Bridging the gap: a systematic literature review and meta-analysis on the management of rectal wall defect after transanal excision

Abstract Background Transanal resection techniques have gained considerable importance in the treatment of benign and malignant rectal neoplasms. However, there is no definitive consensus on whether the rectal defect should be closed or left open after excision. We sought to provide an updated pooled analysis of the management of rectal wall defect after transanal excision. Methods In accordance with PRISMA and Cochrane guidelines, this meta-analysis was performed using the PubMed (MEDLINE), Cochrane Central Register of Controlled Trials, and Google Scholar databases to identify studies comparing perioperative outcomes after rectal defect closure versus leaving the defect open following full-thickness (FT) excision. Odds ratios (ORs) and standardized mean differences (SMDs) with 95% confidence intervals (CIs) were calculated. Heterogeneity was assessed using Cochrane's Q test. Risk of bias and certainty of evidence were judged by ROBINS-I and GRADE, respectively. Results Six comparative studies meeting the inclusion criteria were included in the final analysis. Closing the rectal defect was associated with significantly reduced rectal bleeding (OR = 0.57, 95% CI: 0.35–0.94, p = 0.03; I 2 = 26%) and re-admission rates (OR = 0.34, 95% CI: 0.16–0.76, p = 0.008; I 2 = 0%) compared with the open group, while other outcomes were not significantly different. A prolonged operative time was noted when the rectal wall defect was sutured (SMD = 0.15, 95% CI: 0.03–0.28, p = 0.02; I 2 = 44%). Conclusions The present analysis revealed that both approaches are safe and technically feasible; however, closing the rectal wall defect after FT excision of rectal neoplasms was associated with lower bleeding and re-admission rates. Nevertheless, randomized studies with homogeneous protocols and consistent long-term outcome data are still needed to provide definitive answers.