Journal of Medical and Surgical
Research (JMSR)


Pages: 934-940DOI: 10.46327/msrjg.1.000000000000194

Date of Publication: 30-Nov--0001

Clinical Outcomes of Two-Stages Delayed Colo-Anal Anastomosis: A Literature Review

Author: Anass Mohammed Majbar, Amine Benkabbou, Laila Amrani, Raouf Mohsine, Amine Souadka

Category: JMSR Oncology

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Delayed anastomosis after rectal surgery was first described by Turnbull and Cutait for Hirschprung__ampersandsign#39;s disease, Chagas disease, and rectal cancer. The main objective of this technique is to reduce the risk of anastomotic fistula (AL), thanks to the adhesions that are created between the lowered colon and the anal canal between the first and second operative stages. This technique has seen a revival of interest in recent years, visible in the high number of publications in the last decade. Actual indications for delayed colo-anal anastomosis (DCA) are low rectal cancer and challenging situations in rectal surgery, mainly failed colorectal or colo- anal anastomosis. The rate of pelvic septic complications (anastomotic fistula and pelvic abscess) varies between 0 and 35.3%, with most studies reporting low rates. The rate of salvage ostomy creation in the postoperative period varied from 0 to 18.7%. Mortality was NUL in the majority of studies. The rate of poor functional results varied from 0 to 38.5% and functional outcomes appear to improve over time. Few studies compared DCA to one-stage colo-anal anastomosis, with contradictory resulats. These results should be taken with caution because of the low level of available evidence. The ongoing randomized trials, comparing DCA with one-stage colo-anal anastomosis, will define the place of DCA in rectal surgery.

Keywords: Rectal neoplasms, Delayed colo-anal anastomosis, Anastomotic fistula


  1. Cutait DE, Figliolini FJ. A new method of colorectal anastomosis in abdominoperineal resection. Dis Colon Rectum. 1961;4: 335–342.
  2. Turnbull RB Jr, Cuthbertson A. Abdominorectal pull-through resection for cancer and for Hirschsprung’s disease. Delayed posterior colorectal anastomosis. Cleve Clin Q. 1961;28: 109–115.
  3. Olagne E, Baulieux J, de la Roche E, Adham M, Berthoux N, Bourdeix O, et al. Functional results of delayed coloanal anastomosis after preoperative radiotherapy for lower third rectal cancer. J Am Coll Surg. 2000;191: 643–649.
  4. Maggiori L, Blanche J, Harnoy Y, Ferron M, Panis Y. Redo-surgery by transanal colonic pull-through for failed anastomosis associated with chronic pelvic sepsis or rectovaginal fistula. Int J Colorectal Dis. 2015;30: 543–548.
  5. Baulieux J, Mabrut JY, Adham M, de La Roche E, Olagne E, Ducerf C, et al. [Excision of low rectal carcinomas with sphincter preservation. Multimodal strategy using neoadjuvant radiotherapy and “delayed” coloanal anastomosis without defunctioning stoma]. Bull Acad Natl Med. 2004;188: 1509–24; discussion 1524–7.
  6. Kirwan WO, Turnbull RB Jr, Fazio VW, Weakley FL. Pullthrough operation with delayed anastomosis for rectal cancer. Br J Surg. 1978;65: 695–698.
  7. Baulieux’ J, Olagne’ E, Ducerf’ C, De La Roche’ E, Adham’ M, Berthoux’ N, et al. Résultats oncologiques et fonctionnels des rections avec anastomose coloanale directe différke dans les cancers du bas rectum préalablement irradiés. Chirurgie. 1999;124: 240–251.
  8. Cutait DE, Cutait R, Ioshimoto M, Hyppólito da Silva J, Manzione A. Abdominoperineal endoanal pull-through resection. A comparative study between immediate and delayed colorectal anastomosis. Dis Colon Rectum. 1985;28: 294–299.
  9. Remzi FH, El Gazzaz G, Kiran RP, Kirat HT, Fazio VW. Outcomes following Turnbull-Cutait abdominoperineal pull-through compared with coloanal anastomosis. Br J Surg. 2009;96: 424–429.
  10. Kim HJ, Huh JW, Kim HR, Kim YJ. Oncologic impact of anastomotic leakage in rectal cancer surgery according to the use of fibrin glue: case-control study using propensity score matching method. Am J Surg. 2014;207: 840–846.
  11. Krarup P-M, Nordholm-Carstensen A, Jorgensen LN, Harling H. Anastomotic leak increases distant recurrence and long-term mortality after curative resection for colonic cancer: a nationwide cohort study. Ann Surg. 2014;259: 930–938.
  12. Nesbakken A, Nygaard K, Lunde OC. Outcome and late functional results after anastomotic leakage following mesorectal excision for rectal cancer. Br J Surg. 2001;88: 400–404.
  13. Portale G, Popesc GO, Parotto M, Cavallin F. Delayed Colo-anal Anastomosis for Rectal Cancer: Pelvic Morbidity, Functional Results and Oncological Outcomes: A Systematic Review. World J Surg. 2019;43: 1360–1369.
  14. Hallet J, Milot H, Drolet S, Desrosiers E, Grégoire RC, Bouchard A. The clinical results of the Turnbull-Cutait delayed coloanal anastomosis: a systematic review. Tech Coloproctol. 2014;18: 579–590.
  16. Bianco F, Belli A, De Franciscis S, Falato A, Romano GM. “Scarless” and no-stoma surgery for low rectal cancer: the laparoscopic pull-through delayed “high” colo-anal anastomosis. Updates Surg. 2016;68: 99–104.
  17. Biondo S, Trenti L, Espín E, Frago R, Vallribera F, Jiménez LM, et al. Complicaciones y mortalidad postoperatorias tras anastomosis coloanal en dos tiempos según técnica de Turnbull-Cutait. Cirugía Española. 2012;90: 248–253.
  18. Hallet J, Bouchard A, Drolet S, Milot H, Desrosiers E, Lebrun A, et al. Anastomotic salvage after rectal cancer resection using the Turnbull-Cutait delayed anastomosis. Can J Surg. 2014;57: 405–411.
  19. Fixot K, Galifet M, Scherrer M-L, Germain A, Bresler L. Abdominoperineal pull-through resection with delayed coloanal anastomosis as treatment option for complex recto-urinary fistulas. Int J Colorectal Dis. 2014;29: 407–409.
  20. Bozio G, Mabrut J-Y, Baulieux J. Anastomose colo-anale « différée », après exérèse totale du mésorectum par laparoscopie, pour cancer du rectum: Delayed colo-anal anastomosis after laparoscopic proctectomy with total mesorectal resectionfor rectal cancer. J Chir . 2008;145: 262–265.
  21. Manceau G, Karoui M, Breton S, Blanchet A-S, Rousseau G, Savier E, et al. Right colon to rectal anastomosis (Deloyers procedure) as a salvage technique for low colorectal or coloanal anastomosis: postoperative and long-term outcomes. Dis Colon Rectum. 2012;55: 363–368.
  22. Biondo S, Trenti L, Galvez A, Espin-Basany E, Bianco F, Romano G, et al. Two-stage Turnbull-Cutait pull-through coloanal anastomosis versus coloanal anastomosis with protective loop ileostomy for low rectal cancer. Protocol for a randomized controlled trial (Turnbull-BCN). Int J Colorectal Dis. 2017;32: 1357–1362.
  23. Bianco F, De Franciscis S, Belli A, Ragone V, Romano GM. A pull-through delayed “high” coloanal anastomosis: new tricks to refresh an old procedure. Tech Coloproctol. 2015;19: 259–261.
  24. Pujahari AK, Anand S. Trans-anal exteriorisation of colon and delayed colo-anal anastomosis for sphincter preservation in low carcinoma rectum. Int J Colorectal Dis. 2015;30: 853–855.
  25. Zanguie M, Abdollahi A, Salek R, Jangjoo A, Jabbari Nooghabi M, Shabahang H, et al. Three Anastomotic Techniques Following Laparoscopic Rectal Cancer Resection: Our Experience in 155 Patients. Surg Innov. 2018;25: 57–61.
  26. Prete F, Prete FP. The pull-through: back to the future. G Chir. 2013;34: 293–301.
  27. Jarry J, Faucheron JL, Moreno W, Bellera CA, Evrard S. Delayed colo-anal anastomosis is an alternative to prophylactic diverting stoma after total mesorectal excision for middle and low rectal carcinomas. Eur J Surg Oncol. 2011;37: 127–133.
  28. Facy O, Lagoutte N, Jambet S, Radais F, Favre J-P, Rat P, et al. [After low anterior rectal resection, colonic pull-through with delayed colo-anal anastomosis can avoid the need for a diverting ileostomy]. J Chir . 2009;146: 458–463.
  29. Barugola G, Bertocchi E, Gentile I, Cracco N, Sartori CA, Ruffo G. Hostile pelvis: how to avoid permanent stoma. Updates Surg. 2018;70: 459–465.
  30. Sage P-Y, Trilling B, Waroquet P-A, Voirin D, Girard E, Faucheron J-L. Laparoscopic delayed coloanal anastomosis without diverting ileostomy for low rectal cancer surgery: 85 consecutive patients from a single institution. Tech Coloproctol. 2018;22: 511–518.
  31. Xiong Y, Huang P, Ren Q-G. Transanal Pull-Through Procedure with Delayed versus Immediate Coloanal Anastomosis for Anus-Preserving Curative Resection of Lower Rectal Cancer: A Case-Control Study. Am Surg. 2016;82: 533–539.