Transanal and Transabdominal Combined Endoscopic Redo Surgery for Benign Rectal Anastomotic Stenosis: Multicenter Outcomes and Factors Associated With Anastomosis-Related Failure

BACKGROUND: Benign rectal anastomotic stenosis after sphincter-preserving rectal cancer surgery remains a difficult reconstructive problem, particularly in a fibrotic pelvis. OBJECTIVE: To evaluate outcomes and factors associated with anastomosis-related failure after transanal and transabdominal combined endoscopic redo surgery for benign rectal anastomotic stenosis. DESIGN: Retrospective multicenter observational cohort study. SETTINGS: Three tertiary colorectal referral centers. PATIENTS: Among 239 screened patients with anastomotic stenosis, 149 had benign rectal anastomotic stenosis after rectal cancer surgery and were included in the analysis. MAIN OUTCOME MEASURES: Anatomical success, restoration of bowel continuity, postoperative morbidity, and factors associated with anastomosis-related failure. RESULTS: The cohort included 149 patients, of whom 127 were men (85.2%). Mean age was 58.7 ± 9.9 years, and the mean interval from index surgery to redo surgery was 23.3 ± 28.9 months. Median follow-up was 27 months (IQR, 12-52). Anatomical success was achieved in 134 patients (89.9%), and bowel continuity was restored in 122 patients (81.9%). Anastomosis-related failure occurred in 15 patients (10.1%). In exploratory multivariable Firth penalized logistic regression, a preexisting chronic anastomotic defect was associated with anastomosis-related failure (adjusted OR, 3.249; 95% CI, 1.083-11.404; p = 0.035). Postoperative morbidity occurred in 34 patients (22.8%): Clavien-Dindo Grade I to II and grade III complications occurred in 17 patients each (11.4% each). No grade IV complications or 90-day deaths occurred. LIMITATIONS: The retrospective design, potential selection bias, small number of failure events, and heterogeneity in surgical techniques and perioperative management across centers may limit generalizability. CONCLUSIONS: Transanal and transabdominal combined endoscopic redo surgery was associated with high rates of anatomical success and restoration of bowel continuity, with acceptable morbidity. A preexisting chronic anastomotic defect was associated with anastomosis-related failure and should be considered during patient selection and counseling. See Video Abstract.