Delayed vs Immediate Coloanal Anastomosis after Total Mesorectal Excision for Low Rectal Cancer: An International Multicenter Retrospective Cohort Study

Daichi Kitaguchi; Isaac Seow-En; Ming-Yin Shen; Tao-Wei Ke; Ji-Seon Kim; Jin Kim; Masaaki Ito; William Tzu-Liang Chen; Asian Colorectal Cancer Collaborative

doi:10.1097/XCS.0000000000001410

Delayed vs Immediate Coloanal Anastomosis after Total Mesorectal Excision for Low Rectal Cancer: An International Multicenter Retrospective Cohort Study

J Am Coll Surg. 2025 Apr 14. doi: 10.1097/XCS.0000000000001410. Online ahead of print.

Authors

Daichi Kitaguchi¹, Isaac Seow-En², Ming-Yin Shen³, Tao-Wei Ke⁴, Ji-Seon Kim⁵, Jin Kim⁵, Masaaki Ito¹, William Tzu-Liang Chen^{3

6}; Asian Colorectal Cancer Collaborative

Affiliations

¹ Department of Colorectal Surgery, National Cancer Center Hospital East, Chiba, Japan.
² Department of Colorectal Surgery, Singapore General Hospital, Singapore.
³ Department of Colorectal Surgery, China Medical University Hsinchu Hospital, Hsinchu, Taiwan.
⁴ Department of Colorectal Surgery, China Medical University Hospital, Taichung, Taiwan.
⁵ Division of Colon and Rectal Surgery, Korea University Anam Hospital, Seoul, South Korea.
⁶ School of Medicine, China Medical University, Taichung City, Taiwan.

PMID: 40226931
DOI: 10.1097/XCS.0000000000001410

Abstract

Background: Despite increasing interest in Turnbull-Cutait pull-through delayed coloanal anastomosis (DCAA) for low rectal cancer, its advantages over conventional immediate coloanal anastomosis (ICAA) with a diverting stoma remain unclear. This study aimed to compare postoperative outcomes between DCAA and ICAA following elective total mesorectal excision (TME) for low rectal cancer.

Study design: This international, multicenter, retrospective cohort study included patients who underwent elective minimally invasive TME with hand-sewn coloanal anastomosis (ICAA or DCAA) for primary low rectal adenocarcinoma. The primary outcome was the overall 30-day postoperative complication rate. Postoperative anorectal function was assessed using the Low Anterior Resection Syndrome and Wexner scores one and two years postoperatively.

Results: A total of 305 consecutive patients (109 delayed, 196 immediate) were assessed. The overall 30-day postoperative complication rate was 25%, with a significantly lower incidence in the DCAA group compared to the ICAA group (15% vs. 31%, p=0.002). Both early (≤30 days) and late (>30 days) anastomosis-related complications were significantly lower in the DCAA group than the ICAA group, at 7% vs. 15%, p=0.047, and 2% vs. 11%, p=0.005, respectively. Two years postoperatively, the DCAA cohort had a significantly lower proportion of patients with major Low Anterior Resection Syndrome (38% vs. 60%, p=0.018) and severe incontinence (0% vs. 8%, p=0.029).

Conclusion: DCAA without a diverting stoma for low rectal cancer removes the risks associated with stoma creation and closure-related morbidity. DCAA is also linked to significantly lower postoperative morbidity and improved anorectal function at two years compared to ICAA with a diverting stoma. DCAA may therefore be the optimal anastomotic method for patients with low rectal cancer.

Keywords: Anastomotic Leak; Fecal Incontinence; Rectal Neoplasm; Restorative Proctocolectomy; Surgical Anastomosis.