https://doi.org/10.1177/1553350619834786 Surgical Innovation 1–12 © The Author(s) 2019 Article reuse guidelines: sagepub.com/journals-permissions DOI: 10.1177/1553350619834786 journals.sagepub.com/home/sri Original Article Introduction Anastomotic leakage (AL) is a dreaded complication of rectal surgery. Although the reported overall rate of leak- ages in colorectal anastomoses ranges from 2.4% to 12%, a much higher rate occurs in deep rectal anastomoses. Accordingly, the rate of clinically apparent AL after low anterior rectal resection (LAR; ≤7cm from the anal verge) and circular double-stapled anastomosis (CDSA) without defunctioning stoma is up to 37.5%. 1-11 Since AL may result in life-threatening peritonitis, sepsis, and multiple organ failure, LAR and CDSA are regularly combined with defunctioning stoma. Accordingly, we already evaluated in a previous trial in a pig model 12 whether LAR and CDSA without defunctioning stoma but with extraluminal anastomotic application of an experimental fibrin sealant reduces AL rate until the ninth postoperative day since this procedure might prevent humans from defunctioning stoma, increas- ing quality of life, and decreasing surgical costs. Thus, 834786SRI XX X 10.1177/1553350619834786Surgical InnovationWenger et al research-article 2019 1 Asklepios Südpfalzklinik Kandel, Kandel, Germany 2 Victor Babes University of Medicine and Pharmacy, Timisoara, Romania 3 Ethicon, a Johnson & Johnson Company, Somerville, NJ, USA Corresponding Author: Frank Axel Wenger, Clinic of General, Visceral and Thoracic Surgery, Asklepios Südpfalzklinik Kandel, Luitpoldstraße 14, 76870 Kandel, Germany Email: charipanc@aol.com Is Circular Fibrin Sealing of Low Rectal Anastomosis Able to Prevent Leakage in 21-Day Follow-up? Randomized Experimental Trial in Pigs Frank Axel Wenger, PhD 1,2 , Eduard Szucsik, PhD 1,2 , Bogdan Florin Hoinoiu, PhD 2 , Anca M. Cimpean, PhD 2 , John P. Matonick, PhD 3 , Mihai Ionac, PhD 2 , and Marius Raica, PhD 2 Abstract Purpose. Clinically apparent anastomotic leakage (AL) after low anterior rectal resection (LAR; <7 cm from anal verge) using circular double-stapled anastomosis without defunctioning stoma is up to 37.5%. However, it is unclear whether there is reduction of LAR after 21 postoperative days without defunctioning stoma but with extraluminal anastomotic application of fibrin sealant. Methods. Forty-eight-week-old pigs underwent LAR and circular double- stapled anastomosis in end-to-end technique (descendo-rectostomy). Animals were randomized into therapy and control group (cg). Therapy group (n = 20) received additional extraluminal circular anastomotic application of fibrin sealant. Objective was to assess incidence of clinically apparent and nonclinically apparent leakage through the 21st postoperative day. Remaining animals were sacrificed on the 21st day, and anastomotic region was analyzed. In case of earlier diagnosed AL, animals were sacrificed. Results. In cg, we observed clinically and nonclinically AL in 20% (n = 4). No animal was identified with a nonclinical-apparent leakage in this group, and all 4 animals with leakages presented clinical signs. In the therapy group, no animal (0/20) developed clinically apparent leakage signs. There were no leakages in this group, but 3 animals had ulcerative lesions without leak and without clinical signs. These lesions were observed intraluminally at crossing of staple lines after 21 days. In one of these animals, incomplete leakage was observed, blocked by fibrin sealant. Conclusion. In circular stapled colorectal anastomosis, circular fibrin glue sealant successfully protected anastomotic intraluminal wall defects at crossing of staple lines, reducing leakage rate from 20% to 0% (cg vs therapy group) after 21 postoperative days. Keywords low anterior rectal resection, pig model, circular double-stapled anastomosis, extraluminal circular anastomotic protection, fibrin glue sealant, anastomotic leakage