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

Aim: Despite the potential benefits of abdominoperineal pull-through with delayed coloanal anastomosis (DCAA), it is still infrequently performed as a salvage procedure for pelvic anastomotic failure. We aimed to perform a systematic review on the subject to guide practice.

Method: PubMed, Embase and Cochrane were used to identify studies evaluating DCAA for salvage after pelvic surgery from inception to August 2024. Risk of bias assessment was performed using the Newcastle-Ottawa scale. The primary outcome was overall stoma-free survival. Secondary outcomes included hospital length of stay, high-grade postoperative complication rates, 30-day postoperative mortality rates, incidence of redo surgical intervention after DCAA, and postoperative anorectal function.

Results: Five retrospective cohort studies evaluating a total of 97 patients who underwent salvage abdominoperineal pull-through and DCAA were included in this review. All patients had previous pelvic surgery, predominantly proctectomy (n = 84, 86.6%). The most common indication for redo surgery was chronic fistula (n = 62, 63.9%) followed by anastomotic leak or chronic pelvic sepsis (n = 34, 35.1%). The pooled overall stoma-free survival rate across all five studies was 81.4% over a mean 24-month postoperative follow-up duration. The overall incidence of high-grade complications after DCAA was 39.1% (n = 38). Pooled mean length of stay was 17 days. There were no cases of early postoperative death. Pooled rate of repeat surgery across four studies was 11.6% (n = 8). Pooled mean functional scores across three studies indicated minor low anterior resection syndrome at 26 months.

Conclusion: Abdominoperineal pull-through with delayed coloanal anastomosis is a viable option for salvage surgery following pelvic anastomotic complications, with low rates of permanent stoma and acceptable long-term anorectal function.