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Proctotomy Leak Following Laparoscopic Total Gastrectomy With Meng et al. BMC Surg (2021) 21:218 https://doi.org/10.1186/s12893-021-01217-z CASE REPORT Open Access Proctotomy leak following laparoscopic total gastrectomy with transrectal specimen extraction for gastric cancer: a case report Haipeng Meng1, Jinchao Liu2†, Hui Xu3, Song Wang2, Yu Rong2, Yanling Xu4† and Gang Yu1,2*† Abstract Background: Despite increasing acceptance in colorectal surgery, natural orifce specimen extraction (NOSE) sur- gery for the treatment of gastric cancer is still in its infancy, especially via the transrectal approach, which was barely reported. So little is known about its complications. Here we report the frst case of proctotomy leak after transrectal NOSE gastrectomy, and our experience in preventive interventions. Case presentation: A 62-year-old male patient complaining of upper abdominal pain who underwent open distal gastrectomy for gastric cancer one year ago was diagnosed with recurrent gastric cancer by gastroscopic biopsy. We performed laparoscopic total gastrectomy with transrectal specimen extraction on the patient. The operation was completed in a total laparoscopic approach and the specimen was extracted through a 3 cm longitudinal incision in the anterior wall of the upper rectum, then interrupted sutures were used for full-thickness closure of the rectal incision. The operative time was 470 min and intra-operative blood loss was 100 mL. The postoperative pathologi- cal examination showed pT1bN0M0 gastric adenocarcinoma. The patient developed proctotomy leak on the 10th postoperative day. We analyzed the causes of this rare complication and put forward a series of technical improve- ments. After failure of conservative treatment, a diverting ileostomy was created and the patient eventually recovered. We successfully prevented proctotomy leak in the subsequent 20 transrectal NOSE gastrectomies using improved techniques. Conclusions: Proctotomy leak after transrectal specimen extraction should be considered among the complications of NOSE surgery and can be prevented by technical precautions. Keywords: Gastric cancer, Laparoscopic gastrectomy, Natural orifce specimen extraction, Proctotomy leak, Case report Background postoperative pain, fast recovery, avoidance of wound- Natural orifce specimen extraction (NOSE) surgery related complications and cosmetic efect [1]. While has attracted world-wide attention because of its great the use of transvaginal NOSE gastrectomy has been advantages including minimal abdominal trauma and frequently reported [2], transrectal cases are rare. Like- wise, complications exclusive to use of transvaginal route *Correspondence: [email protected] including rectovaginal fstula, dyspareunia and vaginal †Jinchao Liu, Yanling Xu and Gang Yu contributed equally to this paper cancer recurrence have been reported [3], but no litera- assenior co-authors ture exists regarding the exclusive complication of tran- 1 Department of General Surgery, Cheeloo College of Medicine, Qilu Hospital (Qingdao), Shandong University, 758 Hefei Road, srectal specimen extraction, e.g. proctotomy leak. Tis 266035 Qingdao, Shandong, China study reports a rare and challenging case of proctotomy Full list of author information is available at the end of the article © The Author(s) 2021. This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article’s Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article’s Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://crea- tivecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdo- main/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data. Meng et al. BMC Surg (2021) 21:218 Page 2 of 4 leak after transrectal NOSE gastrectomy, and discusses Ten days after the operation, the patient presented the etiology and precautions. with sudden onset of abdominal pain, accompanied by fever, chills and sweating. Physical examination revealed tenderness in the lower abdomen with rebound pain. Case presentation Meanwhile, 200 ml turbid fuid drained from the pelvic A 62-year-old male patient received open radical gastrec- drainage tube. We injected ioversol into the pelvic drain- tomy with a Billroth I reconstruction for distal gastric age tube under X-ray and found it leaking into the rectal cancer in another hospital. One year after the primary lumen (Fig. 1), thus confrmed the diagnosis of proc- operation, he underwent gastroscopic examination due totomy leak. After nine days of conservative treatment to complaint of upper abdominal pain lasting for one including adequate pelvic irrigation and drainage, par- month. A 1.5 cm × 1.5 cm mass was discovered at the enteral nutrition and antibiotics administration, the leak gastroduodenal anastomosis, which was confrmed by persisted and the intra-abdominal infection deteriorated, pathological biopsy as a gastric adenocarcinoma. Tere so a diverting ileostomy was performed. Ten the patient was no metastasis on radiological screening (clinical gradually recovered and was discharged from hospital. stage: cT1bN0M0). Ten the patient was referred to our Colonoscopy was performed 6 months later, revealing hospital for treatment of recurrent gastric caner. He has healed proctotomy leak with only a streak of mucosal no comorbidities and his body mass index (BMI) was hyperplasia and edema (Fig. 2); no stenosis or scar con- 31.0 kg/m2. He had a history of smoking and drinking tracture was present in the rectal lumen. So the ileostomy for more than 30 years. Tere was no signifcant family was closed. After 3 years of follow up, no tumor recur- history. rence or anal dysfunction was detected. Te patient was operated under general anesthesia as American Society of Anesthesiologists Grade 1. He was Discussion and conclusions placed in the functional lithotomy position and the con- We analyzed the etiology of proctotomy leak and thought ventional V glyph 5-port method was used to set the the following reasons were of utmost importance. First, trocars [4]. Radical total gastrectomy was performed in the incision in the anterior wall of the rectum was too a complete laparoscopic approach. Upon resection, the short (3 cm) to remove the specimen (the maximum specimen was transferred to the pelvic cavity for extrac- diameter was 5 cm) smoothly despite the malleability of tion later. Ten an intracorporeal Roux-en-Y diges- the rectal wall. Te patient was obese and the omentum tive tract reconstruction was completed, in which the was thick, leading to a relatively large specimen for tran- esophagojejunostomy was handsewn. srectal extraction. Violent withdrawal led to rupture of Te specimen extraction procedure was as follows. Te the rectal wall. Second, the rectal incision was too low, anus was sufciently dilated and the rectum was exten- just above the peritoneal refection, so the rupture of the sively rinsed with iodine water. Electrocautery was used rectal wall went below the peritoneal refection, making it to cut the anterior wall of the upper rectum just above difcult to be repaired. Tird, we failed to make a straight the peritoneal refection longitudinally by 3 cm in length. rectal incision because of the fexure of rectum, making it A sterile plastic sleeve was introduced into the peritoneal cavity through the anus. Te specimen was grasped with an ovary clamp through the anus-rectum and pulled out of the body. After removal of the plastic sleeve, the rectal incision was repeatedly disinfected with iodophor gauze, and then interrupted sutures were used for full-thickness closure of the incision. Te operation was completed after irrigation of the pelvic cavity and rectal lumen with iodine water. Te operative time was 470 min and intra-operative blood loss was 100 mL. Te postoperative pathological examination showed T1bN0M0 gastric adenocarcinoma. Postoperatively, the patient followed the same protocol of nutritional support with the standard total gastrectomy patients. He was allowed to take sips of water on the frst postoperative day. A fuid diet was introduced on postop- erative day 3, and he was allowed to eat soft bread 5 days postoperatively. Fig. 1 Ioversol leaks from the pelvic drainage tube to the rectal cavity Meng et al. BMC Surg (2021) 21:218 Page 3 of 4 Fig. 2 Colonoscopy shows healed proctotomy leak (arrow) with no Fig. 4 The rectal incision is closed with a continuous full-thickness stenosis in the rectal cavity suture Fig. 3 An incision is made in the anterior wall of the upper rectum Fig. 5 An air infation test is used to check the completeness of the sutured incision difcult to be closed. Fourth, interrupted sutures might be insufcient to close the rectal incision, as under lap- large enough for smooth specimen extraction [5]. Fourth, aroscopic vision it was difcult to perceive the distance for closing the rectum longitudinally, a barbed wire between stitches precisely, sometimes it maybe too large. suture should be made from the distal end to the proxi- Fifth, the water injection and air infation methods were mal end with a continuous full-thickness suture, followed not used to check if the rectal incision was completely by inversion of the suture line with another round of closed. full-thickness stitches which locate between the former Based on the aforementioned analysis, we improved round of stitches to guarantee a complete closure (Fig. 4) the procedure in fve aspects. First, strict indications are [6]. Fifth, after stitching, an air test is required to detect implemented for transrectal specimen extraction. Te whether the sutured incision is intact (Fig.
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