Anastomotic Complications

Abstract

Mechanical bowel prep and oral antibiotics prior to colon resection are associated with a lower risk of anastomotic leak.• A significant proportion of anastomotic leaks present after the immediate postoperative period, especially if there is a history of pelvic radiation. • Most early anastomotic bleeds are self-limited; late bleeds may be a sign of anastomotic leak. • Anastomotic stricture after cancer resection should undergo endoscopic biopsy and imaging to rule out recurrent cancer. • Benign anastomotic strictures may be amenable to endoscopic management, but some will require surgical revision or completion proctectomy with permanent colostomy if the strictured anastomosis is in the pelvis. • Anastomotic complications often lead to significant detriments to quality of life with regard to pain, defecatory function, sexual function, and urinary function. Discussion of these issues with patients is critical for surgical decision-making. Anastomotic LeakThe unfortunate reality faced by every surgeon who performs bowel resections is the occurrence of anastomotic leaks. The incidence of anastomotic leak after bowel anastomosis ranges from 2% to 21% and is associated with significant risk of short-and long-term morbidity [1][2][3][4][5]. This complication can be a devastating event that sets off a cascade of other unfortunate events, resulting in significant det-riments to quality of life, increased pain, prolonged disability, and sometimes death. Anastomotic leaks are associated with significantly higher healthcare resource utilization and cost, as patients with this complication are more likely to require additional diagnostic tests, procedures or reoperations, hospital days, outpatient care, and readmissions [6,7]. Perhaps the most frustrating aspect of anastomotic leaks in colorectal surgery is the fact that leaks and their severe consequences still occur despite the adoption of evidence-based perioperative guidelines, efforts to optimize patient risk factors, and adherence to surgical principles. Although important progress has been made toward reducing the risk of anastomotic leak, there is still much work to be done to increase our understanding of the pathophysiology of anastomotic leak, and effective strategies for prevention.

Prevention of Anastomotic Leak in Colorectal Surgery: Current Knowledge and Next Steps

“…Defunctioning loop ileostomies or colostomies are often performed in patients undergoing low anterior resection (LAR) with colorectal or coloanal anastomoses, which are associated with higher risk of anastomotic leak. 3 Defunctioning stomas have been shown to decrease the rate of clinically significant anastomotic leaks in patients undergoing LAR, including leaks which require re-operation. In the meta-analysis of eight RCTs with 892 patients, clinically significant leaks occurred in 6.3% of patients in the defunctioned group compared to 18.3% without defunctioning (p <0.00001).…”

“…Management of colorectal anastomotic leak are determined by the severity of the leak, timing of the leak, location of the leak (intraperitoneal versus extraperitoneal), and patient's clinical status. 3 Management options include antibiotics alone, radiological-guided drainage, and surgery. Antibiotics alone is reserved for patients who only have low-grade sepsis and/ or a localized collection of less than 3 cm.…”

“…1 Leak rates have been reported to be as low as 1-3% in right sided colon resections but up to 19% in coloanal anastomoses. 2,3 Anastomotic leak typically presents on days 5-7 postoperatively with resumption of bowel function, and can be defined either clinically or radiologically. 3 Resumption of bowel function may occur earlier after minimally invasive surgery.…”

“…2,3 Anastomotic leak typically presents on days 5-7 postoperatively with resumption of bowel function, and can be defined either clinically or radiologically. 3 Resumption of bowel function may occur earlier after minimally invasive surgery. Understanding the factors associated with anastomotic leak can allow surgeons to adopt preventative measures.…”

Predictive Factors of Anastomotic Leakage after Resection of Left Colon Cancer: A Single Center Experience

“…It is defined as a bowel wall defect at the site of the anastomosis, causing communication between the intra and extraluminal compartments (4). This problem could be encountered in 2% to 21% of patients undergoing bowel anastomosis, and it is associated with a significant short-and long-term morbidity (5)(6)(7). Hence, identification and prevention of its risk factors are crucial in current surgical practice (8,9).…”