared to standard coloanal anastomosis in a 2024 meta-analysis by Pompeu et al. [ 38 ]. DCAA may also be the more cost-effective option compared with immediate anastomosis [ 39 , 40 ]. While these reviews demonstrate the advantages of DCAA in the elective setting, its application for salvage surgery has been less thoroughly evaluated. To our knowledge, this is the first systematic review specifically assessing outcomes of DCAA for salvage surgery. Redo anastomosis in a scarred postoperative pelvis renders patients at increased risk of further complications including redo anastomotic leak, fistulation, or persistent pelvic sepsis [ 14 ], with surgeons often electing to perform an end stoma instead of a high risk re-anastomosis. DCAA provides the means to overcome these challenges by allowing sepsis to resolve or ischaemia to demarcate prior to creation of the anastomosis. Our findings of a 81.4% stoma-free survival at 2 years, with acceptable postoperative morbidity, mortality, and reoperation rates, affirm the utility of DCAA following pelvic anastomotic failure. Few reported complications after DCAA were directly attributable to the technique itself. Moreover, two studies reported no instances of patients requiring repeat surgery after DCAA [ 29 , 31 ]. There were also no cases of early postoperative mortality across any of the reviewed studies. These results may be viewed even more favourably considering that many of the patients in the included studies were assessed by the authors to be unsuitable for upfront re-anastomosis. Despite the high 24-month stoma-free rate, a considerable proportion of patients had bowel diversion immediately following DCAA. If not already present, several authors justified bowel diversion at the time of abdominoperineal pull-through given the high-risk nature of salvage surgery. The benefit of concurrent stoma formation with abdominoperineal pull-through may be contentious as the DCAA procedure has been well recognised to reduce the risk of anastomotic complications to the extent that ostomy creation is deemed unnecessary [ 36 – 38 ]. For higher risk anastomoses, it may be that prolonging the interval between pull-through and DCAA may be sufficient for avoidance of stoma, at the expense of an increased length of hospital stay. Nonetheless, initial faecal diversion may be a contributory factor to the good outcomes after DCAA observed in this review and warrants further evaluation. This review has several limitations, including the relatively small sample size and clinical heterogeneity of the study population precluding meta-analysis of data and specific subgroup analyses. Furthermore, all included studies were noncomparative observational studies with a relatively high risk of bias on the Newcastle-Ottawa Scale. Several potentially relevant clinical factors, including the prior use of radiotherapy and initial anastomotic height from anal verge, were also not consistently reported. Nonetheless, the results of this review may form the basis for prospective trials on the use of DCAA for salvage surgery. While abdominoperineal pull-through with delayed anastomosis may have advantages, it is important for operators to be conscious of the inherent difficulties of redo surgery for pelvic morbidity. Moreover, all authors emphasised the challenges of adequate bowel mobilisation to allow sufficient length for transanal exteriorisation, with three studies [ 28 , 30 , 31 ] describing the use of the Deloyers procedure when necessary. Despite these concerns, the safety and feasibility of a minimally invasive laparoscopic approach to salvage surgery and abdominoperineal pull-through were demonstrated among 14 selected patients across two studies [ 27 , 28 ]. No intraoperative complications or operative conversions were reported among these 14 patients.

Colorectal cancer is the third most common cancer globally, with the second highest cancer-related mortality [ 1 ]. While improved operator experience, surgical technology, and perioperative therapies have enhanced patient outcomes, low rectal cancer surgery deep within the bony pelvis remains technically difficult. Moreover, pelvic anastomotic complications following restorative rectal surgery represent one of the most challenging conditions faced by colorectal surgeons. A 2022 nationwide Italian study including 5398 rectal cancer patients showed a 10.2% rate of anastomotic leak after anterior resection [ 2 ]. Bowel diversion did not affect the risk of leak but significantly reduced symptom severity [ 2 ]. A cross-sectional Dutch study of 2095 patients demonstrated a 20% anastomotic leak rate after low anterior resection, with an almost 50% nonhealing rate at 12 months and a 9.5% overall rate of chronic presacral sinus formation [ 3 ]. While nonoperative management including percutaneous or endoscopic therapies may be instituted in selected patients, anastomotic complications often require takedown of the anastomosis with end colostomy creation or redo anastomosis with faecal diversion [ 4 , 5 ]. Difficulties involved in redo pelvic surgery include adhesions, inflammation or abscess, obliterated anatomical planes, and reduced bowel length rendering tension-free redo anastomosis challenging [ 5 ]. The Turnbull-Cutait abdominoperineal pull-through procedure with delayed coloanal anastomosis (DCAA) was first described in 1961 in separate publications by Turnbull [ 6 ] and Cutait [ 7 ] for the management of benign rectal disease. This technique involves two stages: rectal resection and transanal delivery of the proximal colon, followed by amputation of the exteriorised segment and coloanal handsewn anastomosis after a planned interval, which allows time for adhesions to form between the pull-through segment and upper anal canal. This reduces the risk of clinically significant intraperitoneal leakage, avoiding the need for bowel diversion, thus offering DCAA as an attractive option in redo pelvic surgery. Moreover, despite the theoretical benefits of abdominoperineal pull-through with delayed anastomosis for anastomotic salvage, subgroup analysis of a 2022 meta-analysis of 11 studies reporting outcomes of redo rectal anastomoses demonstrated a 51% postoperative morbidity rate following DCAA compared to only 35% with immediate coloanal anastomosis [ 8 ]. This may imply unexpected complications related to the pull-through procedure or improper application of the technique, which remains infrequently performed in the setting of redo surgery. Given the accumulating evidence, a systematic review synthesising the current evidence on the use of DCAA in redo anastomotic surgery is timely and may help guide optimal practice.

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