Skip to main content

Advertisement

SpringerLink
Log in

Effective initial management of anastomotic leak in the maintenance of functional colorectal or coloanal anastomosis

  • Original Article
  • Published:
Surgery Today Aims and scope Submit manuscript

Abstract

Purpose

The present study assessed the factors associated with the maintenance of a functional anastomosis in a large consecutive series of patients with anastomotic leakage (AL).

Methods

All consecutive patients presenting with AL after colorectal or coloanal anastomosis (2012–2019) were analyzed. The primary end point was a functional anastomosis without a stoma at 1 year.

Results

A total of 156 patients were included. AL was initially treated by antibiotics (38%), drainage (43%) or urgent surgery (19%). Initial treatment of AL was not adequate in 24.3%, and reintervention in the form of drainage or surgery was required. A total of 60.9% of patients had a functional anastomosis without a stoma 1 year after surgery. Factors associated with the risk of anastomotic failure at 1 year were diabetes (odds ratio [OR] = 4.24 [95% confidence interval {CI} 1.39–14.24] p = 0.014), neoadjuvant chemoradiotherapy (OR = 3.03 [95% CI 1.14–8.63] p = 0.03) and Grade B (OR = 6.49 [95% CI 2.23–21.74] p = 0.001) or C leak (OR = 35.35 [95% CI 9.36–168.21] p < 0.001). Among patients treated initially by drainage, side-to-end or J-pouch anastomoses were significantly associated with revision of the anastomosis compared to end-to-end (OR = 12.90, p = 0.04).

Conclusion

After acute AL following coloanal or colorectal anastomosis, 60.9% of patients had a functional anastomosis without a stoma at the 1 year of follow-up. The type of treatment of AL influenced the risk of anastomotic failure.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2

Similar content being viewed by others

Data availability

All data are available on request to the corresponding author.

Abbreviations

ASA:

American Society of Anesthesiologists

AL:

Anastomotic leak

POD:

Postoperative day

References

  1. Denost Q, Rouanet P, Faucheron JL, Panis Y, Meunier B, Cotte E, et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: the GRECCAR 5 randomized trial. Ann Surg. 2017;265:474–80. https://doi.org/10.1097/SLA.0000000000001991.

    Article  PubMed  Google Scholar 

  2. Lefevre JH, Mineur L, Kotti S, Rullier E, Rouanet P, de Chaisemartin C, et al. Effect of interval (7 or 11 weeks) between neoadjuvant radiochemotherapy and surgery on complete pathologic response in rectal cancer: a multicenter, randomized, controlled trial (GRECCAR-6). J Clin Oncol. 2016;34:3773–80. https://doi.org/10.1200/JCO.2016.67.6049.

    Article  PubMed  Google Scholar 

  3. Matthiessen P, Hallbook O, Rutegard J, Simert G, Sjodahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007;246:207–14. https://doi.org/10.1097/SLA.0b013e3180603024.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Branagan G, Finnis D, Wessex Colorectal Cancer Audit Working G. Prognosis after anastomotic leakage in colorectal surgery. Dis Colon Rectum. 2005;48:1021–6. https://doi.org/10.1007/s10350-004-0869-4.

    Article  PubMed  Google Scholar 

  5. Lee WS, Yun SH, Roh YN, Yun HR, Lee WY, Cho YB, et al. Risk factors and clinical outcome for anastomotic leakage after total mesorectal excision for rectal cancer. World J Surg. 2008;32:1124–9. https://doi.org/10.1007/s00268-007-9451-2.

    Article  PubMed  Google Scholar 

  6. Mirnezami A, Mirnezami R, Chandrakumaran K, Sasapu K, Sagar P, Finan P. Increased local recurrence and reduced survival from colorectal cancer following anastomotic leak: systematic review and meta-analysis. Ann Surg. 2011;253:890–9. https://doi.org/10.1097/SLA.0b013e3182128929.

    Article  PubMed  Google Scholar 

  7. Ptok H, Marusch F, Meyer F, Schubert D, Gastinger I, Lippert H, et al. Impact of anastomotic leakage on oncological outcome after rectal cancer resection. Br J Surg. 2007;94:1548–54. https://doi.org/10.1002/bjs.5707.

    Article  CAS  PubMed  Google Scholar 

  8. Rahbari NN, Weitz J, Hohenberger W, Heald RJ, Moran B, Ulrich A, et al. Definition and grading of anastomotic leakage following anterior resection of the rectum: a proposal by the International Study Group of Rectal Cancer. Surgery. 2010;147:339–51. https://doi.org/10.1016/j.surg.2009.10.012.

    Article  PubMed  Google Scholar 

  9. Challine A, Cazelles A, Frontali A, Maggiori L, Panis Y. Does a transanal drainage tube reduce anastomotic leakage? A matched cohort study in 144 patients undergoing laparoscopic sphincter-saving surgery for rectal cancer. Tech Coloproctol. 2020;24:1047–53. https://doi.org/10.1007/s10151-020-02265-y.

    Article  CAS  PubMed  Google Scholar 

  10. Boyce SA, Harris C, Stevenson A, Lumley J, Clark D. Management of low colorectal anastomotic leakage in the laparoscopic era: more than a decade of experience. Dis Colon Rectum. 2017;60:807–14. https://doi.org/10.1097/DCR.0000000000000822.

    Article  PubMed  Google Scholar 

  11. Abdalla S, Cotte E, Epin A, Karoui M, Lefevre JH, Berger A, et al. Short-term and long-term outcome of endoluminal vacuum therapy for colorectal or coloanal anastomotic leakage: results of a nationwide multicenter cohort study from the French GRECCAR Group. Dis Colon Rectum. 2020;63:371–80. https://doi.org/10.1097/DCR.0000000000001560.

    Article  PubMed  Google Scholar 

  12. Maggiori L, Bretagnol F, Lefevre JH, Ferron M, Vicaut E, Panis Y. Conservative management is associated with a decreased risk of definitive stoma after anastomotic leakage complicating sphincter-saving resection for rectal cancer. Colorectal Dis. 2011;13:632–7. https://doi.org/10.1111/j.1463-1318.2010.02252.x.

    Article  CAS  PubMed  Google Scholar 

  13. Collard MK, Anyla M, Lefevre JH, Shields C, Laforest A, Gutton C, et al. Patients’ refusal as major limitation of early discharge after colorectal resection in an enhanced recovery program. Langenbecks Arch Surg. 2020;405:337–44. https://doi.org/10.1007/s00423-020-01879-y.

    Article  PubMed  Google Scholar 

  14. Benoit O, Faron M, Margot N, Creavin B, Debove C, Tiret E, et al. C-reactive protein values after colorectal resection: can we discharge a patient with a C-reactive protein value > 100? A retrospective cohort study. Dis Colon Rectum. 2019;62:88–96. https://doi.org/10.1097/DCR.0000000000001216.

    Article  PubMed  Google Scholar 

  15. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: a new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004;240:205–13. https://doi.org/10.1097/01.sla.0000133083.54934.ae.

    Article  PubMed  PubMed Central  Google Scholar 

  16. Gerard JP, Andre T, Bibeau F, Conroy T, Legoux JL, Portier G, et al. Rectal cancer: French Intergroup clinical practice guidelines for diagnosis, treatments and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO). Dig Liver Dis. 2017;49:359–67. https://doi.org/10.1016/j.dld.2017.01.152.

    Article  PubMed  Google Scholar 

  17. McDermott FD, Heeney A, Kelly ME, Steele RJ, Carlson GL, Winter DC. Systematic review of preoperative, intraoperative and postoperative risk factors for colorectal anastomotic leaks. Br J Surg. 2015;102:462–79. https://doi.org/10.1002/bjs.9697.

    Article  CAS  PubMed  Google Scholar 

  18. Nikolian VC, Kamdar NS, Regenbogen SE, Morris AM, Byrn JC, Suwanabol PA, et al. Anastomotic leak after colorectal resection: a population-based study of risk factors and hospital variation. Surgery. 2017;161:1619–27. https://doi.org/10.1016/j.surg.2016.12.033.

    Article  PubMed  Google Scholar 

  19. Bonjer HJ, Deijen CL, Abis GA, Cuesta MA, van der Pas MH, de Lange-de Klerk ES, et al. A randomized trial of laparoscopic versus open surgery for rectal cancer. N Engl J Med. 2015;372:1324–32. https://doi.org/10.1056/NEJMoa1414882.

    Article  CAS  PubMed  Google Scholar 

  20. Gessler B, Eriksson O, Angenete E. Diagnosis, treatment, and consequences of anastomotic leakage in colorectal surgery. Int J Colorectal Dis. 2017;32:549–56. https://doi.org/10.1007/s00384-016-2744-x.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Frouws MA, Snijders HS, Malm SH, Liefers GJ, Van de Velde CJH, Neijenhuis PA, et al. Clinical relevance of a grading system for anastomotic leakage after low anterior resection: analysis from a National Cohort Database. Dis Colon Rectum. 2017;60:706–13. https://doi.org/10.1097/DCR.0000000000000800.

    Article  PubMed  Google Scholar 

  22. Frasson M, Flor-Lorente B, Rodriguez JL, Granero-Castro P, Hervas D, Alvarez Rico MA, et al. Risk factors for anastomotic leak after colon resection for cancer: multivariate analysis and nomogram from a multicentric, prospective, national study with 3193 patients. Ann Surg. 2015;262:321–30. https://doi.org/10.1097/SLA.0000000000000973.

    Article  PubMed  Google Scholar 

  23. Singh PP, Zeng IS, Srinivasa S, Lemanu DP, Connolly AB, Hill AG. Systematic review and meta-analysis of use of serum C-reactive protein levels to predict anastomotic leak after colorectal surgery. Br J Surg. 2014;101:339–46. https://doi.org/10.1002/bjs.9354.

    Article  CAS  PubMed  Google Scholar 

  24. Sirois-Giguere E, Boulanger-Gobeil C, Bouchard A, Gagne JP, Gregoire RC, Thibault C, et al. Transanal drainage to treat anastomotic leaks after low anterior resection for rectal cancer: a valuable option. Dis Colon Rectum. 2013;56:586–92. https://doi.org/10.1097/DCR.0b013e31827687a4.

    Article  PubMed  Google Scholar 

  25. Challine A, Lefevre JH, Creavin B, Benoit O, Chafai N, Debove C, et al. Can a local drainage salvage a failed colorectal or coloanal anastomosis? A prospective cohort of 54 patients. Dis Colon Rectum. 2020;63:93–100. https://doi.org/10.1097/DCR.0000000000001516.

    Article  PubMed  Google Scholar 

  26. Shalaby M, Emile S, Elfeki H, Sakr A, Wexner SD, Sileri P. Systematic review of endoluminal vacuum-assisted therapy as salvage treatment for rectal anastomotic leakage. BJS Open. 2019;3:153–60. https://doi.org/10.1002/bjs5.50124.

    Article  CAS  PubMed  Google Scholar 

  27. Shiomi A, Ito M, Maeda K, Kinugasa Y, Ota M, Yamaue H, et al. Effects of a diverting stoma on symptomatic anastomotic leakage after low anterior resection for rectal cancer: a propensity score matching analysis of 1014 consecutive patients. J Am Coll Surg. 2015;220:186–94. https://doi.org/10.1016/j.jamcollsurg.2014.10.017.

    Article  PubMed  Google Scholar 

  28. Blok RD, Stam R, Westerduin E, Borstlap WAA, Hompes R, Bemelman WA, et al. Impact of an institutional change from routine to highly selective diversion of a low anastomosis after TME for rectal cancer. Eur J Surg Oncol. 2018;44:1220–5. https://doi.org/10.1016/j.ejso.2018.03.033.

    Article  CAS  PubMed  Google Scholar 

  29. Westerduin E, Klaver CEL, van Geloven AAW, Westerterp M, Bemelman WA, Tanis PJ. Outcome after redo surgery for complicated colorectal and coloanal anastomosis: a systematic review. Dis Colon Rectum. 2018;61:988–98. https://doi.org/10.1097/DCR.0000000000001129.

    Article  PubMed  Google Scholar 

  30. Calmels M, Collard MK, O’Connell L, Voron T, Debove C, Chafai N, et al. Redo-surgery after failed colorectal or coloanal anastomosis: morbidity, mortality and factors predictive of success. A retrospective study of 200 patients. Colorectal Dis. 2022;24:511–9. https://doi.org/10.1111/codi.16025.

    Article  PubMed  Google Scholar 

  31. Anderin K, Gustafsson UO, Thorell A, Nygren J. The effect of diverting stoma on long-term morbidity and risk for permanent stoma after low anterior resection for rectal cancer. Eur J Surg Oncol. 2016;42:788–93. https://doi.org/10.1016/j.ejso.2016.04.001.

    Article  CAS  PubMed  Google Scholar 

  32. Gadan S, Floodeen H, Lindgren R, Rutegard M, Matthiessen P. What is the risk of permanent stoma beyond 5 years after low anterior resection for rectal cancer? A 15-year follow-up of a randomized trial. Colorectal Dis. 2020. https://doi.org/10.1111/codi.15364.

    Article  PubMed  Google Scholar 

  33. den Dulk M, Smit M, Peeters KC, Kranenbarg EM, Rutten HJ, Wiggers T, et al. A multivariate analysis of limiting factors for stoma reversal in patients with rectal cancer entered into the total mesorectal excision (TME) trial: a retrospective study. Lancet Oncol. 2007;8:297–303. https://doi.org/10.1016/S1470-2045(07)70047-5.

    Article  Google Scholar 

  34. Gavaruzzi T, Pace U, Giandomenico F, Pucciarelli S, Bianco F, Selvaggi F, et al. Colonic J-pouch or straight colorectal reconstruction after low anterior resection for rectal cancer: impact on quality of life and bowel function: a multicenter prospective randomized study. Dis Colon Rectum. 2020;63:1511–23. https://doi.org/10.1097/DCR.0000000000001745.

    Article  PubMed  Google Scholar 

  35. Marti WR, Curti G, Wehrli H, Grieder F, Graf M, Gloor B, et al. Clinical outcome after rectal replacement with side-to-end, colon-J-pouch, or straight colorectal anastomosis following total mesorectal excision: a Swiss prospective, randomized, multicenter trial (SAKK 40/04). Ann Surg. 2019;269:827–35. https://doi.org/10.1097/SLA.0000000000003057.

    Article  PubMed  Google Scholar 

  36. Morales-Conde S, Alarcon I, Yang T, Licardie E, Camacho V, Aguilar Del Castillo F, et al. Fluorescence angiography with indocyanine green (ICG) to evaluate anastomosis in colorectal surgery: where does it have more value? Surg Endosc. 2020;34:3897–907. https://doi.org/10.1007/s00464-019-07159-1.

    Article  PubMed  Google Scholar 

  37. Blanco-Colino R, Espin-Basany E. Intraoperative use of ICG fluorescence imaging to reduce the risk of anastomotic leakage in colorectal surgery: a systematic review and meta-analysis. Tech Coloproctol. 2018;22:15–23. https://doi.org/10.1007/s10151-017-1731-8.

    Article  CAS  PubMed  Google Scholar 

Download references

Funding

No funding to report.

Author information

Authors and Affiliations

  1. Department of Digestive Surgery, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, 184 rue du faubourg Saint-Antoine, 75012, Paris, France

    Alexandra Nassar, Alexandre Challine, Thibault Voron, Najim Chafaï, Clotilde Debove, Yann Parc & Jeremie H. Lefèvre

  2. Centre for Colorectal Disease, St Vincent’s University Hospital, Elm Park, Dublin 4, Ireland

    Lauren O’Connell

Authors
  1. Alexandra Nassar
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Alexandre Challine
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Lauren O’Connell
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Thibault Voron
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Najim Chafaï
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Clotilde Debove
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Yann Parc
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Jeremie H. Lefèvre
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

All authors have contributed to the study and approved the version submitted to the journal.

Corresponding author

Correspondence to Jeremie H. Lefèvre.

Ethics declarations

Conflict of interest

The authors have no conflicts of interest to declare.

Ethical standards

All patients were informed of the study and agreed to participate.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Nassar, A., Challine, A., O’Connell, L. et al. Effective initial management of anastomotic leak in the maintenance of functional colorectal or coloanal anastomosis. Surg Today 53, 718–727 (2023). https://doi.org/10.1007/s00595-022-02603-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00595-022-02603-7

Keywords

Search

Navigation