EP206 - Functional Outcomes of Turnbull-Cutait Pull-Through as Salvage for Anastomotic Leak After Low Anterior Resection: Case Series Study

Purpose/Background: Anastomotic leaks after low anterior resection (LAR) for rectal cancer occur in 7-13% of cases and may lead to permanent ostomy in 56-65% of patients. The Turnbull-Cutait pull-through 2-stage coloanal anastomosis (TCA) can serve as a sphincter-preserving salvage procedure. Limited data exists on functional outcomes when TCA is used as salvage for anastomotic leak after LAR in the setting of pelvic radiation. This study assesses functional outcomes patients that underwent TCA as a salvage operation - 4 patients who underwent LAR complicated by anastomotic leak and 1 patient with rectal lymphoma initially treated with chemoradiation and complicated by chronic rectocutaneous fistula.

Methods/Interventions: Retrospective case series with prospective functional assessment at AdventHealth sites. After IRB approval, we identified patients who underwent two-stage TCA as salvage for anastomotic leak following LAR. Data collected from electronic medical records included demographics, tumor characteristics, leak timing, and TCA procedure details. Functional outcomes were assessed via telephone interviews using validated questionnaires: Wexner Incontinence Score, Low Anterior Resection Syndrome (LARS) Score, and Functional Assessment of Cancer Therapy-General 7 (FACT-G7).

Results/Outcomes: Five patients (3 male, 2 female) with median age 65 years (range 40-80) underwent TCA as salvage between August 2023 and February 2024. All patients whose indication was rectal adenocarcinoma (n=4) received neoadjuvant chemoradiation therapy. The interval between LAR and TCA ranged between 2 to 21 months for these patients. Clinical staging: T2N1 (n=1), T3N0 (n=1), T3N1 (n=2), T3N2 (n=1). Anastomotic leaks were diagnosed at median 3 months post-LAR (range 1-4 months). All patients had diverting ostomies. TCA was performed after LAR using robotic, laparoscopic, or open approaches. A single patient was included whose indication was rectal lymphoma. This patient prior to operation had a necrotizing perineal infection resulting in chronic rectocutaneous fistula and underwent TCA initially. The interval between TCA and ileostomy reversal ranged between 1 to 4 months for all 5 patients. Median follow-up for functional assessment was 13 months. Wexner scores ranged from 5-15 (median 11) with 2 patients with mild incontinence, 2 patients with moderate incontinence, and 1 patient with severe incontinence. LARS scores ranged from 29-39 (median 37) with 1 patient with minor MARS and the remaining 4 patients with major LARS. Despite this, the median FACT-G7 score was 22 (range 15-25), reflecting good overall quality of life in most patients. All patients achieved ostomy reversal and maintained intestinal continuity. A single patient underwent sacral nerve stimulator placement 16 months after ileostomy reversal after TCA performed and her functional outcomes will be reassessed 1 month postoperatively.

Conclusion/Discussion: Two-stage Turnbull-Cutait pull-through coloanal anastomosis is a safe salvage procedure for anastomotic leak following LAR and prior pelvic radiation for rectal cancer and effective option for operative management of rectal lymphoma with local complications after chemoradiation. Functional outcomes demonstrate good quality of life measures despite variable incontinence measures. TCA successfully avoided permanent ostomy in all patients while maintaining oncologic principles. This technique should be considered as a viable salvage option for complex anastomotic leaks in appropriately selected patients.