Anastomotic stricture after ultralow anterior resection or intersphincteric resection for very low-lying rectal cancer

Background Anastomotic stricture following colorectal cancer surgery is not a rare complication, but proper management of anastomotic stricture located close to the anal verge is uncertain. This study aimed to investigate risk factors and management strategies for anastomotic stricture after ultralow anterior resection (ULAR). Methods We retrospectively reviewed a database of patients with rectal cancer who underwent surgery between January 2007 and June 2015, and included patients with an anastomosis within 4 cm from the anal verge. Clinical outcomes and risk factors for anastomotic stricture were investigated. Results Among the 586 patients included, 46 (7.8%) were diagnosed as having anastomotic stricture. Multivariable logistic regression analysis revealed that intersphincteric resection (ISR) with hand-sewn anastomosis (odds ratio [OR] = 3.070; 95% confidence interval [CI] 1.247–7.557) and postoperative radiotherapy (OR 6.237; 95% CI 1.961–19.841) were independent risk factors of anastomotic stricture. Forty-one (89.1%) underwent anastomotic dilatation with a Hegar dilator; while three patients (6.5%) underwent endoscopic balloon dilatation and two (4.3%) underwent surgery initially. Among the patients with initial nonoperative management ( n = 44), 21 (47.7%) were completely cured with nonoperative management alone, 12 (27.3%) experienced complications, such as bowel perforation, anastomotic rupture, and perirectal abscess; and 21 (47.7%) underwent further surgical management. Fifteen patients (32.6%) eventually had permanent stoma. Conclusion ISR with a hand-sewn coloanal anastomosis, compared to ULAR with double-stapling anastomosis, and postoperative radiotherapy were independent risk factors of anastomotic stricture after surgery for very low-lying rectal cancer. Nonoperative anastomotic dilatation showed poor clinical outcome, with high complication rates, and subsequent surgical management. Therefore, nonoperative management of such patients should be carefully selected.