Skip to main content

Advertisement

SpringerLink
Log in

Techniques for Colorectal Anastomotic Construction Following Proctectomy and Variables Influencing Anastomotic Leak

  • Surgery and Surgical Innovations in Colorectal Cancer (S Huerta, Section Editor)
  • Published:
Current Colorectal Cancer Reports

Abstract

Purpose of Review

Examine the various technical considerations for pelvic colorectal reconstruction with respective functional and anastomotic healing outcomes. Additionally, several adjuncts to reduce anastomotic complications are individually explored to understand their relative impact on anastomotic healing.

Recent Findings

The benefit of a colorectal reservoir reconstruction instead of a straight anastomosis, in respect to leak and functional outcomes, is marginal, if any. Recent randomized evidence has shown no difference in morbidity, mortality, survival, leakage, or functional outcomes. Unfortunately, anastomotic leakage still occurs in the ideally constructed and managed pelvic anastomosis; however, modifiable variables appear to reduce the risk.

Summary

Pelvic colorectal anastomosis should be based on the surgeon’s technical ability and comfort level, since the evidence suggests that all techniques are comparable. There may be a slight advantage to colonic J-pouch anastomosis, although this has not been consistently shown. Future studies on the etiology of low anterior resection syndrome may provide insight on optimal reconstruction techniques.

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

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Kingham TP, Pachter HL. Colonic anastomotic leak: risk factors, diagnosis, and treatment. J Am Coll Surg. 2009;208(2):269–78.

    Article  PubMed  Google Scholar 

  2. Neutzling CB, et al. Stapled versus handsewn methods for colorectal anastomosis surgery. Cochrane Database Syst Rev. 2012;(2):CD003144.

  3. Slieker JC, Daams F, Mulder IM, Jeekel J, Lange JF. Systematic review of the technique of colorectal anastomosis. JAMA Surg. 2013;148(2):190–201.

    Article  PubMed  Google Scholar 

  4. Martellucci J. Low anterior resection syndrome: a treatment algorithm. Dis Colon Rectum. 2016;59(1):79–82.

  5. Bryant CL, Lunniss PJ, Knowles CH, Thaha MA, Chan CL. Anterior resection syndrome. Lancet Oncol. 2012;13:e403–8.

  6. Lazorthes F, Gamagami R, Chiotasso P, Istvan G, Muhammad S. Prospective, randomized study comparing clinical results between small and large colonic J-pouch following coloanal anastomosis. Dis Colon Rectum. 1997;40(12):1409–13.

    Article  PubMed  CAS  Google Scholar 

  7. Baker JW. Low end to side rectosigmoidal anastomosis; description of technic. Arch Surg. 1950;61(1):143–57.

    Article  PubMed  CAS  Google Scholar 

  8. Hallbook O, et al. Randomized comparison of straight and colonic J pouch anastomosis after low anterior resection. Ann Surg. 1996;224(1):58–65.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  9. •• Fazio VW, et al. A randomized multicenter trial to compare long-term functional outcome, quality of life, and complications of surgical procedures for low rectal cancers. Ann Surg. 2007;246(3):481–8 discussion 488–90. An important RCT comparing J pouch to coloplasty and coloplasty to straight end-to-end anastomosis demonstrating functional superiority of pouch to coloplasty but no difference between colopasty and straight anastomosis.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Hida J, Yoshifuji T, Tokoro T, Inoue K, Matsuzaki T, Okuno K, et al. Comparison of long-term functional results of colonic J-pouch and straight anastomosis after low anterior resection for rectal cancer: a five-year follow-up. Dis Colon Rectum. 2004;47(10):1578–85.

    Article  PubMed  Google Scholar 

  11. Huber FT, Herter B, Siewert JR. Colonic pouch vs. side-to-end anastomosis in low anterior resection. Dis Colon Rectum. 1999;42(7):896–902.

    Article  PubMed  CAS  Google Scholar 

  12. •• Marti, W.R., 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, 2018. A major RCT that showed no difference in functional outcomes between anastomotic configurations.

  13. Thompson SK, Chang EY, Jobe BA. Clinical review: healing in gastrointestinal anastomoses, part I. Microsurgery. 2006;26(3):131–6.

    Article  PubMed  Google Scholar 

  14. Hawley PR. Causes and prevention of colonic anastomotic breakdown. Dis Colon Rectum. 1973;16(4):272–7.

    Article  PubMed  CAS  Google Scholar 

  15. Thornton FJ, Barbul A. Healing in the gastrointestinal tract. Surg Clin North Am. 1997;77(3):549–73.

    Article  PubMed  CAS  Google Scholar 

  16. Cohn I Jr, Rives JD. Antibiotic protection of colon anastomoses. Ann Surg. 1955;141(5):707–17.

    Article  PubMed  PubMed Central  Google Scholar 

  17. LeVeen HH, Wapnick S, Falk G, Olivas O, Bhat D, Gaurdre M, et al. Effects of prophylactic antibiotics on colonic healing. Am J Surg. 1976;131(1):47–53.

    Article  PubMed  CAS  Google Scholar 

  18. Shogan BD, et al. Collagen degradation and MMP9 activation by enterococcus faecalis contribute to intestinal anastomotic leak. Sci Transl Med. 2015;7(286):286ra68.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  19. Shogan BD, Smith DP, Christley S, Gilbert JA, Zaborina O, Alverdy JC. Intestinal anastomotic injury alters spatially defined microbiome composition and function. Microbiome. 2014;2:35.

    Article  PubMed  PubMed Central  Google Scholar 

  20. Scarborough JE, Mantyh CR, Sun Z, Migaly J. Combined mechanical and oral antibiotic bowel preparation reduces incisional surgical site infection and anastomotic leak rates after elective colorectal resection: an analysis of colectomy-targeted ACS NSQIP. Ann Surg. 2015;262(2):331–7.

    Article  PubMed  Google Scholar 

  21. Kiran RP, et al. Combined preoperative mechanical bowel preparation with oral antibiotics significantly reduces surgical site infection, anastomotic leak, and ileus after colorectal surgery. Ann Surg. 2015;262(3):416–25 discussion 423–5.

    Article  PubMed  Google Scholar 

  22. McSorley ST, Steele CW, McMahon AJ. Meta-analysis of oral antibiotics, in combination with preoperative intravenous antibiotics and mechanical bowel preparation the day before surgery, compared with intravenous antibiotics and mechanical bowel preparation alone to reduce surgical-site infections in elective colorectal surgery. BJS Open. 2018;2(4):185–94.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  23. •• European Society of Coloproctology collaborating, G. Association of mechanical bowel preparation with oral antibiotics and anastomotic leak following left sided colorectal resection: an international, multi-centre, prospective audit. Color Dis. 2018;20(Suppl 6):15–32 A large prospective "real world" analysis showing a reduction in anastomotic leakage when mechanical bowel preparation with oral antibiotics is administered for left sided colorectal anastomoses.

    Article  Google Scholar 

  24. Jung B, Påhlman L, Nyström PO, Nilsson E, for the Mechanical Bowel Preparation Study Group. Multicentre randomized clinical trial of mechanical bowel preparation in elective colonic resection. Br J Surg. 2007;94(6):689–95.

    Article  PubMed  CAS  Google Scholar 

  25. Bucher P, et al. Mechanical bowel preparation for elective colorectal surgery: a meta-analysis. Arch Surg. 2004;139(12):1359–64 discussion 1365.

    Article  PubMed  Google Scholar 

  26. Senagore A. Difficult Decisions in Colorectal Surgery. In: Ferguson M, editor. Difficult decisions in surgery: an evidence-based approach. Switzerland: Springer; 2017.

    Google Scholar 

  27. Lange MM, Buunen M, van de Velde CJH, Lange JF. Level of arterial ligation in rectal cancer surgery: low tie preferred over high tie. A review. Dis Colon Rectum. 2008;51(7):1139–45.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Lange JF, Komen N, Akkerman G, Nout E, Horstmanshoff H, Schlesinger F, et al. Riolan’s arch: confusing, misnomer, and obsolete. A literature survey of the connection(s) between the superior and inferior mesenteric arteries. Am J Surg. 2007;193(6):742–8.

    Article  PubMed  Google Scholar 

  29. Matsuda K, Hotta T, Takifuji K, Yokoyama S, Oku Y, Watanabe T, et al. Randomized clinical trial of defaecatory function after anterior resection for rectal cancer with high versus low ligation of the inferior mesenteric artery. Br J Surg. 2015;102(5):501–8.

    Article  PubMed  CAS  Google Scholar 

  30. Koda K, Saito N, Seike K, Shimizu K, Kosugi C, Miyazaki M. Denervation of the neorectum as a potential cause of defecatory disorder following low anterior resection for rectal cancer. Dis Colon Rectum. 2005;48(2):210–7.

    Article  PubMed  Google Scholar 

  31. •• Fujii S, et al. Randomized clinical trial of high versus low inferior mesenteric artery ligation during anterior resection for rectal cancer. BJS Open. 2018;2(4):195–202 A RCT of "high vs low" tie vessel ligation showing no difference in rate of anastomotic leak.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  32. • Bonnet S, et al. High tie versus low tie vascular ligation of the inferior mesenteric artery in colorectal cancer surgery: impact on the gain in colon length and implications on the feasibility of anastomoses. Dis Colon Rectum. 2012;55(5):515–21 A cadaver anatomic study demonstrating the impact and feasibility of low anastomosis by demonstrating successive gain in length of colon reach with increasing level of vascular ligation.

    Article  PubMed  CAS  Google Scholar 

  33. Nachiappan S, Askari A, Currie A, Kennedy RH, Faiz O. Intraoperative assessment of colorectal anastomotic integrity: a systematic review. Surg Endosc. 2014;28(9):2513–30.

    Article  PubMed  Google Scholar 

  34. Beard JD, Nicholson ML, Sayers RD, Lloyd D, Everson NW. Intraoperative air testing of colorectal anastomoses: a prospective, randomized trial. Br J Surg. 1990;77(10):1095–7.

    Article  PubMed  CAS  Google Scholar 

  35. Li VK, et al. Use of routine intraoperative endoscopy in elective laparoscopic colorectal surgery: can it further avoid anastomotic failure? Surg Endosc. 2009;23(11):2459–65.

    Article  PubMed  Google Scholar 

  36. •• Ricciardi R, et al. Anastomotic leak testing after colorectal resection: what are the data? Arch Surg. 2009;144(5):407–11 discussion 411–2. A large institutional experience reporting the impact of mechanical leak testing on anastomotic leak rates, suggesting its high clinical value and implications when a positive leak test is identified.

    Article  PubMed  Google Scholar 

  37. Singh DB, et al. Intraoperative measurement of colonic oxygenation during bowel resection. Adv Exp Med Biol. 2009;645:261–6.

    Article  PubMed  Google Scholar 

  38. Boni L, Fingerhut A, Marzorati A, Rausei S, Dionigi G, Cassinotti E. Indocyanine green fluorescence angiography during laparoscopic low anterior resection: results of a case-matched study. Surg Endosc. 2017;31(4):1836–40.

    Article  PubMed  Google Scholar 

  39. • Jafari MD, et al. Perfusion assessment in laparoscopic left-sided/anterior resection (PILLAR II): a multi-institutional study. J Am Coll Surg. 2015;220(1):82–92 e1 The landmark prospective trial investigating fluorescence angiography to assess perfusion of the colonic conduit showed feasibility, but no definitive evidence in reduction in anastomotic leakage rates.

    Article  PubMed  Google Scholar 

  40. Shen R, Zhang Y, Wang T. Indocyanine green fluorescence angiography and the incidence of anastomotic leak after colorectal resection for colorectal cancer: a meta-analysis. Dis Colon Rectum. 2018;61(10):1228–34.

    Article  PubMed  Google Scholar 

  41. Kin C, Vo H, Welton L, Welton M. Equivocal effect of intraoperative fluorescence angiography on colorectal anastomotic leaks. Dis Colon Rectum. 2015;58(6):582–7.

    Article  PubMed  Google Scholar 

  42. • Montedori, A., et al., Covering ileo- or colostomy in anterior resection for rectal carcinoma. Cochrane Database Syst Rev, 2010(5): p. CD006878. A Cochrane review of 6 RCT's showing significant reduction in anastomotic leak and re-operation when fecally diverted after a pelvic colorectal anastomosis.

  43. Thoker M, Wani I, Parray FQ, Khan N, Mir SA, Thoker P. Role of diversion ileostomy in low rectal cancer: a randomized controlled trial. Int J Surg. 2014;12(9):945–51.

    Article  PubMed  Google Scholar 

  44. Chude GG, et al. Defunctioning loop ileostomy with low anterior resection for distal rectal cancer: should we make an ileostomy as a routine procedure? A prospective randomized study. Hepatogastroenterology. 2008;55(86–87):1562–7.

    PubMed  CAS  Google Scholar 

  45. Matthiessen P, Hallbk O, Rutegrd J, Simert G, Sjdahl R. Defunctioning stoma reduces symptomatic anastomotic leakage after low anterior resection of the rectum for cancer: a randomized multicenter trial. Ann Surg. 2007;246(2):207–14.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Sagar PM, Hartley MN, Macfie J, Mancey-Jones B, Sedman P, May J. Randomized trial of pelvic drainage after rectal resection. Dis Colon Rectum. 1995;38(3):254–8.

    Article  PubMed  CAS  Google Scholar 

  47. Merad F, Hay JM, Fingerhut A, Yahchouchi E, Laborde Y, Pélissier E, et al. Is prophylactic pelvic drainage useful after elective rectal or anal anastomosis? A multicenter controlled randomized trial. French Association for Surgical Research. Surgery. 1999;125(5):529–35.

    Article  PubMed  CAS  Google Scholar 

  48. •• Denost Q, et al. To drain or not to drain infraperitoneal anastomosis after rectal excision for cancer: the GRECCAR 5 randomized trial. Ann Surg. 2017;265(3):474–80 A major RCT comparing drain or no drain in patients undergoing infraperitoneal anastomosis showing no difference in pelvic septic complications, rate of re-operation, or somta closure between the groups, suggesting drain placement intraoperatively does not confer benefit.

    Article  PubMed  Google Scholar 

  49. Rondelli F, Bugiantella W, Vedovati MC, Balzarotti R, Avenia N, Mariani E, et al. To drain or not to drain extraperitoneal colorectal anastomosis? A systematic review and meta-analysis. Color Dis. 2014;16(2):O35–42.

    Article  CAS  Google Scholar 

  50. Klein M, Gogenur I, Rosenberg J. Postoperative use of non-steroidal anti-inflammatory drugs in patients with anastomotic leakage requiring reoperation after colorectal resection: cohort study based on prospective data. BMJ. 2012;345:e6166.

    Article  PubMed  PubMed Central  CAS  Google Scholar 

  51. Kverneng Hultberg D, Angenete E, Lydrup ML, Rutegård J, Matthiessen P, Rutegård M. Nonsteroidal anti-inflammatory drugs and the risk of anastomotic leakage after anterior resection for rectal cancer. Eur J Surg Oncol. 2017;43(10):1908–14.

    Article  PubMed  CAS  Google Scholar 

  52. Inan A, Koca C, Sen M. Effects of diclofenac sodium on bursting pressures of anastomoses and hydroxyproline contents of perianastomotic tissues in a laboratory study. Int J Surg. 2006;4(4):222–7.

    Article  PubMed  Google Scholar 

  53. de Sousa JB, Soares EG, Aprilli F. Effects of diclofenac sodium on intestinal anastomotic healing. Experimental study on the small intestine of rabbits. Dis Colon Rectum. 1991;34(7):613–7.

    Article  PubMed  Google Scholar 

  54. Klein M, Krarup PM, Kongsbak MB, Ågren MS, Gögenur I, Jorgensen LN, et al. Effect of postoperative diclofenac on anastomotic healing, skin wounds and subcutaneous collagen accumulation: a randomized, blinded, placebo-controlled, experimental study. Eur Surg Res. 2012;48(2):73–8.

    Article  PubMed  CAS  Google Scholar 

  55. Kotagal M, Hakkarainen TW, Simianu VV, Beck SJ, Alfonso-Cristancho R, Flum DR. Ketorolac use and postoperative complications in gastrointestinal surgery. Ann Surg. 2016;263(1):71–5.

    Article  PubMed  PubMed Central  Google Scholar 

  56. • Smith SA, et al. Postoperative nonsteroidal anti-inflammatory drug use and intestinal anastomotic dehiscence: a systematic review and meta-analysis. Dis Colon Rectum. 2016;59(11):1087–97 A meta-analysis showing no significant increase in anastomotic leak among the included RCT's (n=6), however, a statistically signficant increase in leak rate among the included observation studies (n=11).

    Article  PubMed  Google Scholar 

Download references

Author information

Authors and Affiliations

  1. Department of Gastrointestinal Oncology, Colorectal Surgical Oncology, Moffitt Cancer Center, 12902 Magnolia Drive, Tampa, FL, 33612, USA

    Seth Felder

  2. Department of Oncologic Sciences, MDC 44, College of Medicine, University of South Florida, Tampa, FL, 33612, USA

    Seth Felder

  3. Division of Colon & Rectal Surgery, University of Minnesota, Minneapolis, MN, 55455, USA

    Janet T. Lee

Authors
  1. Seth Felder
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Janet T. Lee
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Seth Felder.

Ethics declarations

Conflict of Interest

The authors declare they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Additional information

Publisher’s Note

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

This article is part of the Topical Collection on Surgery and Surgical Innovations in Colorectal Cancer

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Felder, S., Lee, J.T. Techniques for Colorectal Anastomotic Construction Following Proctectomy and Variables Influencing Anastomotic Leak. Curr Colorectal Cancer Rep 15, 8–17 (2019). https://doi.org/10.1007/s11888-019-00425-3

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11888-019-00425-3

Keywords

Search

Navigation