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Utility of contrast enema to assess anastomotic integrity and the natural history of radiological leaks after low rectal surgery: systematic review and meta-analysis

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Abstract

Purpose

There is no clear consensus on how to assess low rectal anastomotic integrity and patency prior to reversal of de-functioning stoma. The aim of this systematic review was to assess the utility of contrast enema (CE) in this context and to clarify the natural history of radiological leaks.

Methods

Keyword search of electronic databases (Embase, MEDLINE, Cochrane Library, Google Scholar) and bibliographic cross-referencing were performed to identify appropriate studies. Data extraction and synthesis was performed with the primary outcomes being the sensitivity and specificity of CE for detecting clinically significant abnormalities. Statistical analysis was performed using Open Meta-Analyst software. Narrative review of outcomes including those of clinical and radiological leaks was also undertaken.

Results

A total of 1,142 CE from 11 articles were included in the final meta-analysis. CE had high specificity (95.4; 95 % confidence interval = 92.0–97.4) and negative predictive value (98.4; 97.4–99.1) and moderate sensitivity (79.9; 63.9–89.9) and positive predictive value (64.6; 55.5–72.9) for the detection of clinically significant anastomotic problems. There was a high degree of correlation between CE and clinical examination findings (96.7 %). Occult radiological leaks were seen in 5.7 % of CE, and all but one (97 %) eventually underwent successful reversal. Only three quarters of patients with clinical leak underwent successful reversal.

Conclusion

CE is effective at excluding clinically significant anastomotic problems, especially after clinical anastomotic leaks. However, false positive results can be observed in asymptomatic patients, and it is unclear how much additional information CE provides over clinical assessment in the low uncomplicated anastomosis.

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Author information

Authors and Affiliations

  1. Department of General & Gastrointestinal Surgery, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, UK

    K. Habib, A. Gupta, Fayyaz A. K. Mazari & T. R. Wilson

  2. Department of Radiology, Doncaster and Bassetlaw Hospitals NHS Foundation Trust, Doncaster, UK

    D. White

  3. Department of General Surgery, Doncaster Royal Infirmary, Armthorpe Road, Doncaster, DN2 5LT, UK

    Fayyaz A. K. Mazari

Authors
  1. K. Habib
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  2. A. Gupta
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  3. D. White
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  4. Fayyaz A. K. Mazari
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Corresponding author

Correspondence to Fayyaz A. K. Mazari.

Electronic supplementary material

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Supplementary Fig. 5

This forest plot represents the cumulative sensitivity of contrast enema for detecting clinically significant anastomotic leak. Size of the solid boxes represents weight of each individual study and the bars represent 95 % confidence interval. The blue diamond at the bottom of the plot on the left represents cumulative sensitivity with the edges of the diamond representing 95 % confidence interval. Estimates and plot on the right represents contribution of individual studies to the cumulative sensitivity estimate. CI—Confidence interval, TP—True positive, FN—False negative. (GIF 3 kb)

High resolution image (TIFF 6,003 kb)

Supplementary Fig. 6

This forest plot represents the cumulative specificity of contrast enema for detecting clinically significant anastomotic leak. Size of the solid boxes represents weight of each individual study and the bars represent 95 % confidence interval. The blue diamond at the bottom of the plot on the left represents cumulative specificity with the edges of the diamond representing 95 % confidence interval. Estimates and plot on the right represents contribution of individual studies to the cumulative specificity estimate. CI—Confidence interval, TN—True negative, FP—False positive. (GIF 3 kb)

High resolution image (TIFF 6,043 kb)

Supplementary Fig. 7

This forest plot represents the cumulative sensitivity of contrast enema for detecting clinically significant anastomotic stricture. Size of the solid boxes represents weight of each individual study and the bars represent 95 % confidence interval. The blue diamond at the bottom of the plot on the left represents cumulative sensitivity with the edges of the diamond representing 95 % confidence interval. Estimates and plot on the right represents contribution of individual studies to the cumulative sensitivity estimate. CI—Confidence interval, TP—True positive, FN—False negative. (GIF 3 kb)

High resolution image (TIFF 5,978 kb)

Supplementary Fig. 8

This forest plot represents the cumulative specificity of contrast enema for detecting clinically significant anastomotic stricture. Size of the solid boxes represents weight of each individual study and the bars represent 95 % confidence interval. The blue diamond at the bottom of the plot on the left represents cumulative specificity with the edges of the diamond representing 95 % confidence interval. Estimates and plot on the right represents contribution of individual studies to the cumulative specificity estimate. CI—Confidence interval, TN—True negative, FP—False positive. (GIF 3 kb)

High resolution image (TIFF 6,029 kb)

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Habib, K., Gupta, A., White, D. et al. Utility of contrast enema to assess anastomotic integrity and the natural history of radiological leaks after low rectal surgery: systematic review and meta-analysis. Int J Colorectal Dis 30, 1007–1014 (2015). https://doi.org/10.1007/s00384-015-2225-7

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