Early anastomotic complications in colorectal surgery: a systematic review of techniques for endoscopic salvage

Abstract

BackgroundAnastomotic complications following colorectal surgery are associated with significant morbidity and mortality. For patients in whom systemic sepsis is absent or well controlled, minimal access techniques, such as endoscopic therapies, are being increasingly employed to reduce the morbidity of surgical re-intervention. In this review, we aim to assess the utility of endoscopic management in the acute setting of colorectal anastomotic complications, focusing on anastomotic leak.MethodA literature search was performed for published full text articles using the PubMed, Cochrane and Scopus databases using the search criteria string “colorectal anastomotic (“leak” OR “bleed”), “endoscopy”, endoscopic management”. Additional papers were detected by scanning the references of relevant papers. Data were extracted from each study by two authors onto a dedicated pro-forma. Given the nature of the data extracted, no meta-analysis was performed.ResultsA total of 89 papers were identified, 16 of which were included in this review; an additional 14 papers were obtained from reference searches. In patients who are not physiologically compromised, there are promising data regarding the salvage rate of stents, over-the-scope endoscopic clips, vacuum therapy and fibrin glue in the early management of colorectal anastomotic leak. There is no consensus regarding the optimal approach, and data to assist the physician in patient selection are lacking. Whilst data on salvage (i.e. healing and avoidance of surgery) are well understood, no data on functional outcomes are reported.ConclusionEndoscopic therapy in the management of stable patients with colorectal anastomotic leaks appears safe and in selected patients is associated with high rates of technical success. Challenges remain in selecting the most appropriate strategy, patient selection, and understanding the functional and long-term sequelae of this approach. Further evidence from large prospective cohort studies are needed to further evaluate the role of these novel strategies.

Mechanotechnical faults and particular issues of anastomotic complications following robot‐assisted anterior resection in 968 rectal cancer patients

“…A transient diversion may mitigate the clinical impact of anastomotic failure without preventing AL, as in the current study . About three‐quarters of our patients with AL underwent transient diversion with or without drainage, similarly to a previous report . Regardless of size or position, AL with narrow tracks can be healed by mucosal contact, which facilitates tract healing .…”

“…Transanal repair of the leakage site may be helpful, specifically for the low‐lying anastomoses observed in six of our patients with AL. Other methods have been proposed to treat AL, including sinus unroofing, application of an endo‐vacuum, and fibrin glue injection, but their efficacy remains undetermined. AS in our patients was initially treated by dilatation at the stricture site, either manually or with the Hegar and a balloon, showing success in one‐third of AS patients.…”

“…4,24 About three-quarters of our patients with AL underwent transient diversion with or without drainage, similarly to a previous report. 25 Regardless of size or position, AL with narrow tracks can be healed by mucosal contact, which facilitates tract healing. 17 Transanal repair of the leakage site may be helpful, specifically for the low-lying anastomoses observed in six of our patients with AL.…”

Endoscopic Treatment of Anastomotic Bleeding in Laparoscopic Colorectal Surgery

“…Discharge happened on day 6. Our reported small series of course does not provide sufficient evidence supporting routine verus selective use of intraoperative colonoscopy thus confirming other studies (13). Intra-operative endoscopy can in fact prolong operating time significantly.…”

“…Major rectal bleeding is fortunately a very rare complication. It's incidence has been reported to be approximately 1% of cases after stapled colorectal anastomoses (7,13). Anticoagulant or antiaggregant therapy are reported to increase the risk of lower gastrointestinal bleeding after colorectal surgery.…”