Early detection of anastomotic leakage after colorectal surgery

Abstract

Anastomotic leaks occur in approximately 2% to 24% of patients undergoing colorectal surgery with higher rate in rectal anastomoses, and can lead to significant morbidity and mortality. AL could be detected anytime from 3 to 45 days postoperatively. Clinical anastomotic leakage was considered to be present if any of the followings was observed: gas or fecal discharge from the wound or the vagina, fecal peritonitis, and an intra-abdominal abscess or peritonitis along with an anastomotic defect verified by rectal examination, image study, sigmoidoscopy or at laparotomy. A pelvic abscess near the anastomotic site without an obvious fecal fistula was also classified as a clinical leakage.

There are many risk factors that have been attributed to anastomotic leakage. Risk factors can be categorized as patient-specific, intraoperative, and specific for low rectal anastomosis. Patient-specific risk factors include malnutrition, steroids, tobacco use, cardiovascular disease, alcohol use, and diverticulitis. Intraoperative risk factors include low anastomoses, suboptimal anastomotic blood supply, operative time > 2 hours, bowel obstruction, perioperative blood transfusion, and intraoperative septic conditions not conducive to primary anastomosis. Risk factors for low rectal anastomosis include gender and obesity. Additional risk factors have been relegated to low colonic anastomoses, thereby stressing the importance of stratifying the location of anastomoses when interpreting the literature.

An adequate blood supply, assurance of tension-free anastomosis, adequate matching of the luminal diameters, proper technical placement of sutures or staples and avoidance of an unduly prolonged operation with excessive blood loss, can minimize AL rate. Adequate preoperative antibiotic prophylaxis has been shown to reduce the risk of postoperative infection in all types of bowel surgery and must be given at the start of the operation. Furthermore, some patient related risk factors may be addressed prior to surgery, before an elective procedure, the patient is assessed with regard to systemic diseases (e.g., cardiovascular, respiratory, or diabetes), anemia is corrected, malnourished patients should receive nutritional support delivered enterally or parenterally before and after operation, and poor hydration status in emergency setting need preoperative fluid optimization and may require the aid of intensivists. The colon leakage score can accurately predict the risk of anastomotic leakage following left-sided colorectal surgery, and determines which patients could undergo primary anastomosis and which should receive a proximal nonfunctional stoma or a definitive stoma. Also, the intraoperative leak testing is a simple and quick technique with potential value in predicting postoperative anastomotic disruption.