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Paper text:
anastomotic leak after low anterior resection ( lar ) in patients with rectal cancer can be challenging to treat .
incidence of anastomotic leak is 3 - 21% with mortality rates as high as 22% ( 1,2 ) .
traditionally , treatment of anastomotic leak after lar involved resection of the anastomosis with end colostomy or suturing of the anastomosis with proximal diversion .
twenty to 60% of patients with colostomy after repair of anastomotic leak are unable to have colostomy reversal ( 3 ) .
we present a case of anastomotic leak following lar managed via transanal endoscopic microsurgery ( tem ) .
endorectal ultrasound staged the lesion ut2n1 ; american joint committee on cancer staging was iiia ( t2 n1 m0 ) .
baker - type side - to - end anastomosis seven weeks after neoadjuvant chemoradiotherapy , the patient underwent lar with diverting loop ileostomy .
a baker - type side - to - end anastomosis was created using a 33-eea stapler ( covidien / jj ) 5 cm from the perianal skin ( figure 1 ) .
gastrograffin enema demonstrating normal anastomosis with no leak after completing chemotherapy , the anastomosis was evaluated with gastrograffin enema , which showed a normal anastomosis and no leak ( figure 2 ) .
contrast ct scan of the abdomen and pelvis demonstrated a 2 cm fluid collection along the linear staple line with small amount of free air in adjacent mesenteric fat ( figure 4 ) .
flexible sigmoidoscopy shows healed eea anastomosis flexible sigmoidoscopy performed 5 months later was unchanged without evidence of inflammation .
repeat ct with rectal contrast demonstrated a recurrent 18 x 11 mm pre - sacral abscess but no leakage of rectal contrast from the staple line .
ct scan of abdomen / pelvis a ) small amount of free air adjacent to linear staple line , b ) abscess adjacent to linear staple line with persistent anastomotic leak despite multiple courses of antibiotics and fecal diversion , options considered for definitive repair included resection of anastomosis and recreation of the colon - anal anastomosis via hand - sewn approach ; resection of anastomosis with end colostomy ; attempt at repair / resection of colon distal to eea staple line ; or a novel endoscopic approach .
after extensive discussion , we proceeded with transanal endoscopic repair 8 months after diagnosis of anastomotic leak and 15 months after lar .
leak site from linear staple line under general anesthesia the sphincter was dilated with the pratt anoscope .
a pliable single incision laparoscopic surgery ( sils ) device was inserted across the eea staple line without difficulty . through this device ,
attempts to suture the area closed with 3 - 0 pds were unsuccessful due to the small confines of the colon distal to the eea anastomosis .
an endostitch was used to place a figure - of - eight suture at the leak site .
friable , chronically inflammed tissue tore when the knot was secured . with manipulation , a small amount of pus drained from the chronic abscess cavity .
hook electrocautery opened the linear staple line ; inflammatory tissue debrided and wound edges cauterized .
studies have shown laparoscopic surgery is associated with decreased postoperative pain , shorter length of stay , improved cosmesis and earlier return to normal daily activities ( 4,5 ) .
tem is a minimally invasive technique being used more frequently for treatment of rectal diseases .
eighty - nine patients with colorectal cancer were studied ; 40 ( 45% ) required reoperation for anastomotic leak and/or intra - abdominal abscess .
the group of patients requiring reoperation had significantly higher morbidity , including infections and number of readmissions when compared to the group that did n't require reoperation .
tem can be used as a minimally invasive approach to anastomotic leak in select patients after lar for rectal cancer .
tem provides an alternative to major redo pelvic surgery , which carries the risk of intra - operative and postoperative complications resulting in permanent stoma creation , and prevents the morbidity associated with re - exploration and colostomy .
anastomotic leak after low anterior resection ( lar ) in patients with rectal cancer who have received neoadjuvant chemoradiation can be challenging to treat and can lead to the creation of a permanent stoma . 
 we report the case of a post - operative anastomotic leak after a baker - type anastomosis during a low anterior resection was successfully managed with transanal endoscopic microsurgical ( tem ) debridement and repair . 
 tem can be a successful endoluminal alternative treatment in the management of anastomotic leak after lar and can prevent the morbidity associated with re - exploration and colostomy .