Management of low colorectal anastomotic leak: Preserving the anastomosis

Endoscopic therapy of colorectal anastomotic hematoma with hypertonic dextrose

Anastomotic dehiscence and leak are dreaded complications after a colorectal resection and can often present with rectal bleeding and pelvic abscess or sepsis. Although most cases of bleeding after gastrointestinal anastomoses are minor and self-limited, major bleeding, as defined by hemodynamic instability or the need for blood transfusions, poses a significant challenge for management. Here we report a case in which a patient presenting with profuse rectal bleeding and pelvic hematoma secondary to a colorectal anastomotic leak was treated endoscopically with 50% dextrose spray then enema.

Transanal Drainage of Coloanal Anastomotic Leaks

The conventional operative intervention for leaks following coloanal anastomoses has been proximal fecal diversion with or without take-down of anastomosis. A few of these cases are also amenable to percutaneous drainage. Ostomies created in this situation are often permanent, specifically in cases where coloanal anastomoses are taken down at the time of reoperation. We present two patients who developed perianastomotic pelvic abscesses that were treated with transanal large bore catheter drainage resulting in successful salvage of coloanal anastomoses without the need for a laparotomy or ostomy creation. We propose this to be an effective therapeutic approach to leaks involving low coloanal anastomoses in the absence of generalized peritonitis.

A novel endoscopic treatment for anastomotic leakage post anterior resection: Padlock over the scope clip

BACKGROUND

Anastomotic dehisense is a serious complication of anterior resections. We have had success in our centre utilising Endosponge therapy to salvage anastomotic leaks but this requires multiple endoscopic sessions and can take around 6 weeks to heal in some cases. This can delay further management such as chemotherapy.

AIM

We describe the novel use of Padlock over the scope clips to manage patients with anastomotic dehisense post anterior resection.

METHOD

Padlock over the scope clips were used to manage three patients who presented with anastomotic breakdown post laparoscopic anterior resection between February 2016 and July 2017.

RESULTS

These patients were initially managed conservatively with IV antibiotics and fluids. One case was first managed with Endosponge treatment before a Padlock clip was utilised to bridge a narrow defect. The other cases were managed initially with CT-guided percutaneous drains before clip deployment. Patients were followed up with regular clinic and sigmoidoscopies. All three cases demonstrated anastomotic salvage and satisfactory healing. This allowed the patients to be fit for their chemotherapy in less than 4 weeks from presentation. There were no complications from utilising the Padlock clips in these cases.

CONCLUSION

Utilising over the scope endoclips previously has been thought to be limited by the size of defect. Our experience details novel combination techniques that allow for quick resolution and the expeditious commencement of further management such as chemotherapy. These clips also proved to be cost-effective in our centre, utilising less inpatient and outpatient resources than alternative management plans.

Management of Low Colorectal Anastomotic Leakage in the Laparoscopic Era: More Than a Decade of Experience

BACKGROUND

Anastomotic leak after colorectal surgery increases postoperative mortality, cancer recurrence, permanent stoma formation, and poor bowel function. Anastomosis between the colon and rectum is a particularly high risk. Traditional management mandates laparotomy, disassembly of the anastomosis, and formation of an often-permanent stoma. After laparoscopic colorectal surgery it may be possible to manage anastomotic failure with laparoscopy, thus avoiding laparotomy.

OBJECTIVE

The purpose of this study was to determine the feasibility of the laparoscopic management of failed low colorectal anastomoses.

SETTING

This was a single-institute case series.

PATIENTS

A total of 555 laparoscopic patients undergoing anterior resection with primary anastomosis within 10 cm of the anus in the period 2000-2012 were included.

MAIN OUTCOME MEASURES

Anastomotic failure, defined as any clinical or radiological demonstrable defect in the anastomosis; complications using the Clavien-Dindo system; mortality within 30 days; and patient demographics and risk factors, as defined by the Charlson index, were measured.

RESULTS

Leakage occurred in 44 (7.9%) of 555 patients, 16 patients with a diverting ileostomy and 28 with no diverting ileostomy. Leakage was more common in those with anastomoses <5 cm form the anus, male patients, and those with a colonic J-pouch and rectal cancer. Diverting ileostomy was not protective of anastomotic leakage. In those patients with anastomotic leakage and a primary diverting ileostomy, recourse to the peritoneal cavity was required in 4 of 16 patients versus 24 of 28 without a diverting ileostomy (p = 0.0002). In 74% of those cases, access to the peritoneal cavity was achieved through laparoscopy. Permanent stoma rates were very low, including 14 (2.5%) of 555 total patients or 8 (18.0%) of 44 patients with anastomotic leakage. Thirty-day mortality was rare (0.6%).

LIMITATIONS

This study was limited by the lack of a cohort of open cases for comparison.

CONCLUSIONS

Laparoscopic anterior resection is associated with low levels of complications, including anastomotic leak, postoperative mortality, and permanent stoma formation. Anastomotic leakage can be managed with laparoscopy in the majority of cases. See Video Abstract at http://links.lww.com/DCR/A353.

Anastomotic leaks in gastrointestinal surgery and their prevention

Anastomotic leak in the gastrointestinal tract is one of the most important complications of resection. They are the main cause of reoperation, their occurrence worsens the prognosis of the patient, increasing the proportion of direct mortality, as well as being a significant risk factor for recurrence of cancer. The risk of leaks within the gastrointestinal tract is greatly varied, depending on the location and extent of the resection, but also on patient, disease or a surgical procedure, including surgeon. To determine the potential risk of leakage can be significant for introduction some prophylactic actions. Some of them have the character of general recommendations, as proper nutrition of the patient in the perioperative period, while another part is directly connected to the surgical procedure. The second group includes protective stoma, the use of tissue glues, insertion transrectal drain for rectal anastomosis decompression, the use of stents or the use of collagen matrix coated with fibrinogen and thrombin. Important to reduce the proportion of leaks can be more precise and targeted prophylactic recommendations, based on the individualized determination of risk factors leaks. Further research for this purpose are necessary for this purpose, the big hope can be associated with data obtained through mobile applications.

Minimally invasive management of anastomotic leaks in colorectal surgery

Anastomotic leakage is an unfortunate complication of colorectal surgery. This distressing situation can cause severe morbidity and significantly affects the patient’s quality of life. Additional interventions may cause further morbidity and mortality. Parenteral nutrition and temporary diverting ostomy are the standard treatments of anastomotic leaks. However, technological developments in minimally invasive treatment modalities for anastomotic dehiscence have caused them to be used widely. These modalities include laparoscopic repair, endoscopic self-expandable metallic stents, endoscopic clips, over the scope clips, endoanal repair and endoanal sponges. The review aimed to provide an overview of the current knowledge on the minimally invasive management of anastomotic leaks.