Fluorescence angiography during transanal total mesorectal excision: steps to a safer anastomosis

We thank Dr. Baldari and colleagues for having commented upon our article on fluorescence angiography during transanal total mesorectal excision. We agree with their statement that “anastomotic leakage is a multifactorial complication”. Towards that end, one of the senior authors (SD Wexner) routinely mobilizes the splenic flexure and both senior authors (SD Wexner and AM Lacy) routinely perform high ligation of the inferior mesenteric artery and vein. Both senior authors routinely intracorporeally divide the mesentery from the pedicle of the inferior mesenteric vessels to the sigmoid descending colonic junction. In addition, both senior authors routinely air test the anastomosis and, in the case of a hand-sewn anastomosis perform a “reverse” leak test (1). Direct endoscopic visualization of the anastomosis is always a part of every operation. We also agree with the statement of Baldari and coauthors that “adequate blood supply is one of the main factors in anastomotic healing”. For that reason, both senior authors routinely employ indocyanine green fluorescence angiography for all high risk left sided colorectal and coloanal anastomoses (2-5).

Acknowledgments

Funding: None.

Footnote

Provenance and Peer Review: This article was commissioned by the editorial office, Annals of Laparoscopic and Endoscopic Surgery. The article did not undergo external peer review.

Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at http://dx.doi.org/10.21037/ales.2019.05.03). The author has no conflicts of interest to declare.

Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.

Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.

References

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